Recommendation of the American Geriatrics Society:
People with dementia often exhibit aggression, resistance to care and other challenging or disruptive behaviors. In such instances, antipsychotic medicines are often prescribed, but they provide limited and inconsistent benefits, while posing risks, including oversedation, cognitive worsening and increased likelihood of falls, strokes and mortality. Use of these drugs in patients with dementia should be limited to cases where non-pharmacologic measures have failed and patients pose an imminent threat to themselves or others. Identifying and addressing the causes of behavior change can make drug treatment unnecessary.
Behavioral and psychological symptoms of dementia (BPSD) occur in up to 97% of people living with dementia. These symptoms are most often referred to as “behaviors.” The most common behaviors are agitation, anxiety, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes. BPSDs result from the merge of changes in the brain of a person with dementia and their reactions and relationship to the social and physical environment.
In an article published in The Gerontological Society of America entitled, Evidence-Based Nonpharmacological Practices to Address Behavioral and Psychological Symptoms of Dementia, the authors describe the progressively lowered stress threshold of those with dementia. A person without dementia may encounter uncomfortableness in their environment and be able to either tolerate it or express their displeasure and make changes. However, a person living with dementia is unable to do either of these things. The article uses the example of someone with dementia being “confronted with bath water that is an uncomfortable temperature, a person living with dementia may strike out rather than convey discomfort through words.” The person being struck will label this person as having a behavior.
Because BPSDs can cause not only uncomfortable feelings for the person with dementia, the behaviors make it challenging for caregivers to assist the person throughout their day. When caregivers describe these behaviors to their loved one’s doctor, the doctor may prescribe medication to reduce the behaviors. At times antipsychotics are used. However, there is growing evidence that antipsychotics can be detrimental to someone with dementia. The American Geriatrics Society and American Association for Geriatric Psychiatry both recommend that physicians review what underlying causes may be triggering the concerning behaviors, and that clinicians and caregivers consider and respond to physical discomforts such as: thirst, hunger, pain, toileting difficulties, nausea, fatigue, loneliness, boredom or overstimulation before jumping to the conclusion that medications should be used.
The US Food and Drug Administration (FDA) has not approved the use of antipsychotic medication for the use of BPSD because while there isn’t evidence of the benefit, there is evidence of the negative effects these drugs can have on a person with dementia. The FDA requires a “black box” warning on antipsychotics when used for people with dementia because of the risks. Antipsychotics do not stop yelling or the repeating of questions over and over, they cannot stop memory problems, they cannot help a person do more for themselves or interact better with others, and they can’t keep a person from saying something inappropriate. On the other hand, antipsychotics do make a person unsteady when they walk increasing their fall risk, which in turn multiplies their chance of a broken bone. Additionally, antipsychotics have the potential to cause more incontinence, and there is an elevated risk for stroke and premature death.
If BPSD becomes so severe that a person is a harm to themselves or others, their physician may decide that the benefits will outweigh the risks and choose to use an antipsychotic. In an article published on Medscape.com, Primary Care Physician Perspectives About Antipsychotics and Other Medications for Symptoms of Dementia, the authors studied how and why primary care physicians (PCP) are prescribing antipsychotic medications to their dementia patients. The study revealed that although there are guidelines, policies, and warnings around the reduction of the use of antipsychotics for BPSD because of dangerous side effects, that PCPs are still prescribing these medications for the following reasons; nonpharmacologic methods have substantial barriers because they take more time and effort to employ; prescribing these drugs is perceived as easy, effective, reasonably safe, and appropriate; caregivers urge PCPs to deliver a quick response because of the stress caused by these behaviors which is felt by both the person with the disease as well as the caregiver; and PCPs need practical, evidence-based guidelines for all aspects of BPSD management.
Before making the decision to use antipsychotic medication, there are several nonpharmacological alternatives to attempt that studies have proven are beneficial. In the study mentioned above, Evidence-Based Nonpharmacological Practices to Address Behavioral and Psychological Symptoms of Dementia, the authors discovered several nonpharmacological methods that were met with success. The article describes in detail the following nonpharmacological approaches to consider to alleviate BPSDs.
- Aromatherapy: This long-standing practice uses scented oils to “regulate body activities by control and activation of the autonomic nervous system and neuroendocrine system.” There is a link between smell and memory which has the potential to improve an individual’s mood.
- Massage: This may help offset the social isolation that triggers negative affect and related behaviors. A simple hand massage can help a person living with dementia feel comforted and cared about. Touch may also lead to a physiological response such as a sense of reassurance or calm.
- Multi-Sensory Stimulation: The use of a variety of lighting effects, calming sounds, familiar smells, and/or tactile stimulation can promote control and autonomy which may otherwise be denied to persons living with dementia.
- Bright Light Therapy: A light box, light visor, ceiling-mounted light fixtures, or exposure to natural bright light is used to help with a person’s sleep-rest cycle, and the agitation of sundowning.
- Validation Therapy: Clinicians and caregivers are taught to be empathetic and validate the person’s emotional state with the goal of alleviating negative feelings and enhancing positive feelings.
- Reminiscence Therapy: Talking about or viewing pictures of past pleasant events and experiences can increase a person’s well-being and provide pleasure and cognitive stimulation.
- Music Therapy: Not only can music be pleasant to listen to, it can also promote well-being and foster sociability. Music can facilitate reminiscence and has the potential to reduce anxiety by creating a sense of familiarity and regularity in the environment.
- Pet Therapy: Animal-assisted therapy has been used for several decades to treat mental and physical health disorders including dementia. It can promote socialization and emotional support. Quiet interaction with an animal can help lower blood pressure and increase the production of neurochemicals associated with relaxation. In one study of the use of pet therapy and residents with dementia, there was a reduction in agitation and disruptive behavior, increased social and verbal interactions, and decreased passivity. There has even been a preliminary study showing that the use of robotic dogs and cats have shown positive increases in mood and decreased agitation.
- Meaningful Activities: Providing individualized, meaningful activities is an important part of person-centered care and can help prevent or alleviate BPSD by enhancing the overall quality of life through engagement, enhanced social interaction, and opportunities for self-expression and self-determination.
These techniques may be more easily utilized by clinicians taking care of a person who resides in a community because they have the constant support of co-workers and the necessary tools at their disposal. It may be more difficult for an at-home caregiver to try these methods, especially if they are exhausted and in need of the hope of a quick fix. In addition to the caregiver seeking the help of their loved one’s PCP, they would do well to seek the advice of their own doctor, join a support group, and take advantage of in-home care that can provide them with a much-needed break from caregiving.
For more information visit:
Consumer Reports Choosing Wisely Fact Sheet:
http://www.choosingwisely.org/wp-content/uploads/2017/06/ChoosingWiselyAntipsychoticsAGS-ER-1.pdf
American Health Care Association Fact Sheet:
https://www.ahcancal.org/quality_improvement/qualityinitiative/Documents/Antipsychotics%20Consumer%20Fact%20Sheet%20-%20English.pdf
