Elderly – Non-pharm approach

Dementia and Cognitive Decline

• Non-Pharmacological Treatments:
  • Cognitive stimulation therapy (structured group activities to improve cognitive function)
  • Reminiscence therapy (discussing past experiences to enhance mood and cognition)
  • Physical exercise programs
  • Environmental modifications to reduce confusion and promote safety
  • Routine and structure to provide a sense of stability

Stage	Non-Pharmacological Approaches	Evidence-Based Benefits
Mild to Moderate Cognitive Decline
Cognitive Stimulation Therapy	– Group activities designed to improve cognitive function and social interaction. – Sessions involve games, discussions, and problem-solving tasks.	– Improvements in cognitive function and quality of life (Woods et al., 2012).
Physical Exercise	– Regular physical activities such as walking, swimming, or tailored exercise programs.	– Improves physical health, mood, and cognitive function (Blondell et al., 2014).
Reminiscence Therapy	– Discussing past experiences, often with the aid of photos, music, or other mementos.	– Enhances mood, cognitive function, and social interaction (Woods et al., 2018).
Environmental Modifications	– Simplifying the living environment to reduce confusion and enhance safety. – Use of clear signage, contrasting colors, and good lighting.	– Reduces anxiety, improves orientation, and increases independence (Gitlin et al., 2001).
Routine and Structure	– Establishing consistent daily routines. – Involvement in meaningful activities.	– Provides a sense of security and reduces behavioral problems (Volicer et al., 2006).
Social Engagement	– Encouraging participation in social activities and community groups.	– Reduces feelings of isolation and depression, enhances cognitive function (Fratiglioni et al., 2004).
Severe Cognitive Decline
Sensory Stimulation	– Activities that stimulate the senses, such as music therapy, aromatherapy, and tactile stimulation.	– Improves mood and reduces agitation and anxiety (Van der Ploeg et al., 2013).
Music Therapy	– Using music to engage, calm, and evoke positive memories.	– Reduces agitation, improves mood, and can enhance communication (Gerdner, 2000).
Person-Centered Care	– Tailoring care to the individual’s history, preferences, and needs. – Involves family members in care planning.	– Improves quality of life and reduces behavioral issues (Brooker et al., 2006).
Validation Therapy	– Acknowledging and validating the emotions and concerns of the individual.	– Reduces stress and improves communication (Feil, 2003).
Comfort and Calming Techniques	– Using gentle touch, calm voice, and familiar objects to soothe the individual.	– Reduces agitation and enhances feelings of safety and comfort (Snyder et al., 1995).
Environmental Adjustments	– Creating a calm and familiar environment with minimal distractions. – Use of personal items and familiar furniture.	– Reduces confusion and agitation, enhances comfort (Kovach et al., 1996).

Delirum

Stage	Non-Pharmacological Approaches	Evidence-Based Benefits
Prevention and Early Management
Orientation and Cognitive Stimulation	– Provide clocks, calendars, and orientation boards. – Regularly reorient the patient to time, place, and person.	– Reduces the incidence of delirium by maintaining cognitive function and orientation.
Sleep Hygiene	– Encourage a regular sleep-wake cycle. – Minimize noise and light disruptions at night. – Avoid unnecessary nighttime interventions.	– Improves sleep quality, which can reduce the risk of delirium.
Hydration and Nutrition	– Ensure adequate hydration and nutrition. – Monitor and manage electrolyte imbalances.	– Prevents metabolic disturbances that can contribute to delirium.
Sensory Aids	– Provide appropriate glasses and hearing aids. – Ensure that these aids are used and functioning properly.	– Enhances sensory input, reducing confusion and the risk of delirium.
Mobility and Exercise	– Encourage early mobilization and physical activity. – Use physical therapy as needed.	– Promotes physical health and reduces the risk of delirium.
Environmental Modifications	– Ensure a calm and safe environment. – Use familiar objects and minimize changes in surroundings.	– Reduces anxiety and confusion, which can trigger delirium.
Regular Monitoring and Assessment	– Frequent monitoring for early signs of delirium. – Use standardized tools like the Confusion Assessment Method (CAM).	– Early detection and intervention can reduce the severity and duration of delirium.
Family Involvement	– Encourage family visits and involvement in care. – Educate family members about delirium prevention.	– Provides emotional support and familiarity, which can reduce the incidence and severity of delirium.
Address Underlying Causes	– Identify and treat underlying medical conditions (e.g., infections, pain, hypoxia).	– Resolving the underlying causes can prevent or reduce delirium.

