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 non-drug approaches
actually work better, and carry far fewer risks, experts conclude in a new
report.
Non-drug
approaches should be the first choice for treating dementia persons’ 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 Medical Journal.
Clinicians
at the University of Michigan and Johns Hopkins have developed a strategy to
minimize the use of potentially dangerous drugs for behaviour 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 collaboration among
doctors, caregivers and, when possible, the person with Alzheimer’s disease and
involves the following steps.
THE COMPONENTS OF THE DICE APPROACH ARE:
Describe - First, caregivers and AD persons should describe the
“who, what, when, where and why” of specific behavioural problems that the
person with Alzheimer’s disease 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 disease 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 behavioural issues and
prevent future problems. These might include establishing regular routines for
the person with Alzheimer’s disease, 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 disease 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 non-drug 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 disease, it’s important to assess whether he or she might be
suffering from physical problems that are exacerbating the difficult behaviour.
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 behaviour problems.
Treatment of the underlying medical problem can help to ease agitation.
In the home
environment, over stimulation or lack of stimulation can also aggravate
behavioural problems. A loud TV or radio can be unpleasant for someone with
Alzheimer’s disease, 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 behaviour problems.
“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,” 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
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 behavioural and environmental
interventions.
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 disease. 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 behaviour issues. They include:
1. Providing education for the caregiver;
2. Enhancing effective communication between
the caregiver and the person with dementia;
3. Creating meaningful activities for the
person with dementia;
4. Simplifying tasks and establishing
structured routines; and
5. Ensuring safety and simplifying and enhancing
the environment around the Alzheimer’s person, whether in the home or the
nursing/assisted living setting.
Specific
measures might include:
1. Removing
clutter from the home;
2. Using
calming music or simple activities that help to engage a person with dementia;
or
3. 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 the persons living with Alzheimer’s.
“Behaviour-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 behavioural
symptoms is needed, the authors conclude. But in the meantime, the evidence to
date comes down in favour of non-drug approaches in most cases.
(Source: By ALZinfo.org,
The Alzheimer’s Information Site. Reviewed by William J. Netzer, Ph.D., Fisher
Center for Alzheimer’s Research Foundation at The Rockefeller University. Helen
C. Kales, Laura N. Gitlin, Constantine G Lyketsos: “State of the Art Review:
Assessment and management of behavioural and psychological symptoms of
dementia.” BMJ, March 2, 2015.)
