This will be a busy week for Alzheimer’s and dementia news. The Alzheimer’s Association’s 2016 International Conference (AAIC) is being held in Toronto. It is always a rich news week for those of us who depend on the conference to highlight the latest and most promising research.
In the news today was some exciting research which validates something that many of us in the dementia care world have known for years. That the use of antipsychotic medications to reduce behavioral and psychological symptoms of dementia (BPSD) is not very effective and what we should be doing instead is focusing on meeting the unmet needs of the person living with dementia through person centered approaches.
The highlight of today’s news from the conference was research conducted by Australian researchers who presented results from a research project where they dramatically reduced the use of antipsychotic medicines to treat the Behavioral and Psychological Symptoms of Dementia (BPSD).
“The Halting Antipsychotic use in Long Term care (HALT) Project, based in New South Wales, Australia, successfully eliminated regular antipsychotic medication from the treatment plan in 75 percent of study participants after 6 months following initial reduction of antipsychotics (12 month follow up data to come). In this study — which involved 140 residents across 23 care facilities — deprescribing was achieved through training of long-term care facility nurses in non-pharmacological and person-centered approaches to managing BPSD.”
Click here to read the full press release and many others from the conference.
There’s a new word we need to add to our lexicon about Alzheimer’s and dementia care, “deprescribing”. In my experience, it is not so much the training of the nurses to use a non-pharmacological/person centered approach, although we at Brookdale believe strongly in this training and that it is a very important ingredient in all good dementia care. In my opinion, it is also important for us as a society to start questioning the culture that supports these drugs being in the picture in the first place.
The researchers are quoted in the press release as saying:
“Deprescribing of antipsychotics in long-term care residents with previous BPSD is feasible without reemergence of BPSD; however, challenges still exist regarding sustainability and culture of prescribing in aged care,” said Henry Brodaty, MD, DSc, of the Dementia Collaborative Research Centre, University of New South Wales, Sydney, Australia. Brodaty added, “Often there can be cultural and logistical barriers to moving away from antipsychotics in aged care settings, but we hope the results of this project will serve as a positive example towards a more person-centered approach globally.”
Ah, so there it is. All we have to do is change the culture. Not so easy right? Well maybe we need to start by looking at dementia differently. In order to begin to remove the barriers the researchers identified and have the person centered/non-pharmacological approaches (what works) become the norm, we must transition away from always viewing dementia through a biomedical lens. There are many of us who now clearly recognize that the more humane and sane way to view dementia is through a bio-psychosocial-spiritual lens. A person centered view that puts the person living with the disease at the center. So, why does this continue to be such a struggle?
Also in the news this week was an article in the NY Times that highlighted another release from the AAIC conference. This one involved a proposal presented at the conference by a group of neuropsychiatrists and Alzheimer’s experts that calls for a new diagnosis of Mild Behavioral Impairment (MBI). A companion to Mild Cognitive Impairment (MCI), it is thought that “the idea is to recognize and measure something that some experts say is often overlooked: Sharp changes in mood and behavior may precede the memory and thinking problems of dementia.”
The article goes on to make the case that this new diagnosis (MBI) would enable physicians to more readily diagnose early behavioral symptoms as another measure of who may be starting down the path of Alzheimer’s–all in the name of good treatment getting started. And, although they do not say it explicitly, I wonder how long after this new diagnosis hits the books will it be before we see the TV commercials for the new MBI drug.
So, the struggle continues. We know what works is viewing dementia differently, but we continue to use the wrong and frankly out of focus, lens. The NYT article uses the example of a woman’s drastic behavior changes as a recognizable early sign of her later diagnosis of Frontotemporal dementia (FTD). Clearly this is a different situation than someone who is unusually short tempered because they are experiencing frustration with new memory loss. Why would they both carry the same diagnosis? Does the second scenario truly warrant a diagnosis and as the article suggests, the upside of “…medications which help manage mood and behavior”? Or do people living with early dementia symptoms simply need our support and understanding?
