Management of Behavioral and Psychological Symptoms of Dementia

Due to the dangers associated with psychotropic medications, there is an urgent need for non-pharmacologic therapies to treat behavioral and psychological symptoms of dementia (BPSD). Acupuncture and acupressure are safe and well-tolerated non-pharmacologic therapies for this population, but currently no review has explored acutherapy for management of distressing dementia symptoms. This review synthesizes research on acupuncture and acupressure for BPSD. Upon searching five databases, 15 studies met inclusion/exclusion criteria. Nine examined acupressure, six acupuncture, and eight were randomized controlled trials. The percent of studies demonstrating statistically significant improvements in symptoms were: activities of daily living (ADLs; 75%), agitation (100%), anxiety (67%), depression (100%), mood (100%), neuropsychological disturbances (67%), and sleep disturbances (100%). Variations in study design, intervention procedures, and outcomes limit interpretations about effectiveness. It is recommended that further research be done to examine the efficacy of these therapies and promote generalizability.

present throughout the lifetime of the diagnosis (Aalten, de Vugt, Jaspers, Jolles, & Verhey, 2005;Steinberg et al., 2004). The causes of BPSD are extremely diverse and complex, and are related to multiple factors. Some individuals with dementia may be more at risk than others to experience certain types and degree of BPSD. Research has shown that females may be more at risk for depressive symptoms (Buchanan, Wang, Ju, & Graber, 2004;Lövheim, Sandman, Karlsson, & Gustafson, 2009;Steinberg et al., 2006), while men may be more at risk for aggressive type behaviors (Buchanan, Wang, Ju, & Graber, 2004;Hall & O'Connor, 2004;Lövheim et al., 2009). BPSD are most common in the middle stages of the disease, with an estimated prevalence of 61%-88% (Lövheim, Sandman, Karlsson, & Gustafson, 2008;Steffens, Maytan, Helms, & Plassman, 2005). Specific BPSD have been shown to vary depending on dementia type. For example, depressive and anxious type symptoms have consistently shown to be more prevalent among individuals with vascular type dementia compared to Alzheimer's dementia, although a substantial overlap can exist between these two types (Cerejeira, Lagarto, & Mukaetova-Ladinska, 2012;Steinberg et al., 2006). Meanwhile, worsening general health and serious comorbidities are associated with increased risk for a number of BPSD, including agitation/aggression, aberrant motor behavior disinhibition, and irritability (Steinberg et al., 2006). BPSD further complicate the diagnosis and have been shown to be a leading factor of worsening caregiver burden (Campbell et al., 2008). BPSD negatively impact the quality of life of the individual with dementia, as well as family caregivers (Banerjee et al., 2006;Hurt et al., 2008). Similarly, these symptoms have been associated with increased stress and burden in nursing staff members in geriatric-acute care and nursing home settings (Cocco, Gatti, de Mendonça Lima, & Camus, 2003). These difficult behaviors can ultimately result in early institutionalization, or placement in long-term care settings, and increased health care utilization (Gaugler, Yu, Krichbaum, & Wyman, 2009). BPSD are also incredibly costly to society, as they account for 30% of the $277 billion total health costs for Alzheimer's disease in the United States (Alzheimer's Association, 2018;Schnaider Beeri, Werner, Davidson, & Noy, 2002).
