The DICE Approach: How Can It Help?

DICE is another way to examine and treat certain behaviors associated with Parkinson's disease (PD). It is a joint effort between caregivers and doctors to identify what factors may contribute to the onset or magnitude of some non-motor PD behaviors. DICE is an acronym that stands for Describe, Investigate, Create, and Evaluate. This article will describe why it is effective and how it can be used. DICE is an approach you can discuss with your doctor to see if it is appropriate for your situation.

Cognitive & behaviorial issues in Parkinson's

Parkinson's disease is generally characterized as a motor disorder. Yet cognitive and behavioral dysfunction may create substantial challenges for some individuals with Parkinson's, their families and caregivers. Traditional treatment for psychological and behavioral issues has been to prescribe medications, which can diminish or alleviate symptoms. Yet research from the University of Michigan and Johns Hopkins University confirms that drugs are not necessarily the best treatment approach for non-cognitive neuropsychiatric symptoms.

Behavioral and psychological symptoms, such as aggression and depression can be the most difficult to manage. Because they are disruptive, often with physical and emotional consequences, they can lead to caregiver stress and increased frequency of PD hospitalizations, often resulting in early placement in a nursing home.1

Psychotropic medications are currently the most common approach to symptom management, but the DICE approach promotes alternatives that do not require drugs. DICE is "evidence-informed." It is a drug-free method based on training and instruction on how to collect information and report it to the medical team in order to customize an approach. This assists in identifying causes, triggers, and remedies for certain behaviors.

The DICE approach is for caregivers

DICE is an analytical process designed to help PD caregivers manage individual behavioral and psychological symptoms. Many caregivers of those with advanced PD or Parkinson's disease dementia (PDD) experience difficulties handling symptoms of aggression, wandering, refusing medications, and other forms of care. DICE teaches caregivers an approach to "give context to and identify the possible causes of these symptoms and behaviors."2 With these new skills, medical professionals have the ability to recognize and report contributing causes of disruptive behaviors. That allows them to create specific evidence-based strategies as part of an individually tailored plan to reduce or eliminate issues that arise.

Teamwork is important with the DICE approach

The DICE approach depends on teamwork. It can be taught so family and professional caregivers can learn to assess particular patient behavior, collecting information on circumstances in many different settings. It accounts for each individual's environment and the sharing of specific information to medical providers so that they can help develop the best possible treatment plan. Some of the DICE approach is likely already being used in caring for people with PD and dementia. Caregivers tend to note what conditions make symptoms better or worse. Simple strategies can be used on a regular basis to gain cooperation, improve communications and create a safe environment.4

Dementia is generally associated with cognitive symptoms. Some with PD or PDD experience behavioral and psychological symptoms, creating more disruptions for those people and their caregivers. Medical illness, environmental circumstances, as well as preexisting PD factors, can all contribute to developing these issues. This can result in deteriorating quality of life for both the patient and the caregiver.2

The DICE steps


The caregiver is taught how to describe symptoms and circumstances when and where they arise. Caregivers are also taught to think about and identify what happened before symptoms started (antecedents). Conditions often identified include, but are not limited to: irritability, anxiety, sleep problems, and apathy.2,4


Caregivers report back to the medical team on information collected. Clinicians then try to figure out underlying and modifiable causes, while also looking to see what information can be excluded as contributing factors.


This step is a collaboration between the patient, caregiver and medical provider to create a series of interventions in response to specific conditions. There can be different approaches based on psychological, medical or environmental symptoms or causes. Plans developed are not fixed; they can be modified based on positive or unsuccessful results.


The last step is to determine if tools developed and recommended were tried and done effectively, whether there was any noticeable improvement in targeted symptoms, and whether caregiver stress was reduced along with the changed behaviors. As caregivers learn what causes symptoms, they often become adept at spotting these triggers before the symptoms fully develop.

Why the DICE approach is helpful

DICE guides caregivers as they gain a better understanding of when and why certain behaviors occur. It helps to identify and target underlying causes and to use an evidence-based behavioral analysis approach. This includes environmental strategies to create an individualized approach to symptom management, when possible without drugs.

Individual symptoms change and fluctuate throughout the course of dementia. Effective use of DICE involves ongoing monitoring to see if some symptoms resolve, and whether new ones appear. Part of the evaluation also includes patient safety, level of caregiver distress, and review of strategies learned in the DICE process.4

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