Exploring how cognitive therapies offer promising alternatives to medication for managing Behavioral and Psychological Symptoms of Dementia (BPSD)
Imagine your loved one, who has dementia, becoming suddenly agitated, aggressive, or withdrawn. These experiences are often symptoms of Behavioral and Psychological Symptoms of Dementia (BPSD)—a term describing the distressing psychological reactions, psychiatric symptoms, and behavioral abnormalities seen in persons with dementia. These symptoms include agitation, aggression, apathy, depression, and psychosis. BPSD is incredibly common, affecting a significant majority of people with dementia at some point, and represents one of the most challenging aspects for caregivers, often leading to burnout, caregiver stress, and premature institutionalization 5 .
Cognition-oriented treatments (COTs) offer safer alternatives with dual benefits for both cognitive functions and behavioral symptoms 1 .
Cognition-oriented treatments are not a one-size-fits-all approach. Scientists and clinicians categorize them into three distinct types, each with a different mechanism and goal.
This approach involves engaging people with dementia in a range of group activities and discussions designed to generally improve cognitive and social functioning. Think of it as a social workout for the brain—it targets overall mental agility through social interaction, reminiscence, and themed activities rather than focusing on specific cognitive skills. A well-known protocol is Cognitive Stimulation Therapy (CST), which consists of 14 structured group sessions 2 8 .
In contrast, cognitive training involves guided practice on a set of standard tasks designed to target specific cognitive functions like memory, attention, or problem-solving. It's comparable to targeted mental exercises, often using computerized or paper-and-pencil tasks to repeatedly challenge particular cognitive domains, either individually or in groups 1 2 .
This is a highly individualized approach that focuses on real-world functioning. Rather than trying to improve underlying cognitive abilities, cognitive rehabilitation collaborates with patients and their caregivers to identify personally relevant goals (such as remembering names or using appliances safely) and devises practical strategies to achieve them. The focus is on improving everyday life and supporting independence 1 2 .
While these interventions are often discussed separately, in practice they're sometimes combined, and the terms have historically been used interchangeably, creating some challenges in research. However, understanding their distinct philosophies is key to appreciating how they might differently impact BPSD 2 .
With these definitions in mind, what does the scientific evidence actually tell us about their effectiveness? Recent systematic reviews and meta-analyses—which combine results from multiple studies to draw more powerful conclusions—have shed light on this question.
Cognition-oriented treatments consistently produce small to moderate benefits on cognitive performance across different populations, including healthy older adults, those with mild cognitive impairment, and people with dementia 1 .
When comparing cognitive interventions to passive control groups, the analysis found significant moderate effects on reducing BPSD . This suggests that engaging residents' minds through structured activities can meaningfully soothe behavioral and psychological symptoms.
Based on 2025 Systematic Review 2 9
| Intervention Type | Effective For | Primary Benefits |
|---|---|---|
| Cognitive Stimulation | People with dementia at any severity level | Supporting global cognitive functions |
| Cognitive Training | People with mild dementia | Improving global cognitive functions |
| Cognitive Rehabilitation | People with mild dementia | Improving functional abilities in daily life; reducing caregiver burden |
Interestingly, cognitive rehabilitation emerged as particularly effective for reducing caregiver burden—a crucial outcome since caregiver stress directly impacts the quality of care and the decision to institutionalize loved ones 2 9 . This makes intuitive sense: when patients become more capable in their daily activities through rehabilitation, caregivers experience less strain.
To understand how researchers test these interventions, let's examine a specific randomized controlled trial conducted in India and published in 2023—a particularly interesting study as it adapted traditional methods during the COVID-19 pandemic 8 .
The research team recruited 57 patients with major neurocognitive disorder (dementia) and their caregivers. The participants were divided into two groups using a block-randomized design:
Received 14 sessions of virtual Cognitive Stimulation Therapy over seven weeks, with each session lasting 45 minutes.
Continued with their treatment as usual (including anti-dementia medications) but did not receive the additional CST sessions.
