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Just say no to Alzheimer’s drugs?

By Kara Gavin
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A new approach to Alzheimer’s treatment

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.

Are antipsychotic drugs more dangerous to dementia patients than we think? Read more.
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 published March 2 by the British Medical Journal (BMJ).

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.

A tailored framework

The components of the DICE approach:

  • 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 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, Create, and Evaluate — 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, MD, 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.

Adopting a more proactive approach

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.”

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 possible.

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.

Testing the DICE approach

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.

“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, 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.”

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.

This story appears courtesy of the University of Michigan Health System.

  • Reference: BMJ 2015; 350 doi: http://dx.doi.org/10.1136/bmj.h369 (Published 02 March 2015)
  • Funding: National Institutes of Health, NR014200, Johns Hopkins Alzheimer’s Disease Research Center (P50AG005146).
  • Previous publication – the DICE model: Journal of the American Geriatrics Society, April 2014. Paper | Press release
Kara Gavin

Kara Gavin

KARA GAVIN is a science/medical writer, media relations officer and communications adviser in the public relations and marketing communications department of the U-M Health System. She stepped back into this role in March 2012 after several years as PR director. Gavin also a founding member, executive committee member, and French horn player with the U-M Life Sciences Orchestra. Follow her on Twitter: @karag.

COMMENTS

  • Ebba Sayre - 1957

    The training of caregivers first is essential. Where are those caregivers?
    (Generally raising families and working long hours with little chance of
    time out.) Good luck with the project. It certainly is needed. Both my Mom
    and Mother-in-law had alzheimers. (We had their brains biopsied.)

    Family medical leave once actually adopted could relieve some of the
    situation until care is in place. I took a part-time teaching position to be
    with my mother-in-law. A caregiver support network would have helped.
    She ultimately spent over 10 years in a nursing home.

    Reply

  • Barbara Goldoftas - 1978

    Thank you for this important article and also for the beautiful photograph accompanying it.

    Reply

  • Dr. Gloria D. Gibson - 1995

    FINALLY… a manifesto to what I’ve been practicing and advocating since 1995 when I undertook three years of Post-Doctoral studies, first at UMICH and then at Johns Hopkins in Baltimore. I was a AD support group leader and 24/7 caregiver in Ann Arbor while completing my doctoral work. Working with ahead of its time Turner Geriatric Center, I requested and received substantial support for quickly weaning my mom off of drugs. When she died more than ten years later, she had been off drugs for a decade and had avoided the long-term side effects they typically bring. I’m grateful to the U-M Medical System and the work in Gerontology I did there and in Maryland (JHU) for research that supports a non-drug approach for some of the behavioral symptoms of Alzheimer’s disease. Well done…

    Reply

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