The Mother loved flowers, gardening and butterflies. She was a master shopper and enjoyed the hunt for a good sale. The first incident occurred in a butterfly exhibit. Butterflies were flying around them, landing on hair and bodies. She became agitated and wanted to leave immediately. Her family was puzzled at her response but left with her. 

The second incident occurred in a shopping mall. The Mother did not recognize the need for new clothes or how to try them on. Her behaviors continued to change in the coming months, and the family became increasingly concerned. The diagnosis of dementia was devastating, but even more devastating were the changes in her behaviors.

According to Dr. Helen Kales, there are an estimated 16 million informal (family or friend) caregivers of people living with dementia in the U.S., and those numbers will increase rapidly as baby boomers age.

While the public often thinks of dementia as a “memory disorder,” behavioral symptoms, including depression, anxiety, apathy, hallucinations, agitation, aggression and many more, almost universally accompany memory problems. One or more of these behaviors will affect nearly every person with dementia over the course of the illness, causing one of the most difficult, stressful and costly aspects of care — and often, stress, burden and depression in caregivers. 

These symptoms are most often treated with psychiatric medications. Still, in many cases, we are merely sedating the person with dementia rather than dealing with the problems and triggers underlying the behavioral symptom.

Recognizing this critical gap in care, Drs. Kales, Laura Gitlin and Constantine Lyketsos created and published The DICE Approach™ in 2014 as a research paper. The approach was designed to be an easy-to-use, step-by-step method for assessing and managing behaviors in dementia. 

DICE: Describe, Investigate, Create and Evaluate 


  • The first stage in the process involves asking the caregiver(s) to describe the who, what, where and when of situations in which behavioral problems occur. The goal is for clinicians to better understand the social and physical context surrounding the individual outbursts so everyone can get a clearer picture of the actions.


  • The next step involves having the clinician(s) look into all aspects of the individual’s health. This includes their dementia symptoms, sleep habits, current medications and so on. These are then compared to the physical and social factors that might combine to produce a certain set of behaviors.


  • Next, the caregiver and healthcare providers create a plan to prevent and respond to these behavioral issues when they arise. 
  • This step is really meant to serve as a brainstorming opportunity for more intensive interventions. Additionally, detailed plans are made so that environmental modifications can be made at home in order to enhance the individual’s quality of life from all angles.


  • Finally, continually assessing an individual’s improvements and outcomes to see if the given treatment plan is working as it should. If not, recommend changes to try to provide the best care possible.

The DICE Approach is a simple but systematic method crucial for understanding, assessing and managing behavioral and psychological symptoms in dementia (BPSD). It’s an adaptation of the reasoning process used by dementia behavior experts and has been proven effective in numerous research trials. As a caregiver, you are not just a passive observer but an active participant in implementing this approach, making your role integral to its success. 

The Mother who became afraid of butterflies was this author’s own mother. Her primary care providers did not know how to help with the changes in her behaviors. 

They, in essence, told us we were on our own. No family should be left to “figure it out.” The use of the DICE model needs to be implemented in all care settings. The training is free and it is a powerful tool for caregivers. 

Martie L. Moore, MAOM, RN, CPHQ, is the President/CEO of M2WL Consulting. She has been an executive healthcare leader for more than 20 years. She has served on advisory boards for the National Pressure Injury Advisory Panel, American Nurses Association, Dean’s Advisory Board at the University of Central Florida College of Nursing and Sigma, International Honor Society for Nursing. She was honored by Saint Martin’s University with an honorary doctorate degree for her service and accomplishments in advancing healthcare. She recently published “The Leadership Sandwich,” now available on Amazon.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.