To ensure objective results, the researchers who assessed outcomes were "blinded"—they didn't know which participants had received the therapy. All participants were evaluated at the beginning of the study and again eight weeks later using standardized measures including the Montreal Cognitive Assessment (MoCA), the Neuropsychiatric Inventory (NPI) for BPSD symptoms, and the Zarit Burden Interview (ZBI) for caregiver burden 8 .
The findings, published in the Annals of Indian Academy of Neurology, demonstrated that CST delivered impressive benefits across multiple domains:
| Outcome Measure | CST Group | Control Group | Significance |
|---|---|---|---|
| Global Cognition (MoCA) | Significant increase | Significant decrease | P < 0.05 |
| BPSD Symptoms (NPI) | Significant decrease | Not significant | P < 0.05 |
| Caregiver Burden (ZBI) | Significant decrease | Not significant | P < 0.05 |
Perhaps most notably for our topic, the study found a statistically significant decrease in the severity of BPSD symptoms in the CST group, measured by the Neuropsychiatric Inventory 8 . This provides compelling evidence that a non-pharmacological intervention focusing on cognitive engagement can directly improve the behavioral and psychological symptoms that cause so much distress.
"CST has a significant impact on cognitive outcomes in dementia and it also proved its effectiveness in controlling the BPSD outcomes and caregiver burden in dementia" 8 .
This triple benefit—supporting cognition, reducing behavioral symptoms, and easing caregiver strain—highlights the multi-faceted value of this approach.
Conducting rigorous research on cognitive interventions requires specific tools and methods. Here are some of the key "research reagents" that scientists use in this field:
| Tool Category | Specific Examples | Function in Research |
|---|---|---|
| Cognitive Assessment Scales | Montreal Cognitive Assessment (MoCA), Alzheimer's Disease Assessment Scale-Cognitive (ADAS-Cog) | Standardized instruments to measure cognitive abilities before and after interventions |
| BPSD Measures | Neuropsychiatric Inventory (NPI), BPSD Diary | Tools to document the frequency, severity, and triggers of behavioral and psychological symptoms |
| Functional & QoL Measures | Lawton Instrumental Activities of Daily Living (IADL) Scale, Quality of Life measures | Assess real-world functioning and well-being beyond cognitive test scores |
| Caregiver Impact Measures | Zarit Burden Interview (ZBI) | Quantify the impact of dementia symptoms and interventions on caregiver stress and burden |
| Novel Assessment Tools | BPSDiary (used in an ongoing trial) | Digital tools to reduce recall bias by allowing real-time recording of symptoms and triggers 5 |
The development of tools like the BPSDiary—designed to help caregivers record specific behaviors, their timing, severity, and potential triggers—represents an exciting advancement. By providing more objective data about BPSD patterns, such tools can help researchers and clinicians better understand which interventions work for which specific symptoms 5 .
The growing body of evidence tells a compelling story: engaging the mind can calm the distress of behavioral and psychological symptoms in dementia. While cognitive-oriented treatments were initially developed to support thinking and memory, we now understand that their benefits extend much further, potentially reducing the need for risky pharmacological interventions that often come with dangerous side effects 7 .
The scientific community continues to refine these approaches. Future research aims to better identify which interventions work best for specific types of patients, symptoms, and stages of dementia 2 4 . There's also growing recognition that combining different approaches—perhaps cognitive stimulation for general engagement with cognitive rehabilitation for specific functional goals—might yield the best outcomes.
"The potential of cognition-focused interventions has probably been obscured by the methodological inconsistencies and limitations of the clinical studies conducted thus far" 4 .
As research methods improve and we learn to better personalize these interventions, we move closer to a future where dementia care is not only more effective but also more humane—addressing the whole person rather than just their symptoms.
For families and caregivers living with dementia, this research offers tangible hope. Something as simple as participating in structured group activities, practicing targeted cognitive exercises, or working on personally meaningful goals with a therapist can make a meaningful difference in the daily experience of both the person with dementia and those who care for them. In the challenging journey of dementia, these approaches provide tools to navigate the behavioral and psychological symptoms with greater confidence and compassion, improving quality of life on all sides of the care relationship.
Cognitive therapies improve both cognition and behavioral symptoms
Non-pharmacological approaches avoid dangerous side effects
Some interventions significantly reduce caregiver burden
Different interventions work for different patients and symptoms