Alzheimer's, Dementia & Mental Health
Method to Better Manage Agitation, Aggression in
Dementia Patients Introduced
Technique called DICE helps manage the most troubling
symptoms of dementia, lessen use of drugs by building link between
caregivers, patients and health providers; recommended by Medicare
21, 2014 - A new approach to handling agitation, aggression and other
unwanted behaviors by people with dementia may help reduce the use of
antipsychotics and other psychiatric drugs in this population, and make
life easier for them and their caregivers, a team of experts says. It
has already become a part of Medicares recommended toolkit for carrying
for dementia patients.
Publishing their recommendations under the
easy-to-remember acronym of "DICE", the panel - all specialists in
senior mental health - hope to spark better teamwork among those who
care for dementia patients at home, in residential facilities and in
hospitals and clinics.
The federal agency that runs Medicare and funds
much dementia-related care has even made the DICE approach an official
part of its toolkit for reducing the use of antipsychotic drugs and
other mental health medications in people with dementia.
Though these drugs may still help some patients,
the new paper in the Journal of the American Geriatrics Society
says, many non-medication approaches could also help reduced unwanted
behaviors, also known as neuropsychiatric symptoms of dementia. But it
will take teamwork and communication to do it.
Most people with Alzheimer's disease and other
memory-affecting conditions also get aggressive, agitated, depressed,
anxious, or delusional from time to time, says senior author Helen C.
Kales, M.D., head of the U-M Program for Positive Aging and Geriatric
Psychiatry at the University of Michigan Health System and investigator
at the VA Center for Clinical Management Research. Or, they might have
delusions, hallucinations, or lose inhibitions.
"Often more than memory loss, behavioral symptoms
of dementia are among the most difficult aspects of caring for people
with dementia. These symptoms are experienced almost universally, across
dementia stages and causes," she says. "Sadly, these symptoms are often
associated with poor outcomes including early nursing home placement,
hospital stays, caregiver stress and depression, and reduced caregiver
Doctors often prescribe these patients medications
often used in patients with mental health disorders, despite little hard
evidence that they work well and despite the risks they can pose --
including hastening death. Meanwhile, studies have shown promise from
non-medication approaches to changing dementia patients' behavior and
reducing triggers for behavioral issues in their environment and daily
life. But too few health teams are trained in their use.
Kales and her colleagues Laura N. Gitlin, Ph.D. and
Constantine G. Lyketsos, M.D. from Johns Hopkins University authored the
new paper on behalf of a group of experts, called the Detroit Expert
Panel on the Assessment and Management of the Neuropsychiatric Symptoms
of Dementia, who developed the DICE approach.
Sponsored by Kales' program, the national
multidisciplinary panel of experts met in Michigan to create a
comprehensive approach to behavioral management.
Dubbed "DICE" for Describe, Investigate, Evaluate,
and Create, it details key patient, caregiver and environmental
considerations with each step of the approach and describes the "go-to"
behavioral and environmental interventions that should be considered.
Briefly described, the components are:
D: Describe - Asking the
caregiver, and the patient if possible, to describe the "who, what, when
and where" of situations where problem behaviors occur and the physical
and social context for them. Caregivers could take notes about the
situations that led to behavior issues, to share with health
professionals during visits.
I: Investigate Having the
health provider look into all the aspects of the patient's health,
dementia symptoms, current medications and sleep habits, that might be
combining with physical, social and caregiver-related factors to produce
C: Create Working
together, the patient's caregiver and health providers develop a plan to
prevent and respond to behavioral issues in the patient, including
everything from changing the patient's activities and environment, to
educating and supporting the caregiver.
E: Evaluate Giving the
provider responsibility for assessing how well the plan is being
followed and how it's working, or what might need to be changed.
The authors say that doctors should prescribe
psychotropic drugs only after they and the patient and caregiver have
made significant efforts to change dementia patients' behavior through
environmental modifications and other interventions, with three
exceptions related to severe depression, psychosis or aggression that
present risk to the patient or others.
Now, the authors say, health providers of all kinds
who care for dementia patients should familiarize themselves with the
DICE approach as should the spouses, adult children and others who
care for dementia patients at home.
"Innovative approaches are needed to support and
train the front-line providers for the burgeoning older population with
behavioral symptoms of dementia," says Kales, a professor in the U-M
Medical School's Department of Psychiatry and member of the U-M
Institute for Healthcare Policy & Innovation. "We believe that the DICE
approach offers clinicians an evidence-informed structured clinical
reasoning process that can be integrated into diverse practice
Gitlin, who directs the Center for Innovative Care
in Aging at the Johns Hopkins School of Nursing, adds, "The DICE
approach is inherently patient- and caregiver-centered because the
concerns of individuals with dementia and their caregivers are integral
to each step of the process. DICE also enables clinicians to consider
the roles of nonpharmacologic, medical and pharmacologic treatments
Lyketsos, chair of the Department of Psychiatry at
Johns Hopkins Bayview, stresses that the approach "has tremendous
utility in clinical trials of treatments for behavioral symptoms,
particularly in testing new medications. DICE can be used to better
subtype behaviors, or focus on particular behaviors at randomization
coupled with systematic treatment approaches".
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