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6 Steps to Nondrug Management of Dementia
From existing evidence and their own clinical experience, researchers at Johns Hopkins University have come up with 6 nonpharmacologic steps to better identify and manage behavioral problems in patients with dementia.
Behavioral issues, which can include psychiatric symptoms such as depression, psychosis, apathy, agitation, aggression, delusions, and hallucinations, as well as troubling conduct such as repetitive vocalizations and wandering, are frequently difficult to manage and can both increase the risk for dangerous activities (walking out in traffic, for example) and be hugely stressful for caregivers. Physicians sometimes prescribe atypical antipsychotics to manage difficult behavioral symptoms.
Six nondrug approaches to identifying and managing behavioral problems are summed up in an article by Laura N. Gitlin, PhD, from the Department of Community Public Health, School of Nursing, Johns Hopkins University, Baltimore, Maryland, and colleagues. The article was published in the November 21 issue of JAMA.
The researchers searched PubMED for studies published in peer-reviewed journals between January 1992 and July 1, 2012, and also searched for recent published systematic reviews, meta-analyses, Cochrane reviews, and home- and community-based randomized trials of nonpharmacologic treatments.
From this search and the example of Mr. P, a 93-year-old man with mild cognitive impairment resulting from brain vascular disease who lives with his cousin, his primary caregiver, investigators developed 6 key approaches to uncovering and managing disruptive behaviors:
• Screen for behaviors and implement preventive actions: Experts recommend proactive yearly screening for behaviors, using a reliable and validated instrument (eg, the Neuropsychiatric Inventory). Preventive measures might include discussing with caregivers the importance of patient self-care, adequate stimulation, nutrition, sleep, and detection of early symptoms.
• Describe presenting behaviors: When disruptive or troubling behaviors develop, clinicians should do a formal assessment, a process that involves interviewing both the patient and caregiver. Although clinicians should consider behaviors from the patient's perspective, caregiver involvement becomes essential, especially as the disease progresses. Determining the caregiver's burden is important, as a depressed caregiver can benefit from referral to a psychiatrist or counselor.
• Identify underlying causes: Clinicians should try to find possible causes for behaviors, including the contribution of patient-related factors such as medical illness, pain, or medications. They should observe the caregiver's coping and communication styles, closeness to the patient, and level of access to support. The home environment should also be evaluated for the presence of excessive stimulation or lack of stimulation.
• Devise a treatment plan: A treatment plan should target behaviors and eliminate modifiable triggers. Simple activities such as accompanied daily walks can enhance feelings of well-being and improve sleep. Social and other activities that the patient enjoys can reduce agitation. Depression can sometimes be reduced through a combination of physical exercise and caregiver training in behavioral management techniques. The authors cite a randomized trial with 272 community-dwelling patients and their caregivers that showed that targeting behaviors and modifying potential triggers improves or eliminates patient symptoms and enhances caregiver well-being and skills. "Based on identifying contributing factors to the behavior, potential strategies might include eliminating caffeinated beverages, afternoon napping, and stimulating environmental distractions (television at bedtime); and implementing a structured daily routine of exercise, meaningful activity, a structured nighttime routine possibly involving soft music and otherwise setting a tranquil tone," the authors write.
• Determine effectiveness of nonpharmacologic strategies: If there are no behavioral improvements, it's important to determine whether there have been any changes in the characteristics of the behavior, the patient's environment, or the patient's health status, the authors note. It might also be a good idea to look at how the caregiver has implemented various strategies.
• Determine whether new behavioral symptoms are emerging: Behavioral symptoms and caregiver distress should be reassessed on a regular basis, and monitoring should be ongoing, the authors write.
They note that reimbursement and care systems do not adequately support nonpharmacologic therapies. "Busy clinicians may find it challenging to integrate the 6 steps over short patient visits. However, forming a dementia team with other health professionals may address this challenge," they conclude.