Falls and Mobility Issues

• Balance and strength training exercises (e.g., Tai Chi)
• Physical therapy to improve mobility and strength
• Home safety assessments and modifications (grab bars, non-slip mats)
• Use of assistive devices (canes, walkers)
• Footwear advice (sturdy, non-slip shoes)

Intervention	Description	Evidence-Based Benefits
Balance and Strength Training	– Regular exercises such as Tai Chi, yoga, and strength training. – Programs designed to improve balance and muscle strength.	– Improves physical function, reduces fall risk, and enhances overall mobility.
Physical Therapy	– Individualized physical therapy programs tailored to the patient’s needs. – Focus on improving gait, balance, and strength.	– Enhances mobility, reduces pain, and decreases the likelihood of falls.
Home Safety Modifications	– Assess and modify the home environment to remove hazards. – Install grab bars, handrails, and non-slip mats. – Improve lighting and remove clutter.	– Reduces environmental risks that contribute to falls, creating a safer living space.
Use of Assistive Devices	– Prescribe and educate on the proper use of canes, walkers, and other mobility aids. – Ensure the devices are correctly fitted.	– Provides stability and support, reducing the risk of falls and improving confidence.
Footwear Advice	– Recommend sturdy, non-slip shoes with proper support. – Advise against wearing slippers or socks without grip.	– Improves stability and reduces the risk of slips and falls.
Exercise Programs	– Encourage participation in group exercise classes or individual exercise plans – Activities like walking, swimming, or cycling.	– Improves overall physical health, strength, and balance, reducing fall risk.
Vision and Hearing Checks	– Regular vision and hearing assessments. – Ensure glasses and hearing aids are up to date and properly used.	– Enhances sensory input, which is crucial for maintaining balance and preventing falls.
Education and Behavioral Strategies	– Educate on the importance of safe movement and fall prevention techniques. – Teach strategies for safe transfers and movements.	– Empowers patients with knowledge and techniques to avoid risky behaviors and movements that could lead to falls.
Nutritional Support	– Ensure adequate intake of calcium and vitamin D. – Address any nutritional deficiencies that may affect bone health and muscle function.	– Supports bone density and muscle strength, reducing the risk of fractures from falls.
Hydration and Medication Management	– Monitor hydration levels and encourage regular fluid intake. – Regularly review medications to identify those that may increase fall risk.	– Prevents dehydration-related dizziness and identifies medication-related risks that can contribute to falls.

Chronic Pain (e.g., Osteoarthritis)

• Physical therapy and regular exercise
• Heat and cold therapy
• Weight management to reduce joint strain
• Acupuncture or massage therapy
• Occupational therapy to assist with daily activities

Intervention	Description	Evidence-Based Benefits
Physical Therapy	– Customized exercise programs to improve strength, flexibility, and range of motion. – Techniques such as manual therapy, massage, and hydrotherapy.	– Reduces pain, improves function, and enhances quality of life.
Exercise and Movement	– Regular low-impact aerobic activities like walking, swimming, or cycling. – Strengthening and stretching exercises.	– Decreases pain perception, improves physical function, and promotes overall health.
Cognitive Behavioral Therapy (CBT)	– Psychological approach to manage pain by changing negative thought patterns. – Techniques include relaxation training, stress management, and coping strategies.	– Reduces pain intensity, improves emotional well-being, and enhances coping mechanisms.
Mind-Body Practices	– Practices such as yoga, Tai Chi, and Pilates. – Focus on mindfulness, breathing techniques, and gentle movements.	– Enhances physical function, reduces stress, and alleviates pain.
Acupuncture	– Insertion of fine needles into specific points on the body. – Aimed at balancing the body’s energy flow and stimulating natural pain relief.	– Provides pain relief, reduces inflammation, and improves physical function.
Heat and Cold Therapy	– Application of heat (e.g., warm baths, heating pads) to relax muscles and increase blood flow. – Application of cold (e.g., ice packs) to reduce inflammation and numb pain.	– Relieves muscle tension, reduces swelling, and alleviates pain.
Massage Therapy	– Manual manipulation of soft tissues to relieve muscle tension and pain.<br>- Techniques include Swedish massage, deep tissue massage, and trigger point therapy.	– Reduces muscle pain and tension, improves circulation, and enhances relaxation.
Occupational Therapy	– Assistance with activities of daily living (ADLs) and adaptations to the home environment. – Ergonomic advice and assistive devices to reduce strain and pain during daily activities.	– Improves functional ability, enhances independence, and reduces pain during daily activities.
Nutritional Support	– Diet rich in anti-inflammatory foods (e.g., omega-3 fatty acids, fruits, vegetables). – Maintaining a healthy weight to reduce stress on joints and muscles.	– Reduces inflammation, supports overall health, and decreases pain.
Transcutaneous Electrical Nerve Stimulation (TENS)	– Use of low-voltage electrical current to provide pain relief. – Portable TENS units can be used at home under professional guidance.	– Provides short-term pain relief and reduces the need for pain medications.
Relaxation Techniques	– Techniques such as progressive muscle relaxation, guided imagery, and meditation. – Focus on reducing stress and promoting relaxation.	– Reduces pain perception, decreases stress, and enhances overall well-being.

