While millions of prescriptions per year are written for drugs to calm the behavior of people with Alzheimer’s disease and other types of dementia, nonpharmacologic approaches may work better and carry far fewer risks, according to a report published online ahead of print March 2 in BMJ.
Nonpharmacologic approaches should be the first choice for common symptoms such as irritability, agitation, depression, anxiety, sleep problems, aggression, apathy, and delusions in patients with dementia, according to the authors. The best evidence supports nonpharmacologic approaches that focus on training caregivers—whether they are spouses, adult children, or staff in nursing homes and assisted living facilities—to perform behavioral and environmental interventions.
Evidence-Based Recommendations
Researchers from the University of Michigan Medical School in Ann Arbor and Johns Hopkins University in Baltimore reviewed two decades’ worth of research to reach their conclusions about drugs like antipsychotics and antidepressants and nonpharmacologic approaches that help caregivers address behavioral problems in patients with dementia. Their report describes their findings, along with a framework that doctors and caregivers can use to take advantage of current medical understanding. The Describe, Investigate, Create, and Evaluate (DICE) framework enables physicians to tailor approaches to individual patients and to changing symptoms.
“The evidence for nonpharmaceutical approaches to the behavior problems often seen in dementia is better than the evidence for antipsychotics, and far better than [that] for other classes of medication,” said lead author Helen C. Kales, MD, Head of the University of Michigan Program for Positive Aging at the University of Michigan Health System and an investigator at the VA Center for Clinical Management Research in Ann Arbor. “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.”
Corroborating Evidence From Government Report
A US Government Accountability Office (GAO) report published the same day as the BMJ paper addressed the overuse of antipsychotic medication for the behavior problems often seen in dementia. It found that one-third of older adults with dementia who had long-term nursing home stays in 2012 were prescribed an antipsychotic, and that about 14% of older adults with dementia outside nursing homes were prescribed an antipsychotic that same year.
The GAO called on the federal government to reduce the use of these drugs by expanding its outreach and educational efforts. Specifically, the office asked the government to reduce antipsychotic drug use among older adults with dementia who reside outside of nursing homes.
Dr. Kales, however, cautioned that penalizing doctors for prescribing antipsychotic drugs to these patients could backfire if caregiver-based nonpharmacologic approaches are not encouraged. She, Laura N. Gitlin, PhD, Director of the Center for Innovative Care in Aging at Johns Hopkins University, and Constantine Lyketsos, MD, Elizabeth Plank Althouse Professor and Chair of Psychiatry at Johns Hopkins Bayview in Baltimore, noted in their BMJ 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.”
Complementary Approaches
“Drugs still have their place,” the authors noted, “especially for the management of acute situations where the safety of the person with dementia or family caregiver may be at risk.” For instance, antidepressants make sense for patients with dementia and severe depression, and antipsychotic drugs should be used when patients have psychosis or aggression that could lead them to harm themselves or others. But these uses should be closely monitored and ended as soon as possible.
The authors laid out five first-line nonpharmacologic approaches based on their review of the medical evidence. The following approaches have been shown to help reduce behavior problems:
• Provide education for the caregiver.
• Enhance effective communication between the caregiver and the person with dementia.
• Create meaningful activities for the person with dementia.
• Simplify tasks and establish structured routines for the person with dementia.
• Ensure safety and simplify and enhance the the patient’s environment, whether it be the home or the nursing or assisted living setting.
Many “hidden” medical issues in patients with dementia (eg, urinary tract infection and other infections, constipation, dehydration, and pain) can lead to behavioral problems, as can drug interactions, the authors noted. Physicians should assess and address these problems wherever possible.
Drs. Kales, Gitlin, and Lyketsos are working with the University of Michigan’s Center for Health Communications Research to begin a clinical trial in spring 2015 that will test the DICE approach through a computer-based tool for caregivers called the We- CareAdvisor. The tool will help families identify tips and resources in a single computer interface to address behavioral symptoms. The tips are designed to avoid or mitigate the effects of possible triggers for common behavioral symptoms such as pacing, repetitive questioning, restlessness, or shadowing.