Experts call for end to behavior-calming drugs for
Caregiver-based approaches would work better – if
they were used & paid for as often as anti-psychotic drugs targeted by
new federal report
March 5, 2015 - 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
The new DICE model - for Describe, Investigate,
Evaluate, and Create - seeks to reduce psychotropic medication use in
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
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
They lay out their findings along with a framework
that doctors and caregivers can use to make the most of what’s already
DICE for Describe, Investigate, Evaluate, and Create, the
framework tailors approaches to each person with dementia, and as
of the DICE approach are:
D: Describe -
Asking the caregiver, and the person with dementia 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 person’s
health, dementia symptoms, current medications and sleep habits, that
might be combining with physical, social and caregiver-related factors
to produce the behavior.
C: Create –
Working together, the patient’s caregiver and health providers develop a
plan to prevent and respond to behavioral issues in the person with
dementia, including everything from enhancing 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 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.”
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
But they also write, “drugs still have their place,
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 dementia patients with 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
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
● Simplifying tasks and establishing structured
● 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.
Kales, Gitlin and Lyketsos are
working with the
U-M Center for Health Communications Research to launch a National
Institute of Nursing Research-sponsored clinical trial this spring that
will test the DICE approach through a computer based tool for caregivers
called the WeCareAdvisor. The tool will help families identify tips and
resources in a single computer interface to address behavioral
symptoms. The tips are designed to prevent or mitigate possible
triggers for common behavioral symptoms such as pacing, repetitive
questioning, restlessness, or shadowing.
"Behavior-based strategies may take
longer than prescriptions. 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.” -- Helen
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
“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
More research on both new drug
options and the best ways to assess and address behavioral symptoms is
needed, the authors conclude. But in the meantime, the evidence to date
comes down in favor of non-drug approaches in most cases.
Funding: National Institutes of Health,
NR014200, Johns Hopkins Alzheimer’s Disease Research Center
Previous publication - the DICE model:
Journal of the American Geriatrics Society,
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