I am just finishing up a wonderful West Coast trip, having spoken at 6 different events in the Bay area and Portland, Oregon this week. During one talk, I expanded on a concept I very gently broached in a recent blog post, and I got some strongly positive responses, so I will add my thoughts here. Hopefully I can do this without alienating my good friends in the specialty of psychiatry…
It has become clear to me that we use psychiatrists extensively as consultants for people living with dementia, particularly in long-term care settings. It also has become apparent that the majority of referrals center around various types of distress for which the care staff need assistance. Therein lies a very basic problem, another flawed paradigm.
It appears that increasingly (or maybe it’s always been this way), dementia is seen as a psychiatric illness. Psychiatrists–specialists in such illnesses–naturally come to these consults with that mindset, thus reinforcing what I feel are flawed ideas: that the symptoms of distress are akin to the symptoms of psychosis or other psychiatric illnesses, and that neurochemical manipulation is the solution. My experience is that these consultants, more and more, are used as “expert pill jockeys”, helping us navigate the best choice of antipsychotic, or the optimal dose of an anticonvulsant, in order to “control the behavior.”
Here’s the problem as I view it: Dementia is not a psychiatric illness. It is a change in one’s experience of their surroundings and how they process information, based on structural neurologic changes. It is as much a psychiatric illness as would be a stroke. And people’s interpretations of the world around them may seem confused to us, but they are nothing like the symptoms of an organized psychosis.
Unfortunately, the preconceptions that come from this mindset often blind us to the idea of looking for non-medication solutions, which research has shown more and more to be the safest, most successful and most durable ones (especially if they are coupled with supportive operational changes within the care environment).
Don’t get me wrong–I think we need psychiatrists more than ever for people with dementia in long-term care. We just need a different kind of consult.
Psychologist Dr. Richard Taylor, a person with dementia, reminds us that his greatest struggle is to deal with his changing cognitive abilities and to “make sense of today.” There is an ideal opportunity for psychiatrists and psychologists to help the burgeoning number of people with dementia to navigate these difficult changes and find successful ways to cope and adapt to them in a meaningful way. A bit of Viktor Frankl–finding meaning and purpose in one’s life situation–wouldn’t hurt either.
It’s time to reclaim dementia as a neurologic disability with secondary psychological challenges, and to find ways to help people grow and be successful, rather than simply finding another pill of dubious value.