Many pharmacologic treatments for BPSD have been shown to be ineffective and, in some cases, dangerous to people with dementia. For example, antipsychotics continue to be used as a primary treatment for severe agitation and psychosis in dementia; however, these medications have been shown to have limited efficacy and are linked to increased mortality rates in this population (Maust et al., 2015). Current FDA black box warnings caution against the use of all antipsychotics in older adults with dementia due to the increased risk of death (Jeste et al., 2008). Antianxiety medications such as benzodiazepines, which are also commonly used for BPSD management, are associated with worsening cognitive function and with increased falls and fractures in older adults (Defrancesco, Marksteiner, Fleischhacker, & Blasko, 2015;Van Strien, Koek, Van Marum, & Emmelot-Vonk, 2013). Additionally, use of antidepressant medications have been linked to increased risk for suicide in this population (Seyfried, Kales, Ignacio, Conwell, & Valenstein, 2011).
Due to the dangers associated with psychotropic medications in older adults with dementia, recent practice guidelines and recommendations encourage the use of non-pharmacologic interventions for BPSD (Austrom, Boustani, & LaMantia, 2018;Reus et al., 2016). BPSD impact not only the individual with dementia but also their family, friends, health care providers, and society. There is an urgent need for safe and effective alternative treatments for BPSD for family members, caregivers, nurses, and clinicians to better manage these burdensome symptoms in people with dementia. Acupuncture and acupressure present as possible non-pharmacologic therapies for BPSD management.
Acupuncture is a non-pharmacologic treatment that is based in traditional Chinese medicine, which emerged in China as early as the first century bc. The traditional theory of acutherapy is based on scientifically non-detectable energy pathways called meridians that are interconnected throughout the body, and thousands of acupoints that are along these pathways can be stimulated (using needles, manual hand pressure, or electrical stimulation) to correct various disturbances in the harmony of the body (Kaptchuk, 2002). Acupuncture uses thread-like needles to stimulate acupoints, while acupressure uses hands or objects to apply manual pressure to stimulate acupoints. Acutherapy has been integrated into Western medicine throughout the late twentieth century (Vickers, 1998), and it has been found to be a safe and effective treatment option for a number of symptoms/ diseases such as chronic pain, migraines, depression, anxiety, and weight loss. (Amorim et al., 2018;Kim, Shin, & Park, 2018;Lee & Ernst, 2011;Wu, Yeung, Schnyer, Wang, & Mischoulon, 2012).
The understanding of acutherapy has been transformed to a less mysterious, more quantifiable science based on replicable randomized controlled trials and functional magnetic resonance imaging (fMRI) studies. MRI studies have demonstrated how the stimulation of certain acupoints result in the activation of corresponding areas of the brain (Fang, Krings, Weidemann, Meister, & Thron, 2004). The exact mechanism of action of acutherapy is not fully understood, but is thought to stimulate the central nervous system through the release of specific neurotransmitters and hormones. It is speculated that the specific pathways, neurotransmitters, and hormones involved are distinct for different symptoms and disease states (Han, 2003;Kou et al., 2017;Li et al., 2013).
Acupuncture and acupressure have been studied in persons with Alzheimer's and/or vascular type dementias. A systematic review by Zhou, Peng, Xu, Li, and Liu (2015) supports that acupuncture is a safe and reliable non-pharmacologic therapy for improving cognitive function in people with dementia. This systematic review supports that acupuncture is a safe intervention for people with dementia with few adverse effects and that participants often report high satisfaction with the treatments. In addition, MRI studies demonstrate activation of areas of the brain responsible for cognitive function in people with dementia with the use of acupuncture (Shan et al., 2018;Z. Wang et al., 2012).

