Guidelines recommend that health care providers use nonpharmacologic interventions first to manage neuropsychiatric symptoms in people with dementia. Yet, they continue to prescribe pharmacologic agents, which can have adverse effects in this population. Researchers conducted a systematic review and meta-analysis to determine the best interventions and comparative efficacy of pharmacologic and nonpharmacologic interventions to manage aggression and agitation in people with dementia.

A total of 163 studies involving 23,143 patients were included in the analysis. Multidisciplinary care, massage and touch therapy, and music combined with massage and touch therapy were more clinically efficacious than usual care for agitation and aggression. In studies conducted in a nursing home or assisted-living setting, music therapy and cognitive stimulation were also more efficacious than usual care. Nonpharmacologic interventions were the most highly ranked interventions in all subgroups except one. In that group, in which standard diagnostic criteria were used to diagnose dementia, several pharmacologic agents were efficacious compared with placebo; however, only cannabinoids and the combination of dextromethorphan and quinidine had a clinically important effect.

The authors point out that 46% of studies were at high risk for bias because of missing outcome data. They also note that they couldn't determine the efficacy of interventions in people who had specific types of dementia and didn't assess factors related to the interventions, such as adherence, harm, and cost. Nonetheless, they conclude, the results support consideration of nonpharmacologic interventions before pharmacologic options when managing aggression and agitation in people with dementia.