Chronic Pain (non-ambulatory, have limited communication, and are confused)

Intervention	Description	Evidence-Based Benefits
Gentle Massage Therapy	– Gentle hand, foot, or back massages to relieve muscle tension and promote relaxation. – Focus on soothing and repetitive strokes.	– Reduces muscle tension, improves circulation, and enhances relaxation.
Heat and Cold Therapy	– Application of warm compresses or heating pads to relax muscles. – Use of cold packs to reduce inflammation and numb pain.	– Relieves muscle tension, reduces swelling, and alleviates pain.
Music Therapy	– Playing calming and familiar music to soothe the patient and create a relaxing environment. – Can include singing or playing instruments.	– Reduces agitation, improves mood, and can indirectly alleviate pain.
Aromatherapy	– Use of essential oils like lavender, chamomile, or peppermint to promote relaxation and reduce pain. – Diffusers or applying diluted oils to the skin.	– Provides sensory stimulation, reduces anxiety, and promotes relaxation.
Comfort and Calming Techniques	– Gentle touch, using a calm voice, and providing familiar objects to soothe the patient. – Ensuring a comfortable and supportive seating or lying position.	– Reduces agitation and enhances feelings of safety and comfort.
Environmental Modifications	– Creating a calm, quiet, and familiar environment with minimal distractions. – Use of personal items and minimizing changes in surroundings.	– Reduces confusion and agitation, indirectly helping in pain management.
Sensory Stimulation	– Activities that engage the senses, such as tactile stimulation with soft fabrics or textured objects. – Use of visual stimuli like nature videos or picture books.	– Provides comfort, reduces anxiety, and can indirectly alleviate pain by improving mood.
Hydration and Nutrition	– Ensure adequate fluid intake and a balanced diet rich in anti-inflammatory foods. – Monitor for any nutritional deficiencies that may affect pain levels.	– Supports overall health, reduces inflammation, and decreases pain.
Repositioning and Pressure Relief	– Regularly repositioning the patient to prevent pressure ulcers and relieve discomfort. – Use of pressure-relieving cushions or mattresses.	– Prevents pressure sores, reduces pain from prolonged immobility, and improves comfort.
Family and Caregiver Involvement	– Educate and involve family members or caregivers in pain management strategies. – Encourage consistent routines and gentle care practices.	– Provides emotional support, enhances patient comfort, and ensures consistent application of pain management techniques.