Purpose
Despite these encouraging findings, the effects of acupuncture and acupressure on BPSD specifically remain understudied. To date, no review exists on acupuncture and/or acupressure specifically for BPSD. The purpose of this review was to identify, examine and summarize the science relating to the effects of acupuncture and acupressure therapy on BPSD. The research question guiding this review was, "What are the effects of acupuncture and acupressure therapy on the behavioral and psychological symptoms in persons with dementia?"

Methods
This review was guided by the scoping review methodology outlined by the Joanna Briggs Institute Reviewers' Manual , which is based on the scoping review frameworks of Arksey and O'Malley (2005), and Levac, Colquhoun, and O'Brien (2010).
A scoping review framework uses a systematic approach to identify, examine, and summarize available evidence and to identify gaps in knowledge (Arksey & O'Malley, 2005). Prior to this review, it was unknown as to what evidence was available regarding acutherapies for managing BPSD, and what their effectiveness was. A scoping review is useful when the state of the science is emerging, as it allows for a broad view of the nature and range of evidence on the given topic area (Munn et al., 2018). Unlike a systematic review, a scoping review framework would allow for greater breadth and inclusion of all pertinent research regarding acupuncture and/or acupressure for BPSD, irrespective of quality (Peters, Godfrey, et al., 2015). This approach also enables identification and examination of gaps in the evidence, which would be useful to this emerging area of study.

