Non-drug care the ‘first choice’ in dementia

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Doctors write millions of prescriptions a year for drugs to calm the behaviour of people with Alzheimer’s disease and other types of dementia. But researchers have found that non-drug approaches actually work better, and carry far fewer risks. In fact, the researcher say, 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.

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 anti-psychotics and anti-depressants, and non-drug approaches that help caregivers address behavioural 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 (Describe, Investigate, Evaluate and Create), the framework tailors approaches to each person with dementia, and as symptoms change.

“The evidence for non-pharmaceutical approaches to the behaviour problems often seen in dementia is better than the evidence for antipsychotics, and far better than for other classes of medication,” says first author Dr Helen C Kales, head of the U-M Programme for Positive Ageing at the University of Michigan Health System and investigator at the VA Centre for Clinical Management Research. “The issue and the challenge is that our health care system has not incentivised training in alternatives to drug use, and there is little to no reimbursement for caregiver-based methods.”

Coincidentally, a US Government Accountability Office report addresses the issue of overuse of anti-psychotic 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 anti-psychotic medication – and that about 14% of those outside nursing homes were prescribed an anti-psychotic 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 penalising doctors for prescribing anti-psychotic drugs to these patients could backfire, if caregiver-based non-drug approaches aren’t encouraged. She and her colleagues from Johns Hopkins, Dr Laura N Gitlin and Dr Constantine Lyketsos 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 anti-psychotic 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 behaviour 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; and 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 behavioural issues, as can drug interactions. So physicians should look to assess and address these wherever possible.

University of Michigan Medical School material
British Medical Journal abstract
US Government Accountability Office report

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