Non-Drug Remedies Can Help Treat Behavioral Problems Among Older Adults With Dementia
Wednesday, November 21, 2012
Summary of this Report
Older adults with Alzheimer’s disease and other types of dementia often have what are known as “behavioral symptoms.” These symptoms, which tend to occur in clusters, include wandering, disruptive sleep problems, resistance to care, agitation, aggression, delusions, hallucinations, and repetitive speech. These symptoms can be very upsetting for both the older person and his or her caregiver. In fact, behavioral symptoms are more difficult and disruptive for older adults and their caregivers than other symptoms of dementia, such as memory problems.
If untreated, behavioral symptoms can make it harder for the person with dementia to function; increase the speed of his or her mental decline; and lessen their quality of life. Caregivers are also affected. Untreated behavioral symptoms can lessen caregivers’ quality of life, increase his or her risk of depression, and make it harder for them to provide care – which can increase the likelihood that the older adult may be admitted to a nursing home.
Fortunately, studies suggest that a non-drug, multi-step approach to treating behavioral symptoms can help older people with dementia and their caregivers. This approach involves periodically screening (or checking) for behavioral symptoms in older adults with dementia, then identifying the causes of the symptoms, and coming up with a treatment plan tailored to the older adult’s needs. A non-drug approach should be tried first – before medications are prescribed – because it is more effective than drug treatment and doesn’t cause medication side effects, note the authors of an article, “Nonpharmacologic Management of Behavioral Symptoms in Dementia,” in November 21, 2012 Journal of the American Medical Association (JAMA).
“Nonpharmacologic management of behavioral symptoms in dementia can significantly improve quality of life and patient-caregiver satisfaction,” write the authors, Laura N. Gitlin, PhD, Helen C. Kales, MD, and Constantine C. Lyketsos, MD, MHS.
The experiences of an older adult with behavioral symptoms and his caregiver
The JAMA article describes the experience of a 93-year-old man – identified as “Mr. P,” to protect his privacy – who was diagnosed at age 90 with mild but worsening dementia. Mr. P. lived with his cousin, “Mr. C,” who was his main caregiver, and was also employed fulltime. While Mr. C. was at work, Mr. P was alone in their apartment. Though Mr. P could bathe and dress himself, Mr. C had to give him the 13 medications he took daily – for a range of health problems including high blood pressure, diabetes, and heart disease -- and help him with shopping and cooking. Over time, Mr. P become more withdrawn, was spending less time doing things he used to enjoy, such as gardening, began feeling lonely and insecure, and began showing poor judgment. Mr. P also started napping a great deal during the day, and, as a result, was restless at night. In addition, he developed a behavioral symptom – he often went into Mr. C’s bedroom at night, turned on the lights, awakened Mr. C, and told his cousin that he was hearing voices and was frightened. These disturbances left Mr. C. sleep-deprived, and made it hard for him to do his job.
Why non-drug management of dementia-related behavioral symptoms is effective and what it involves
Available medications aren’t particularly effective in treating behavioral symptoms associated with dementia. And the class of drugs most commonly prescribed for these symptoms may cause serious side effects among older people with dementia. Nonpharmacologic (or non-drug) treatments are both safer and more effective.
A nonpharmacologic approach to treating dementia-related symptoms suggests that behavioral symptoms may be due in part to unmet needs of the patient. For example, a person with dementia who continually repeats the same question over and over may be due to feeling insecure or unsafe, or not being able to engage meaningful in their environment. A nonpharmacologic approach to this patient would include setting up a structured routine, providing reassurance (verbally or through touch), and engaging the person in activities that match his/her interest and abilities. “(Research) supports non-pharmacologic approaches as part of standard, comprehensive dementia care,” the authors note.
The six steps to using nondrug approaches in treating dementia-related behavioral symptoms
There are six basic steps -- involving healthcare providers, caregivers, and patients -- to taking a nondrug approach:
- Screen the older adult with dementia for behavioral symptoms and help prevent them: Experts recommend that healthcare professionals screen at-risk older adults for signs of behavioral symptoms every year --or more often if the older person is showing signs of dementia – using a reliable evaluation test. If the adult doesn’t have symptoms, healthcare providers and caregivers should take steps to prevent their development. Among other things, healthcare professionals should counsel caregivers about: what dementia is; the importance of providing older patients with stimulation, daily routines, pain relief when necessary, and an appropriate, nutritious diet. Healthcare professionals should also offer caregivers advice for getting the sleep, nutrition, help and relief they need, and refer them for treatment if they have or are at risk of depression.
- Describe behavioral symptoms: If a patient with dementia has behavioral symptoms, healthcare providers should conduct a formal assessment to characterize the symptoms and identify whether there is an immediate safety or caregiver concern or undetected medical issue (urinary tract infection).
- Identify Underlying Causes – Next, healthcare providers, working with caregivers, need to identify the specific contributors to the symptoms – this may include but is not limited to a systematic review of medications to evaluate polypharmacy, and side effects, evaluating the patient’s environment and whether there is too much or too little stimulation (for example, too much or too little light, sound, or company); a problem with vision, hearing or hearing aids; illnesses; or pain – and treat these.
- Come up with a treatment plan – These plans may include general or specific approaches or referral to specialists or a combination of these approaches. General approaches use structured activities, such as appropriate exercise; caregiver education and training; and adult day services to meet the older adult’s needs overall. Caregiver interventions and support groups that help caregivers deal with the challenges of caring for an older adult with dementia are important as well. Specific approaches include identifying factors contributing to the specific behavior that can be modified (e.g., eliminating caffeine in the afternoon to promote sleep hygiene) and implementing them.
- Determine how effective these efforts are. If approaches aren’t making a difference, it’s important to determine why they did not work and then try other alternatives.
- Continue monitoring behaviors. These can change over time as the disorder progresses.
How nonpharmacologic approaches to dementia-related behavioral symptoms helped Mr. P and his caregiver
Taking a nondrug approach, Mr. P’s physician, and his caregiver, Mr. C, found a way to address the behavioral syndrome – waking and awakening his caregiver every night -- that was making Mr. C feel overwhelmed, sleep deprived, and unable to care for Mr. P. After ruling out other possible causes of the problem, the physician -- aware that Mr. P wore hearing aids in both ears -- checked to see whether these were making the noises that Mr. P noticed at night when it was quiet in the apartment. The hearing aids were the culprit. “We sent (Mr. P) to an audiologist and they adjusted his hearing aids (and)he has not had any further auditory hallucinations,” reported the physician, who also recommended a nightlight so Mr. P. could see, without turning on the lights, if he awoke in the middle of the night. The physician also recommended changes in Mr. P’s routine, so he napped less and was more active during the day, and, as a result, was tired and slept better at night. These changes included cutting back on the amount of caffeinated drinks Mr. P had later in the day, and having him go to an adult day center, which was stimulating, kept him more alert in the daytime, and resulted in his sleeping better at night.
This summary is from the full report titled, “Nonpharmacologic Management of Behavioral Symptoms in Dementia.” It appears in the November 21, 2012 issue of the Journal of the American Medical Association. The report is authored by Laura N. Gitlin, PhD, Helen C. Kales, MD, and Constantine C. Lyketsos, MD, MHS.