Eligibility Criteria
Studies were included that consisted of participants with a diagnosis of dementia. Alzheimer's disease and vascular dementia are the two most common types of dementia and were expected to be the most prevalent dementia diagnoses in this review; however, some studies did not specify the type of dementia of the participants in the study. As the characteristics of the participants and settings were similar among all studies, despite whether they reported dementia type or not, studies were not excluded for not specifying dementia type.
The included studies examined the use of acupuncture and/or acupressure therapy. The studies could use multimodal interventions, but acupuncture or acupressure treatment had to be included. Because the aim of this review was to explore the effects of acupuncture or acupressure therapy on BPSD rather than cognitive function, at least one behavioral or psychological symptom needed to be included as an outcome of interest in the studies to be included in this review. Studies evaluating activities of daily living (ADLs) as an outcome were also included, as BPSD are often marked by increased ADL dependence and poor hygiene (Kar, 2009). Studies that only evaluated cognitive function or no BPSD were excluded.
Included studies had to be published in the English language, as the reviewer was only proficient in English. Studies were excluded that only contained partial English translations. As acupuncture therapy is rooted in traditional Chinese medicine, studies could be conducted within or outside of the United States. No exclusion criteria were applied to the setting of the studies; for example, they could be conducted in acute care, primary care, and/or community settings.
Due to the scope of the project and the need for feasibility, gray literature such as dissertations/theses, conference reports and proceedings, and white papers were excluded. In addition, commentaries, opinion pieces, and letters to the editor were also excluded as they provided little support relevant to the research question. Reviews and meta-analyses that did not include BPSD were also excluded.
A broad range of study designs were included, due to the potential paucity in high quality research studies and unknown state of the science on acupuncture and acupressure therapy for BPSD in those with dementia. Studies were also not excluded based on the date of publication, as to not limit studies that may add historical value to the research question.

Search Strategy
An initial search was done using the MEDLINE database to briefly review the topic of interest, as to ensure no review had been done on the topic already. This was also done to gain a better understanding of keywords to be used in a more systematic search.
A systematized search strategy was then created and conducted. University of Michigan Health Science Library informationalists were involved and provided expertise in creating and conducting the search. Five databases were used in the search strategy and included the following: PubMed, CINAHL, Embase, PsycINFO and AgeLine. Search terms and keywords, along with how they were combined for the database searches are outlined in Table 1. BPSD were not included in the database search, as this concept involves a wide range of examples and could result in excluding relevant studies if a specific BPSD or synonym was not included in the database search. For this reason, the inclusion and exclusion criteria were applied to this concept during the review of titles/abstracts and of full text articles.

Data Management
A review of titles/abstracts and full text articles was conducted by a primary reviewer (M. Harris). Studies that seemed uncertain in regards to inclusion and exclusion criteria were discussed with authors L. Struble and M. Titler until a consensus was reached. Data was extracted pertaining to reference title, author, year, sample characteristics (size, dementia types, and dementia severity), study location, study design, acutherapy intervention procedures, BPSD examined, and other outcomes, adverse effects of interventions, and significant results relating to BPSD. Data extraction was conducted by the primary author (M. Harris). These data were charted in an ongoing, iterative manner in tables, which were then shared and discussed among the review team to synthesize the findings. Figure 1 provides a PRISMA diagram outlining the results of the search process. Database searches were conducted between October 2 through October 19, 2018. All article citations were downloaded to EndNote X8. The total number of citations from the database search was 1,178. EndNote X8 was used to filter duplications, which left a total of  836 citations to be reviewed by title and abstract. Common reasons for exclusion at the title and abstract screening phase were studies that evaluated alternative treatments, but did not include acupuncture or acupressure therapy and studies that did include a BPSD. Fifty-seven articles were then reviewed by full-text. Articles were excluded for the same reasons as the title and abstract review. In addition, some studies were only commentaries (n = 6), one study was a report on a not yet completed study, one study was a conference abstract, and several articles reported on the same study, but in different journals (n = 11). Ultimately, 15 articles were included based on the inclusion and exclusion criteria. The final step of the search was a review of the references of the included studies, no new studies were found.

Summarized Findings
The final 15 studies from the search are summarized in Tables 2 and 3. Categories used for data extraction of articles include authors, sample size, study location and design, acutherapy intervention procedures used, BPSD outcomes examined, and findings related to the targeted BPSD. Data specific to cognitive function and cognitive impairment severity are included in Table 4.