Depression and Anxiety

• Cognitive-behavioral therapy (CBT)
• Social engagement and support groups
• Physical activity and exercise
• Mindfulness and relaxation techniques
• Participation in enjoyable activities and hobbies

Urinary Incontinence

• Pelvic floor muscle exercises (Kegel exercises)
• Bladder training programs
• Scheduled toileting and prompted voiding
• Fluid and diet management (avoiding bladder irritants)
• Use of incontinence pads or protective garments

Stress Incontinence

Intervention	Description	Evidence-Based Benefits
Pelvic Floor Muscle Exercises (Kegels)	Regular exercises to strengthen the pelvic floor muscles. Can be taught by a physiotherapist and done multiple times daily.	Improves pelvic floor strength and reduces episodes of incontinence.
Bladder Training	Techniques to increase the interval between voiding and improve bladder control. Gradually delay urination by small increments.	Enhances bladder capacity and reduces urinary frequency.
Lifestyle Modifications	Avoiding bladder irritants such as caffeine, alcohol, and spicy foods. Maintaining a healthy weight to reduce pressure on the bladder.	Reduces symptoms and improves bladder health.
Timed Voiding and Scheduled Toileting	Establishing a regular schedule for toilet visits. Encouraging voiding at set intervals regardless of the urge to urinate.	Helps manage urinary frequency and prevents accidents.

Urge Incontinence

Intervention	Description	Evidence-Based Benefits
Bladder Training	Techniques to control sudden urges to urinate and increase the interval between voiding. Use distraction and relaxation techniques to delay urination.	Reduces urgency and frequency of urination.
Pelvic Floor Muscle Exercises (Kegels)	Regular exercises to strengthen the pelvic floor muscles and support the bladder. Can help control sudden urges to urinate.	Improves muscle strength and reduces urge incontinence episodes.
Dietary Management	Avoiding foods and drinks that can irritate the bladder, such as caffeine, alcohol, citrus, and artificial sweeteners. Drinking adequate fluids to avoid concentrated urine.	Helps manage bladder irritation and reduces urge symptoms.
Behavioral Therapy	Techniques to recognize and control bladder urges. Use of mental strategies and distractions to manage urgency.	Enhances self-control and reduces incontinence episodes.

Overflow Incontinence

Intervention	Description	Evidence-Based Benefits
Double Voiding	Encouraging the patient to wait a few moments after urinating and then try to urinate again. Helps ensure the bladder is completely emptied.	Reduces residual urine and overflow incontinence.
Scheduled Toileting	Establishing a regular toileting schedule to prevent bladder overfilling. Encouraging toilet visits at regular intervals.	Prevents bladder overfilling and reduces incontinence episodes.
Lifestyle Modifications	Avoiding excessive fluid intake, especially before bedtime. Maintaining a healthy diet and regular physical activity to support bladder health.	Reduces bladder pressure and supports overall bladder function.

Functional Incontinence

Intervention	Description	Evidence-Based Benefits
Environmental Modifications	Ensuring easy access to the toilet. Installing grab bars, raised toilet seats, and using bedside commodes. Removing obstacles and improving lighting to reduce fall risks.	Enhances safety and accessibility, reducing incontinence episodes due to mobility issues.
Use of Assistive Devices	Using walkers, canes, or other mobility aids to facilitate safe and timely access to the toilet. Providing adaptive clothing to make toileting easier.	Improves mobility and independence, reducing incontinence related to mobility difficulties.
Timed Voiding and Scheduled Toileting	Establishing a regular toileting schedule tailored to the patient’s routine and needs. Offering reminders and assistance as needed.	Helps manage incontinence by ensuring regular emptying of the bladder.

Mixed Incontinence

Intervention	Description	Evidence-Based Benefits
Combination of Approaches	Utilizing a combination of pelvic floor exercises, bladder training, scheduled toileting, and lifestyle modifications. Tailoring interventions based on the predominant symptoms.	Provides comprehensive management and reduces overall incontinence episodes.

Pressure Ulcers

• Regular repositioning to relieve pressure
• Use of pressure-relieving mattresses and cushions
• Skin care routines to maintain moisture balance
• Nutritional support to promote skin health
• Regular skin inspections to detect early signs

