New Help for Dealing With Aggression in People With Dementia – KFF Health News

Caring for older adults with dementia is stressful, especially when they become physically or verbally aggressive, wander away from home, develop delusions or hallucinations, engage in inappropriate or repetitive behaviors, or refuse caregivers’ help.

More than 95% of patients experience these neuropsychiatric symptoms of dementia, which fluctuate over time and vary in intensity. These are the primary reasons why people with dementia move into assisted living facilities or nursing homes. At some point, family and friends trying to help at home simply cannot manage.

“When people think of dementia, they usually think of forgetfulness and memory loss,” said Mary Blazek, MD, director of the Geriatric Psychiatry Clinic at the University of Michigan. “But it’s the behavioral and psychological disturbances that cause the most disruption to the lives of patients and caregivers.”

Now, help is available First website of its kind Created by leading experts in the field. It provides free training in a comprehensive approach to managing the neuropsychiatric symptoms of dementia – a method known as DICE – based on several decades of scientific research as well as extensive clinical practice.

The website’s goal is “to give people tools to better manage often distressing situations,” said Helen Kells, chair of the department of psychiatry and behavioral sciences at UC Davis Health in Sacramento, California, and one of DICE’s creators. Users learn that neuropsychiatric symptoms are caused by changes in the brain that increase people’s vulnerability. Nine video modules and two simulations provide comprehensive information and problem-solving techniques.

More than 16 million unpaid caregivers — mainly family members and friends — help people with dementia live at home. (It is estimated that 20% of patients live in institutional settings.) The most common form of dementia, Alzheimer’s disease, affects about 7 million Americans age 65 and older.

Kells said DICE is also designed to help “avoid thoughtless prescribing of psychiatric medications,” which can have potentially serious side effects. Many medical organizations recommend that non-pharmaceutical approaches to troublesome behaviors be tried before drug treatment, but, in practice, this usually does not happen.

Medications prescribed for dementia include antipsychotics, such as risperidone, which carries a black-box warning that it increases the risk of premature death in elderly patients; anticonvulsants, such as gabapentin, whose use is increasing despite safety concerns; benzodiazepines, such as Ativan, which are associated with increasing the risk of falls and thus fractures; and antidepressants such as Celexa and others that have limited data supporting their effectiveness in reducing dementia symptoms.

DICE is a mnemonic – a pattern of letters that serve as a memory aid – that stands for Describe, Investigate, Create and Evaluate, which are the four pillars of this approach. At its core is the notion that people with dementia engage in distressing behaviour for often-unknown reasons that can be addressed once understood.

Take the example of Jennifer on the website, who cares for her 55-year-old mother, Betty, who is 85 years old, and whom she tries to bathe every day late in the evening. When Betty refuses to get into the tub, Jennifer insists, “Come on! I have some things to do.” Betty slaps her and yells, “Leave me alone. I’m in pain.”

DICE urges caregivers to step away from momentary excitement and examine issues from three perspectives: the person with dementia, the caregiver, and the environment. All can contribute to distressing situations and all should be considered in formulating a response.

Examining the problem using the “who, what, when, how, why” prompts can reveal several potential issues:

• Patient. Betty has arthritis and may find it painful to get in and out of the tub. She may feel tired and overwhelmed in the late afternoon.
• care taker. Jennifer becomes easily frustrated when she encounters resistance – she adopts a scolding and commanding tone rather than explaining to Betty what to do in simple steps.
• Environment The bathroom is usually cold, has overly bright lights, the bath water is lukewarm, and there are no grab bars around the tub.

Some possible solutions discussed on the website: Give Betty an over-the-counter pain reliever before bathing her. Try to bathe her in the afternoon, not in the morning. Don’t expect to bathe her every day and give her sponge baths a few times a week. Install grab bars around the tub and make sure the water temperature is comfortable. Use a nice-smelling soap and play music to help Betty relax. Speak calmly and keep things simple.

These include strategies to improve neuropsychological symptoms associated with dementia: identifying and addressing underlying medical problems such as pain, infection, or delirium; simplifying the tasks expected of the person with dementia; and establishing daily routines that provide structure to the day.

Other important steps: Engage the person in activities that are meaningful to them, including social interactions. Minimize clutter and the potential for overstimulation in the environment. Make sure the person is using hearing or vision aids if needed. Take them outside and expose them to light.

If safety, psychosis, or severe depression are immediate concerns, consider the use of psychoactive medications after consulting a physician.

Of course, this is not a comprehensive list of recommendations. Nor is it prescriptive. What works for one person with dementia may not work for another.

Kells said using DICE is an iterative process that involves creativity and frequent evaluation to determine if strategies are working. If not, new interventions should be tried.

Although this is the first time family caregivers can access the DICE toolkit, the program has been available to health care professionals for some time. Notably, all of Wisconsin’s dementia care specialists have been trained in DICE in the past few years (every county in that state has a specialist who helps families with dementia).

“This is a really pragmatic approach that’s been very thoughtfully designed,” said Art Walaszek, a professor of psychiatry and medicine at the University of Wisconsin School of Medicine and Public Health, who has been involved in the effort.

There are also other dementia training programs available, some of which review behavioral and mental symptoms in less depth, and they, too, are beginning to be available online. Another valuable resource, Best programs for careThe website, launched in March, lists evidence-based programs and their availability across the country. Enter a zip code to find information that has not been gathered in one place before. The site is also very useful for counseling.

We look forward to hearing from readers about the questions you want answered, the problems you’re having with your care, and the advice you need in navigating the health care system. kffhealthnews.org/columnists To submit your requests or suggestions.