Behavior changes are among the most visible, disruptive and distressing symptoms of Alzheimer's disease and other dementias. From confusion, repetitive questioning and combativeness to wandering, hallucinations and loss of inhibition, the symptoms carry their own risks of injury. They affect patient's quality of life and that of the family caregiver. These symptoms have been a challenge to physicians, particularly since many medications carry significant risks and have been found to be relatively ineffective.

Screening for early manifestations of behavioral symptoms is not routinely conducted and risk factors for behavioral occurrences may be missed and ultimately precipitate placement in a nursing home or other costly long-term care facility.

Yet, many of dementia's behavioral symptoms can be managed well, without medications, if physicians integrate behavioral management strategies into early, ongoing treatment, according to Johns Hopkins University School of Nursing (JHUSON) professor Laura N. Gitlin, PhD; Johns Hopkins School of Medicine professor of Alzheimer's research Constantine G. Lyketsos, MD, MHS; and Helen C. Kales, MD, University of Michigan associate professor and research scientist at the VA Center for Clinical Management Research. In "Nonpharmacologic management of behavioral symptoms in dementia," a special "Clinician's Corner" (Journal of the American Medical Association, November 22), the authors outline a six-step approach to help clinicians identify and effectively manage most behavioral symptoms of dementia.

• Screen for behavioral symptoms early.

• Identify symptoms.

• Delineate the triggers and risk factors for the symptoms.

• Choose the proper interventions.

For example, an individual with dementia might wake repeatedly each night, voicing fear of being alone in the dark, despite continuous calming efforts. An intervention might mean simply using a nightlight in the patient's room, or adding long family walks in the evening, to help promote better sleep.

• Evaluate the intervention to make sure that it's working.

• Follow the patient's progress over time.

"This six-step process should be a routine part of regular health care for individuals with dementia," observes Gitlin, who directs the JHUSON Center for Innovative Care in Aging. "It should be undertaken in any clinical setting involved in caring for someone with dementia, including primary care and memory clinics, as well as in hospitals, assisted living and nursing facilities."

Clinicians play a key role by educating families and caregivers about dementia and about its behavioral symptoms (including why they occur). Clinicians also can provide tools and strategies to help caregivers prevent challenging behavioral symptoms. Thus, to reduce a patient's confusion and disorientation, a caregiver might be encouraged to break daily activities into small, simple steps and to establish structured routines. Low-tech interventions like these can reduce symptoms and unnecessary healthcare costs related to urgent visits to hospital emergency departments.

Dr. Lyketsos notes that "broad application of this systematic, uniform approach can advance both clinical practice and the development of new pharmacologic and nonpharmacologic therapies for these most challenging symptoms of dementias." Dr. Kales adds, "Given the limitations and risks of current pharmacologic treatments, increasing the uptake of evidence-based non-pharmacologic treatments is imperative."