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Study: Antipsychotics not needed to help many with dementia

Tuesday April 22, 2014
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A new approach to handling agitation, aggression and other unwanted behaviors by people with dementia may help reduce the use of antipsychotics and other psychiatric drugs in this population, potentially making life easier for them and their caregivers, according to experts.

Publishing their recommendations under the acronym of “DICE,” a team of specialists in geriatric mental health from the University of Michigan, Ann Arbor, and Johns Hopkins University, Baltimore, hopes to spark better teamwork among those who care for dementia patients at home, in residential facilities and in hospitals and clinics.

The Centers for Medicare & Medicaid Services has made the DICE approach an official part of its toolkit for reducing the use of antipsychotic drugs and other mental health medications in people with dementia, according to a U-M news release.

Although these drugs may help some patients, many non-medication approaches could also help reduce neuropsychiatric symptoms of dementia. But emphasizing those approaches will take teamwork and communication, the study authors wrote in the April issue of the Journal of the American Geriatrics Society.

Most people with Alzheimer’s disease and other memory-affecting conditions also get aggressive, agitated, depressed, anxious or delusional from time to time, said senior author Helen C. Kales, MD, head of the U-M Program for Positive Aging and Geriatric Psychiatry at the University of Michigan Health System and investigator at the VA Center for Clinical Management Research. They might have hallucinations or lose inhibitions.

Kales and her colleagues Laura N. Gitlin, PhD, and Constantine G. Lyketsos, MD, from Johns Hopkins University, authored the new paper on behalf of the Detroit Expert Panel on the Assessment and Management of the Neuropsychiatric Symptoms of Dementia, which developed the DICE approach.

Briefly described, the components are:

D: Describe — Asking the caregiver, and the patient 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 patient’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 patient, including everything from changing 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 authors say physicians should prescribe psychotropic drugs only after they and the patient and caregiver have made significant efforts to change the patient’s behavior through environmental modifications and other interventions, with three exceptions related to severe depression, psychosis or aggression that present risk to the patient or others.

Health providers who care for dementia patients should familiarize themselves with the DICE approach, as should the spouses, adult children and others who care for dementia patients at home.

“Innovative approaches are needed to support and train the frontline providers for the burgeoning older population with behavioral symptoms of dementia,” Kales, a professor in the U-M Medical School’s Department of Psychiatry and member of the U-M Institute for Healthcare Policy & Innovation, said in the news release. “We believe that the DICE approach offers clinicians an evidence-informed, structured clinical reasoning process that can be integrated into diverse practice settings.”

Study abstract: http://onlinelibrary.wiley.com/doi/10.1111/jgs.12730/abstract


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