From University of Michigan Health Systems News:
Time to “just say no” to behavior-calming drugs for Alzheimer patients? Experts say yes
Caregiver-based approaches would work better – if they were used & paid for as often as anti-psychotic drugs targeted by new federal report
ANN ARBOR, Mich. — Doctors write millions of prescriptions a year for drugs to calm the behavior of people with Alzheimer’s disease and other types of dementia. But non-drug approaches actually work better, and carry far fewer risks, experts conclude in a new report.
In fact, non-drug approaches should be the first choice for treating dementia patients’ common symptoms such as irritability, agitation, depression, anxiety, sleep problems, aggression, apathy and delusions, say the researchers in a paper just published by the British Medical Journal.
The best evidence among non-drug approaches is for those that focus on training caregivers — whether they are spouses, adult children or staff in nursing homes and assisted living facilities — to make behavioral and environmental interventions.
The researchers, from the University of Michigan Medical School and Johns Hopkins University, reviewed two decades’ worth of research to reach their conclusions about drugs like antipsychotics and antidepressants, and non-drug approaches that help caregivers address behavioral issues in dementia patients.
They lay out their findings along with a framework that doctors and caregivers can use to make the most of what’s already known. Called DICE for Describe, Investigate, Evaluate, and Create, the framework tailors approaches to each person with dementia, and as symptoms change.
“The evidence for non-pharmaceutical approaches to the behavior problems often seen in dementia is better than the evidence for antipsychotics, and far better than for other classes of medication,” says first author Helen C. Kales, M.D., head of the U-M Program for Positive Aging at the University of Michigan Health System and investigator at the VA Center for Clinical Management Research. “The issue and the challenge is that our health care system has not incentivized training in alternatives to drug use, and there is little to no reimbursement for caregiver-based methods.”
Coincidentally, a new U.S. Government Accountability Office report published the same day as the BMJ paper addresses the issue of overuse of antipsychotic medication for the behavior problems often seen in dementia. It finds that one-third of older adults with dementia who had long-term nursing home stays in 2012 were prescribed an antipsychotic medication — and that about 14 percent of those outside nursing homes were prescribed an antipsychotic that same year.
The GAO calls on the federal government to work to reduce use of these drugs further than it’s already doing, by addressing use in dementia patients outside nursing homes.
Kales, however, cautions that penalizing doctors for prescribing antipsychotic drugs to these patients could backfire, if caregiver-based non-drug approaches aren’t encouraged.
She and her colleagues from Johns Hopkins, Laura N. Gitlin PhD and Constantine Lyketsos MD, note in their paper that “there needs to be a shift of resources from paying for psychoactive drugs and emergency room and hospital stays to adopting a more proactive approach.”
The authors lay out five non-pharmacologic categories to start with based on their review of the medical evidence. These approaches have been shown to help reduce behavior issues:
- Providing education for the caregiver
- Enhancing effective communication between the caregiver and the person with dementia
- Creating meaningful activities for the person with dementia
- Simplifying tasks and establishing structured routines
- Ensuring safety and simplifying and enhancing the environment around the patient, whether in the home or the nursing/assisted living setting
They also note that many “hidden” medical issues in dementia patients – such as urinary tract infection and other infections, constipation, dehydration and pain – can lead to behavioral issues, as can drug interactions. So physicians should look to assess and address these wherever possible.
For instance, de-cluttering the environment, using music or simple activities that help to engage a person with dementia , or using a calm voice instead of being confrontational, could help greatly to reduce behavioral symptoms, Kales says. And making sure that caregivers get breaks from their responsibilities and take care of themselves, especially in the home, can help them avoid burnout and taking their frustration out on patients.
“Behavior-based strategies may take longer than prescriptions,” acknowledges Kales, a member of the U-M Institute for Healthcare Policy and Innovation. “But if you teach people the principles behind DICE, the approach becomes more natural and part of one’s routine. It can be very empowering for caregivers or nursing home staff.”