Intervention	Description	Evidence-Based Benefits
Regular Repositioning	– Turning and repositioning the patient every 2 hours to relieve pressure on vulnerable areas. – Use of repositioning schedules and charts.	– Reduces prolonged pressure on the skin and prevents ulcer formation.
Pressure-Relieving Devices	– Use of specialized mattresses, mattress overlays, cushions, and pads that redistribute pressure. – Examples include foam, gel, and air-filled supports.	– Distributes weight more evenly and reduces pressure points, decreasing the risk of pressure ulcers.
Skin Care and Hygiene	– Regular skin inspections to identify early signs of pressure damage. – Keeping the skin clean and dry to prevent maceration and breakdown.	– Early detection and prevention of skin breakdown, reducing the risk of ulcers.
Nutritional Support	– Ensuring adequate nutrition and hydration to support skin integrity and overall health. – Diet rich in protein, vitamins (especially vitamin C and zinc), and fluids.	– Promotes skin repair and maintenance, reducing the likelihood of pressure ulcers.
Mobility and Physical Activity	– Encouraging movement and physical activity as much as the patient’s condition allows. – Range of motion exercises for bedridden patients.	– Improves blood circulation, reduces pressure on skin, and enhances overall health.
Use of Protective Dressings	– Application of barrier creams, hydrocolloid, foam, or silicone dressings on high-risk areas. – Dressings can prevent friction and shear.	– Protects the skin from mechanical damage and reduces the risk of pressure ulcer development.
Education and Training	– Educating patients, families, and caregivers about pressure ulcer prevention and care. – Training on proper repositioning techniques and use of equipment.	– Increases awareness and improves prevention strategies, leading to better patient outcomes.
Environmental Modifications	– Adjusting bed height and chair positions to minimize shear and friction. – Ensuring easy access to mobility aids and repositioning tools.	– Reduces mechanical forces that contribute to skin breakdown and pressure ulcer formation.
Hydration	– Encouraging regular fluid intake to maintain skin turgor and elasticity. – Monitoring for signs of dehydration.	– Maintains skin hydration and resilience, reducing susceptibility to pressure damage.

Malnutrition and Weight Loss

• Nutritional assessments and individualized meal plans
• Small, frequent, nutrient-dense meals
• Assistance with feeding if necessary
• Social dining to enhance appetite
• Oral health care to address issues affecting eating

Constipation

• Increased dietary fiber intake (fruits, vegetables, whole grains)
• Adequate fluid intake
• Regular physical activity
• Establishing a regular bowel routine
• Use of natural laxatives (prune juice)

Intervention	Description	Evidence-Based Benefits
Dietary Fiber Intake	– Increase intake of high-fiber foods such as fruits, vegetables, whole grains, and legumes. – Aim for 25-30 grams of fiber per day.	– Fiber adds bulk to stool, which promotes regular bowel movements and prevents constipation.
Hydration	– Encourage drinking plenty of fluids, primarily water. – Aim for at least 1.5-2 liters of fluids per day unless medically contraindicated.	– Adequate hydration softens stool, making it easier to pass and reducing the risk of constipation.
Physical Activity	– Promote regular physical activity, including walking, stretching, and light exercises. – Encourage activities suited to the patient’s abilities and mobility.	– Physical activity stimulates intestinal motility, helping to prevent constipation.
Routine and Scheduled Toileting	– Establish regular toileting routines, ideally after meals to take advantage of the gastrocolic reflex. – Encourage patients to respond to natural urges promptly.	– Consistent toileting routines promote regular bowel habits and prevent the buildup of stool.
Abdominal Massage	– Gentle, circular abdominal massages can be performed to stimulate bowel movements. – Techniques should be taught by a healthcare professional.	– Abdominal massage can help stimulate peristalsis and facilitate bowel movements.
Positioning	– Encourage the use of a footstool to elevate the feet while sitting on the toilet. – Mimics a squatting position, which can facilitate easier bowel movements.	– Improves the anorectal angle, making defecation easier and reducing straining.
Probiotics	– Incorporate probiotic-rich foods such as yogurt, kefir, and fermented vegetables into the diet. – Consider probiotic supplements if recommended by a healthcare provider.	– Probiotics can improve gut flora balance, enhancing bowel regularity and stool consistency.
Avoiding Constipating Foods	– Limit intake of foods that can contribute to constipation, such as processed foods, dairy products, and high-fat foods. – Educate patients on identifying these foods.	– Reducing intake of constipating foods can help maintain regular bowel movements.
Environmental Modifications	– Ensure easy access to bathrooms and provide a comfortable and private environment for toileting. – Use adaptive equipment if necessary, such as raised toilet seats.	– Enhances the ability and comfort of patients to use the toilet regularly, promoting regular bowel movements.
Behavioral and Educational Interventions	– Educate patients and caregivers about the importance of dietary fiber, hydration, and physical activity. Provide support and encouragement to adopt and maintain healthy bowel habits.	– Increases adherence to non-pharmacological strategies and improves overall bowel health.