Participants, Diagnoses and Severity
A total of 1,154 participants were included in the 15 studies. Four studies included participants with Alzheimer's disease (Jia et al., 2017;Simoncini et al., 2015;Sutherland et al., 1999;Y. Wang et al., 2014), while two studies included participants with vascular type dementia (Shi et al., 2012(Shi et al., , 2015 and the remainder of the articles did not specify the type of dementia. Fifty-seven percent of the participants were female, although two studies did not report the gender of participants (Simoncini et al., 2015;Sutherland et al., 1999). The reported age range of participants in all studies was 50-96 years. Table 4 summarizes severity of cognitive impairment and measures for the 12 studies reporting cognitive function of participants at baseline (Fung & Tsang, 2018;Jia et al., 2017;Kwan et al., 2016Kwan et al., , 2017Kwok et al., 2013;Lin et al., 2009;Lombardo et al., 2001;Rodríguez-Mansilla et al., 2015;Shi et al., 2012Shi et al., , 2015Simoncini et al., 2012Simoncini et al., , 2015Y. Wang et al., 2014). The Mini-Mental Status Exam (MMSE) and the Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog) were the tools used across the studies, with the MMSE used most frequently. The MMSE scores range from 0 to 30. MMSE scores greater than 25 indicate no cognitive impairment, 19-23 mild cognitive impairment, 10-18 moderate cognitive impairment, and ≤ 9 severe cognitive impairment (Folstein, Folstein, & McHugh, 1975). The ADAS-Cog subscale scores range from 0 to 70, with higher scores indicative of greater impairment (Rosen, Mohs, & Davis, 1984).

Intervention Procedures
Intervention procedures varied widely among the 15 studies (See Tables 2 and 3). Two studies used acupressure or acupuncture treatments in combination with medication (donepezil) for improving memory in dementia (Jia et al., 2017;Y. Wang et al., 2014). Three studies used multi-modal treatments that involved acupressure therapy in combination with another alternative treatment, such as massage, ontessori-based activities, and aromatherapy. (Fung & Tsang, 2018;Lin et al., 2009;Yang et al., 2015).
Duration of treatment sessions differed throughout the studies, while some studies did not report duration. There was also a variation in the acupuncture points selected for each intervention method. Some studies reported the specific acupoints used, while others did not. Only one study examined optimal dosage of acutherapy for BPSD by evaluating what dosage and frequency yielded the most significant effect on agitation in people with dementia. The optimal dosage of acupressure therapy for agitation was determined to be twice a day for two weeks (Kwan et al., 2016). The findings of this pilot study were then used in a larger RCT (Kwan et al., 2017).
Six studies included agitation as an outcome measure, and all demonstrated significant improvements in agitation scores after the acupuncture or acupressure therapies (Fung & Tsang, 2018;Kwan et al., 2016Kwan et al., , 2017Lin et al., 2009;Yang et al., 2015;Yang et al., 2007). The Cohen-Mansfield Agitation Inventory was used as a measurement tool for agitation in five studies and has good reliability in people with dementia (Cohen-Mansfield, 1986).
Three studies evaluated anxiety as an outcome (Lombardo et al., 2001;Rodríguez-Mansilla et al., 2015;Simoncini et al., 2015) and two found significant improvement. The study that did not demonstrate improvement in anxiety attributed it to many participants with low anxiety at baseline (Simoncini et al., 2015). The Spielberger State-Trait Anxiety Inventory was used in two studies; it is known to have a demonstrated bias of increased anxiety for geriatric adults, which may be confounded by a decreased well-being in this population (Kvaal, Laake, & Engedal, 2001). The Campbell scale was used in one study (Rodríguez-Mansilla et al., 2015); the validity and reliability of this measure in the geriatric or dementia population is unknown. The outcome of depression was measured in two studies (Lombardo et al., 2001;Rodríguez-Mansilla et al., 2015), both of which reported significant improvement in depression scores after the acupuncture or acupressure intervention. The Cornell Scale for Depression in Dementia (CSDD)-a tool that is commonly used to measure depression in people with dementia and validated for this population (Alexopoulos, Abrams, Young, & Shamoian, 1988) -was used to measure depression.
Mood was an uncommon outcome measure and was only examined in one study. This variable was measured using the Profile of Mood States (POMS) instrument (Lombardo et al., 2001). This study did see an improvement in the POMS scores. The validity of this tool has been established in an older adult sample; however, this sample did not include people with cognitive impairment (Kaye et al., 1988).
Neuropsychologic disturbances were examined in three studies (Fung & Tsang, 2018;Jia et al., 2017;Simoncini et al., 2015). The study by Jia et al. did not demonstrate significant improvement in this outcome variable; however, it did demonstrate significant improvement in cognitive function measures after the intervention (2017). The Neuropsychiatric Inventory was used to measure neuropsychological disturbances in all three studies. This tool is widely used for persons with dementia, and has been shown to have high inter-rater reliability and consistency (Cummings et al., 1994). This scale measures a wide array of symptoms including hallucinations, delusions, agitation/aggression, dysphoria/depression, anxiety, irritability, disinhibition, euphoria, apathy, and aberrant motor behavior.
Finally, sleep disturbance was included as an outcome in two studies (Kwok et al., 2013;Simoncini et al., 2015). Both studies demonstrated improvement in the sleep post-intervention. Wrist actigraphy was used in one study (Kwok et al., 2013), while the Pittsburgh Sleep Quality Index (PSQI) was used in the other (Simoncini et al., 2015). The PSQI has been used in a nursing home population and is showed to have good reliability scores; however, the sample included only cognitively intact residents (Gentili, Werner, Kuchibhatla, & Edinger, 1995). Limited information was found on the reliability in people with dementia.
Six studies included physiologic outcome measures. Kwok et al. included wrist actigraphy to measure sleep/rest cycles (2013). The 2012 study by Shi et al. included urine samples to detect an oxidative marker indicative of DNA damage. Kwan et al. (2016Kwan et al. ( , 2017 used salivary cortisol samples to evaluate stress. The results of these studies indicated the acupressure treatment group had a significant reduction in salivary cortisol levels, suggesting a reduction in stress.

