The DICE Approach™

DICE logoDr. Helen Kales’ research group has led the psychiatric field in understanding the risks of using antipsychotic and other psychiatric medications in people with dementia. As a result, Dr. Kales (a fellowship-trained, board certified geriatric psychiatrist) realized that it was not enough to simply tell providers, staff and family caregivers to avoid use of these medications. Behavioral and psychological symptoms of dementia (BPSD) include agitation, aggression, depression, apathy, repetitive questioning, sleep problems and wandering. One or more behaviors will affect nearly every person with dementia over the course of their illness, causing one of the most difficult, stressful and costly aspects of care, and oftentimes, stress and depression in caregivers. It is imperative to help caregivers (both formal and informal) better understand and identify the underlying causes of BPSD, and provide them with tools to manage these symptoms by dealing with the underlying problem, using evidence-based behavioral and environmental strategies, rather than resorting to the knee-jerk use of medications. Teaching caregivers how to use simple techniques (such as improving communication, creating meaningful activities, simplifying tasks, establishing structured routines, ensuring safety, and simplifying and enhancing the environment) can reduce behaviors and improve caregiver quality of life.


The DICE Approach was developed by a national group of experts led by Dr. Kales, in collaboration with Constantine G. Lyketsos, MD, and Laura N. Gitlin, PhD from Johns Hopkins University. It represents a simple but comprehensive method toward understanding and managing problem behaviors. Panel members with clinical and research expertise in managing behavioral symptoms of dementia from the following disciplines participated: geriatric medicine, geriatric psychiatry, geriatric psychology, nursing, social work, pharmacy and behavioral science. This group created an algorithmic approach toward assessment and management of BPSD called DICE which stands for Describe, Investigate, Create and Evaluate. The DICE approach is an adaptation of the clinical reasoning process used by geriatric psychiatrists to assess and manage BPSD as well as underlying numerous randomized trials involving behavioral management skills training for family caregivers.

State of DICE and Further Development in this Project

Since its publication in 2014, the DICE approach has received national (e.g. San Diego county has adopted DICE as its evidence based approach) and international (e.g. use in Canadian nursing homes, UK care homes) adoption and acclaim. Notably, current national and international adoption of DICE is based upon our published approach and various groups’ interpretations of it. The next step for the approach is to manualize it and develop accompanying official training.

In a currently funded Michigan Health Endowment Fund (MHEF) grant and related funding, we are conducting this work: 1) the creation of a training manual; 2) accompanying trainings including video vignettes 3) two in-person pilot trainings for formal and informal caregivers of people with dementia; and 4) for ultimate sustainability and dissemination the creation of a modular, interactive DICE training website.