Historically, the arts and humanities were seldom recognized for their capacity to advance health care and promote quality of life within the fields traditionally reserved for the “hard sciences.” There has been little vision of the powerful analytic and therapeutic applications offered by the myriad of art forms (Rugh & Buckwalter, 1989, unpublished manuscript). However, in recent years, we have seen an increased awareness of the potential value of music, art, and other recreational therapies in persons with dementia. A comprehensive literature review was conducted to identify the most current research in this area. Studies on the use of music and other recreational therapies in patients with dementia are summarized in Table 1.

Our top and middle management initially received thorough training in group theory and group management techniques for organizational reasons. In daily shift meetings, nurse aides (NAs) learn some of the techniques and approaches, translating part of them to work with patients. From the moment we started to focus on the day-care center patients as a group to be managed every minute, we found that disturbances decreased significantly (based on empiric assessment by staff).

This article addresses the following questions about the use of patient characteristics to determine nonpharmacologic interventions for behavioral and psychological symptoms of dementia (BPSD):

1. Why use patient characteristics to determine intervention?

2. How does individualization of treatment fit with the theory of BPSD?

3. What is known about individualization of the treatment of BPSD?

4. How can individualization of nonpharmacologic intervention work in clinical practice?

Appropriate treatment of patients with dementia must incorporate pharmacologic and nonpharmacologic therapies. This is especially true in the treatment of behavioral disturbances in patients with Alzheimer's disease (AD). However, few studies have either compared or combined pharmacologic and nonpharmacologic methods to evaluate treatments that are often used and thought to be clinically effective.

In his presentation, Dr. Burns discussed attributional style and emotional expressiveness as determinants of a caregiver's response to behavioral and psychological symptoms of dementia (BPSD). Dr. Hendrie asked whether attributional style reflected how caregivers felt not only about the patient's problems, but also about their own. Dr. Burns referred to ratings of relative causality, an indication of whether patients' relatives believed they may have contributed to symptoms in the patient or to their own symptoms, such as depression. However, Dr. Burns's studies did not specifically measure relative causality. Also, neither Dr. Burns nor others have studied attributional style and expressed emotion among paid caregivers, either those in private homes or in long-term care settings.

Increased international collaboration in clinical trials has created a need for scale translations and cross-culturally valid instruments. The use of scales that have been poorly translated and of translations that have not been validated can lead to erroneous results. Accordingly, the quality of studies using nonvalidated translations of scales from different cultural regions should be questioned. Scale translation is important, and it is surprising that little attention has been paid to the methodology of translating measurements and scales into other languages and validating them for different cultures, especially in psychiatric and geriatric research.

Race is a critical sociodemographic variable that may serve as a marker for genetic, clinical, cultural, and socioeconomic factors. There have been several studies that found differences between African Americans and Whites in the neuropsychiatric symptoms of dementia. There have been fairly consistent findings that psychotic symptoms—hallucinations and delusions—are more prevalent among African American patients with dementia (Cohen & Carlin, 1993; Cooper et al., 1991, Deutsch et al., 1991; Fabrega et al., 1988), and that depression is higher among Whites than among African Americans (Fabrega et al., 1988; Walker et al., 1995). One study by Class and colleagues (1996) also suggested that behavioral disturbances might be higher among White than among African American nursing home patients, a majority of whom had dementia.

Comparative cross-cultural studies represent a great opportunity for delineating risk factors for the dementias by providing a much wider diversity of both environmental exposures and genetic variation than studies within industrialized countries. Similarly, studies of the behavioral disturbances of dementia that allow for identification of similarities and differences may be useful both in understanding the etiology of these disorders and in determining the best approach to management. So far, few such comparative studies exist.

Alzheimer's disease (AD) and associated behavioral and psychological symptoms of dementia (BPSD) are already recognized as major medical problems of the aging population in the western world. Although BPSD are not yet regarded as a major issue in many developing countries, such as Turkey, these symptoms will undoubtedly become a management issue in the future. Because BPSD contribute most to caregiver burden and interfere with patients' well being, they are predictors of early institutionalization (Hamel et al., 1990). This article reviews the literature on BPSD in eastern and southeastern Europe and the Middle East.

Latin America has a connotation of youth (Mangone & Arizaga, 1999). Yet we cannot ignore the significant increase in life expectancy in many Latin American countries (Table 1); as the economy and level of education improve, so does the health of the population. With the increase in life expectancy, Latin Americans are beginning to perceive dementia in the elderly as a considerable social and medical problem.

The recognition of behavioral and psychological symptoms of dementia (BPSD) varies in Asian countries. In India, for example, symptoms such as repetition, forgetfulness, anxiety, and agitation are simply ignored in the rural setting and are of no concern to family members; other symptoms, such as wandering, are easily tolerated. This cultural acceptance of certain BPSD, combined with the difficulty in locating a physician skilled in the diagnosis and treatment of these symptoms, limits their assessment and treatment in India (International Psychogeriatric Association, 1998). Fortunately, in a few Asian countries, empiric data on the frequency of BPSD have been obtained using formal assessment instruments.

Seeking to explain the difference in the frequency of hallucinations between Afro-Caribbean and White patients with dementia, Dr. Holmes stated that genetic differences are the most obvious explanation. The frequency of the polymorphisms is increased among Afro-Caribbeans, which is reflected in the incidence of schizophrenia in this population. Dr. Holmes also mentioned that serotonin receptor polymorphisms affect binding capacity to the sites, and are instrumental in forming visual hallucinations. He speculated that researchers will find that the different frequencies of behavioral and psychological symptoms of dementia (BPSD) in different countries will be largely accounted for by genetic variation in a number of polymorphisms. However, he emphasized the importance of using the same methodology so that results can be compared across countries and cultures. Dr. Cohen agreed that researchers should be investigating potential genetic differences. How the genetic traits are linked to neuropsychiatric symptoms is an interesting question, and requires a great deal more research.