Safety
No adverse effects were reported in the 15 studies. One acupuncture study reported that 10.8% of participants experienced punctate hemorrhage when acupuncture needles were withdrawn (bleeding stopped within 5-10 seconds of holding dry, sterile cotton to the sites) (Jia et al., 2017). Another study stated that 25% of participants reported mild discomfort at the acupoint sites during treatments and 20% experienced mild bruising (Shi et al., 2015). These side effects were reported as non-significant in both studies.

Discussion
The results of this review suggest that acupuncture and acupressure therapy have the potential to improve BPSD. All 15 of the studies indicated the safety and overall satisfaction of acupuncture and acupressure treatments in individuals with dementia. All of the studies demonstrated statistically significant (p < 0.05) improvements in at least one targeted BPSD outcome, except for two of the acupuncture studies. The two studies that did not demonstrate improvements in the BPSD of interest did report significant improvements in other important outcomes, including cognitive function outcomes and quality of life (Jia et al., 2017;Shi et al., 2012). There is an ongoing need for safe and effective non-pharmacologic treatment options for BPSD for individuals in all stages of the disease. Findings relating to cognitive impairment severity across studies suggest that these therapies are feasible and safe for individuals with mild, moderate, and severe cognitive impairment. The significant BPSD findings suggest that these interventions may be reasonable options for BPSD management. Acupuncture and acupressure offer an area for further scientific and practical examination for treating BPSD.
Although the findings were encouraging, due to variations in study designs and measures, as well as incomplete explanations of intervention procedures (such as use of specific acupoints, acutherapy dose, and who carried out the interventions), it is difficult to determine exact conclusions about the efficacy of these therapies. Given the methodological flaws in these studies, including the limited theoretical basis for the interventions and symptoms, differences in measures, variations in study designs and intervention dosage, and overall limitations in internal and external validity, there remains a gap in the knowledge and quality of evidence needed to use acupuncture and acupressure for BPSD.
There is a need for additional research evaluating the use of acupuncture and acupressure, specifically in countries with a Westernized approach to medical care where acutherapy is not as widely used. The majority of the studies were conducted in China, as acutherapy is rooted in theories of traditional Chinese medicine; however, acupuncture and acupressure have the potential to expand the understanding and treatment of many diagnoses and symptoms in Western society. Therefore, additional studies conducted in Western health care systems are needed to support the generalizability of acupuncture and acupressure treatments for BPSD.
Many families, caregivers, and friends of diagnosed individuals strive to keep the person with dementia living in the home setting, as this is where they feel most safe, secure, and comfortable. In fact, the majority of individuals diagnosed with dementia reside in the home with family caregivers (Alzheimer's Association, 2018). BPSD are often distressing to family members and friends and can become unmanageable, which can lead to early placement to long-term care settings. Despite the impact that BPSD have on home-dwelling individuals with dementia and their family caregivers, the majority of the studies (n = 10/15) were conducted in long-term care facilities. Additional research is needed to evaluate the feasibility of applying these interventions in the home. Furthermore, as family caregivers often play a pivotal role in directing care for their loved ones with dementia, it is important for future research to address the perceptions of family caregivers regarding use of acutherapy as a complementary symptom management strategy. To our knowledge, no studies have examined family caregivers' perceptions regarding use of these therapies. Acupuncture and acupressure have the potential to improve the quality of life of those with dementia and their family caregivers', which could ultimately reduce the risk of long-term care placement.
Acupuncture is often performed by licensed acupuncturists, and state-level regulations may require acupuncturists to work under the supervision of a medical doctor, which can be a limitation for applying this intervention in the home.
Alternatively, this review supports that acupressure can feasibly be performed by a non-professional, given adequate training and education. Acupressure presents as an opportunity to support informal caregivers (such as family members and friends) in having complementary treatment options for better managing BPSD.
Due to the limited efficacy of psychotropic medications in this population, there is an ever-increasing need for complementary treatment options for nursing staff and health care providers to better care for people with dementia. Nurses play a critical role in being educated on and educating others on these alternative treatments for distressing symptoms of dementia, especially due to the vulnerability of this population that has few other effective pharmacologic treatment options. Acupuncture and acupressure therapies represent promising treatment options for nursing staff to implement in a number of settings including long-term care facilities, memory care units, inpatient geriatric-psych units, and medical units that provide care to people with dementia. There is a need to examine the feasibility of formal caregivers in providing acutherapy to people with dementia. Additionally, an evaluation of the costs and benefits is needed to further support the organizational use of these interventions in such settings. This is especially significant as nursing staff are in a meaningful position to incorporate these interventions into many areas of practice.
From an organizational perspective, many national and state-level entities exist to educate health care professionals, family members, friends, and those diagnosed with dementia regarding BPSD management techniques. These organizations can empower health care professionals and families with knowledge regarding these complementary therapies in times when other, more traditional approaches, such as psychotropic medications fail, or when they cause more harm than healing. Organizations such as the Alzheimer's Association and the Alzheimer's Foundation of America present as significant opportunities to promote education for informal and formal caregivers alike regarding alternative and complementary approaches to dementia symptom management.
The policy implications of this work are based on the fact that national programs, such as Medicare, currently cover pharmacologic interventions for dementia care; however, there is limited and/or conditional coverage for nonpharmacologic therapies and psychiatric care. As the evidence for non-pharmacologic treatments continues to grow, there will be a need for policymakers to advocate for better coverage for these treatments.
Behavioral and psychological symptoms are highly prevalent in persons with dementia. They can be physically and mentally devastating to the person with dementia, as well as the caregiver. BPSD ultimately threatens a person's ability to remain in the home, resulting in negative effects on society due to increased health care utilization and cost. Due to the increased susceptibility to adverse effects of pharmacologic treatment in this population, there is an ever-increasing need to include complementary therapies in the management of BPSD.
In conclusion, this review evaluated the current research relevant to acupuncture and acupressure treatments for BPSD. Fifteen studies were included in the final review, and findings tended to be in support of acupuncture and acupressure for symptoms such as agitation, anxiety, ADL function, sleep, mood, depression, and neuropsychological disturbances. Limitations in study designs, intervention procedures, and outcome measures limit the interpretations regarding efficacy of acupuncture and acupressure for BPSD. Additionally, concerns relating to generalizability limit the ability to make broad statements in support of the use of acutherapy in practice. It is recommended that additional rigorous research and randomized controlled trials be conducted to further examine the efficacy of these therapies in Western health care systems and in settings other than long-term care. Nurses play a critical role in promoting the use of non-pharmacologic treatments for BPSD management. Having multiple treatment options is necessary for improving the health and wellness in patients with dementia. Acupuncture and acupressure present as promising therapies for improving distressing BPSD; however, further research is needed to determine efficacy and promote generalizability.