June 17, 2015
Agitation, aggression, irritability and other behavior problems are a common feature of Alzheimer’s and present unique challenges for family members and others caring for someone with the disease. Doctors often prescribe antipsychotic medications and other potent drugs to ease these problems, but they can have serious side effects, including an increased risk of heart attack, stroke and falls.
Now, clinicians at the University of Michigan and Johns Hopkins have developed a strategy to minimize the use of potentially dangerous drugs for behavior problems. The approach is called DICE – for describe, investigate, create and evaluate – and is based on data collected from two decades of research studies. The strategy is intended to be a collaboration among doctors, caregivers and, when possible, the person with Alzheimer’s and involves the following steps.
Describe. First, caregivers and patients should describe the “who, what, when, where and why” of specific behavioral problems that the person with Alzheimer’s might be dealing with, including times of day they may occur, circumstances or situations that trigger them, and the level of distress that they cause. If someone becomes agitated and tends to pace in the evenings after the TV set is turned on, for example, that information should be conveyed to the doctor.
Investigate. The doctor or other health care provider should examine the person with Alzheimer’s to look for any underlying medical or environmental causes that may be contributing to the problem. A variety of medications, for example, can cause problematic side effects or interfere with sleep. Similarly, a lack of daily routines, poor lighting in the home or excess clutter can be confusing for someone with dementia and increase anxiety.
Create: Working together, caregivers and health care professionals should develop a plan to respond to behavioral issues and prevent future problems. These might include establishing regular routines for the person with Alzheimer’s, and providing education and support for caregivers.
Evaluate: Finally, the doctor should assess whether the plan is working, and make adjustments as needed.
The DICE approach can be more effective and safer than prescription medications such as haloperidol (Haldol), olanzapine (Zyprexa), quetiapine (Seroquel) and risperidone (Risperdal), all of which significantly increase the risk of death, the authors say. They note that sometimes the use of such drugs is appropriate, for example, if someone with Alzheimer’s poses a risk to themselves or those around them. And antidepressants can be useful for treating someone with serious depression. But in many cases, a nondrug approach should be tried first, they say, and any drugs that are prescribed should be monitored and discontinued when possible.
For anyone with Alzheimer’s, it’s important to assess whether he or she might be suffering from physical problems that are exacerbating the difficult behavior. Being hungry, thirsty or in pain can all lead to outbursts. Untreated medical problems, such as a urinary tract infection, a toothache or interactions between different drugs, can also contribute to problems. Poor vision or hearing can also be disorienting and contribute to behavior problems. Treatment of the underlying medical problem can help to ease agitation.
In the home environment, overstimulation or lack of stimulation can also aggravate behavioral problems. A loud TV or radio can be unpleasant for someone with Alzheimer’s, and that person may not be able to communicate his frustration or make the mental connection to go and turn the noisy device off. Lack of activity or lack of routines can likewise lead to confusion and contribute to behavior problems.
For caregivers, stress and depression can diminish coping skills. Caregivers need education about the disease and should be taught skills about communicating with a loved one with Alzheimer’s. Caregivers also need to have realistic expectations about the course of the disease, the lack of effective treatments, and challenges that may arise.
The authors describe five non-drug approaches to caregiving that have been shown to help reduce behavior issues. They include: 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; and ensuring safety and simplifying and enhancing the environment around the patient, whether in the home or an assisted living facility.
Specific measures might include removing clutter from the home, using calming music or simple activities that help to engage a person with dementia, or using a calm voice instead of being confrontational. It’s also critical that caregivers get breaks from their responsibilities and take care of themselves, especially in the home, to help them avoid burnout and taking their frustration out on patients.
Getting insurers to pay for such changes remains a challenge. “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,” said study author Dr. Helen C. Kales, head of the University of Michigan Program for Positive Aging. “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.” The findings were published in the British medical journal BMJ.
Source: Helen C. Kales, Laura N. Gitlin, Constantine G Lyketsos: “State of the Art Review: Assessment and management of behavioral and psychological symptoms of dementia.” BMJ, March 2, 2015.