Sleep Disorders

• Establishing a regular sleep schedule
• Creating a sleep-friendly environment (dark, quiet, and cool room)
• Cognitive-behavioral therapy for insomnia (CBT-I)
• Limiting caffeine and alcohol intake
• Promoting relaxation techniques before bedtime

For Caregivers and Environment

Intervention	Description	Evidence-Based Benefits
Creating a Sleep-Conducive Environment	– Ensure the bedroom is dark, quiet, and cool.<br>- Use blackout curtains, white noise machines, and comfortable bedding.	– Reduces environmental factors that can interfere with sleep, promoting better sleep quality.
Consistent Daily Routine	– Establish regular times for meals, activities, and bedtime. – Keep daily routines predictable and structured.	– Helps regulate the body’s internal clock and reduces anxiety and confusion.
Physical Activity	– Encourage regular, moderate physical activity during the day, such as walking or light exercises.<br>- Avoid late evening exercise.	– Helps regulate sleep patterns and reduces sleep disturbances.
Light Therapy	– Expose the patient to bright light during the day, especially in the morning. – Use natural sunlight or light therapy boxes.	– Helps regulate the sleep-wake cycle, particularly in those with circadian rhythm disturbances.
Minimizing Daytime Naps	– Limit naps to short durations (20-30 minutes) and avoid late afternoon naps. – Encourage activity and engagement during the day.	– Helps maintain a regular sleep-wake cycle and improves nighttime sleep.
Aromatherapy	– Use calming essential oils like lavender or chamomile through diffusers or topical application as part of the bedtime routine.	– Promotes relaxation and improves sleep quality.
Comfort and Calming Techniques	– Gentle touch, using a calm voice, and providing familiar objects to soothe the patient. – Ensuring a comfortable and supportive seating or lying position.	– Reduces agitation and enhances feelings of safety and comfort.
Managing Nocturia	– Limit fluid intake in the evening. – Ensure easy and safe access to the bathroom at night.	– Reduces the need for nighttime bathroom trips, promoting uninterrupted sleep.

Pharmacological Management

Medication Class	Examples	Description	Considerations and Side Effects
Melatonin and Melatonin Receptor Agonists	Melatonin, Ramelteon	– Helps regulate the sleep-wake cycle and can be effective in improving sleep onset and quality.	– Generally well-tolerated; may cause drowsiness, headache, or dizziness.
Non-Benzodiazepine Hypnotics	Zolpidem, Eszopiclone	– Used for short-term management of insomnia. – Acts on GABA receptors to promote sleep.	– Risk of dependence, tolerance, and side effects such as dizziness, confusion, and falls.
Antidepressants	Trazodone, Mirtazapine	– Often used for their sedative properties. – May be beneficial in patients with coexisting depression and anxiety.	– Potential side effects include daytime drowsiness, dizziness, and weight gain.
Antipsychotics	Quetiapine, Olanzapine	– Used off-label for sleep in dementia patients with severe behavioral disturbances. – Should be used with caution.	– Risk of significant side effects including increased mortality in elderly patients, sedation, and metabolic effects.
Benzodiazepines	Temazepam, Lorazepam	– Used for short-term treatment of severe insomnia. – Acts on GABA receptors to promote sleep.	– Risk of dependence, tolerance, cognitive impairment, and increased fall risk. Should be used with caution.
Orexin Receptor Antagonists	Suvorexant	– Promotes sleep by inhibiting the wakefulness-promoting orexin neurons. – Suitable for patients with difficulty maintaining sleep.	– May cause next-day drowsiness, dizziness, and parasomnias (e.g., sleepwalking).

Considerations for Management

1. Caregiver Education: Educate caregivers on non-pharmacological strategies and the importance of creating a supportive sleep environment.
2. Monitoring: Regularly monitor the patient for any changes in sleep patterns and side effects from medications.
3. Holistic Approach: Combine non-pharmacological strategies with medications as needed, tailored to the individual’s specific needs and conditions.
4. Safety: Ensure the safety of the patient, especially when using pharmacological treatments that may increase the risk of falls or confusion.