What if with the labeling of BPSD and now MBI we have only served to pathologize and medicalize a person’s normal human responses of fear, frustration, anxiety, anger, resistance, denial, unhappiness, depression, etc. to the cognitive changes that they are experiencing? Might we get farther with person centered approaches being the norm if we move to embrace a culture of understanding that it is perfectly normal for someone to have an emotional response to the cognitive changes that accompany dementia at every stage?
To read more about person centered non-pharmacological approaches to dementia care see these websites:
Hello I am a 320 student at the Erickson School of Aging. First, let me tell you why I find this topic interesting in the first place. I have always been fascinated with Dementia ever since my freshmen year of college and taking introduction to psychology. Since my major is psychology, mental illnesses are intriguing to me. Secondly, I just like how it is extremely difficult to wrap my mind around at the fact we live our entire lives (making memories) just for us not to be able to remember them one day. Thirdly, I am a strong believer on not using medications for illness, but instead using behavioral therapy. I believe that we as a society rely heavily on prescription medications and not actually treating the problem. I like how this article goes right into stating that medications don’t have an positive effect on treating dementia. Most people rely on the medication, using it like a bandaid, but as soon as you rip that bandaid off (stop taking the meds) then the symptoms worst.
Hi, I am a AGNG 200 student at the Erickson School of Aging. I particularly enjoy the insight that his post has provided. From my class this semester i have come to understand different aspect of Dementia and antipsychotic. Administering antipsychotic medications to older adults with dementia got a bad reputation because, in some cases, these drugs may have been given to control patient behavior rather than to treat psychiatric conditions. Now concern about the use of these drugs is centering on serious physical risks. All medications have the potential to cause side effects. The most common side effects noted in patients on antipsychotic drug therapy include movement disorders, dry mouth, blurred vision, constipation, dizziness, and weight gain. In rare cases, antipsychotics can cause more serious side effects such as changes in blood glucose or blood lipid levels, neuroleptic malignant syndrome, and cardiac arrhythmias. Now there are even more serious concerns. Studies over the past decade have shown that antipsychotics can put elderly patients with dementia at risk for stroke and even death. Deciding to prescribe antipsychotic medications to elderly patients is a complex medical issue and it is never an easy decision.
Care providers can find themselves between a rock and a hard place, potentially facing legal ramifications whether they administer these drugs or not. In some cases, particularly when a patient’s violent behavior puts the safety of the patient or nursing staff at risk, ordering antipsychotic medications is a reasonable action, but it puts the patient at increased risk for serious side effects. Although there’s no clear-cut answer, nurses can play a vital role in reducing and, in some cases, eliminating the need to use antipsychotic drugs in elderly patients with dementia. In two essential areas—gerontologic nursing knowledge and nonpharmacologic interventions to treat the behaviors associated with dementia—nurses can have a huge impact. Living with dementia can have a big emotional, social, psychological and practical impact on a person. Many people with dementia describe these impacts as a series of losses and adjusting to them is challenging. personal relationships and someone’s social environment are central to life, regardless of age or mental ability. People can recognize this by being as supportive as possible. Carers, friends and family, can help a person with dementia to feel valued and included. Support should be sensitive to the person as an individual, and focus on promoting their wellbeing and meeting their needs. When addressing this issue,i will advice family members that it will be helpful if we have an understanding of the impact the condition has on that person. This includes understanding how the person might think and feel, as these things will affect how they behave. The person may be experiencing a world that is very different to that of the people around them. I will offers support while trying to see things from the perspective of the person with dementia, as far as possible.
Still the Lucky Few says
It’s such good news that an alternate method of treatment is emerging. I watched doctors pushing various pill based treatments onto my mother, when when she was alive and battling dementia.. We never thought it was a good idea, and we soon discovered that the pills she was given made no difference whatsoever.
Thank you so much for your post. I believe culture change is happening…slowly… and voices like yours are contributing to that change in exciting ways. Thank you for pointing out that emotional responses are not a pathological symptom in need of treatment, but rather should trigger provision of additional compassionate support.
Juliet Holt Klinger says
Thank you for your comment
Hannah–I agree we are seeing the culutre change–albeit slowly!