Behavioral and psychiatric symptoms, such as depression, delusions, hallucinations, yelling, wandering and aggression, affect 80-90 percent of individuals with dementia at some point during the course of their illness. For the vast majority of individuals with dementia, these troubling symptoms are short-lived and can be successfully managed by caregivers who use behavioral modifications and non-pharmacological interventions such as reassurance, social activities to relieve boredom or agitation, reminiscence, and exercise.
The Centers for Medicare and Medicaid Services (CMS) use of policy efforts to reduce the inappropriate use of antipsychotics among dementia patients in nursing homes should be applauded. However, we must be careful not to demonize all use of these medications.
As indicated in the oped by Dr. Cheryl Phillips, ("The false promise of dementia drugs," Aug. 13), there are no medications, including antipsychotics, that are approved by the Food and Drug Administration for treatment of behavioral and psychiatric symptoms of dementia. There is modest evidence in the medical literature to support the short term use of antipsychotics among a small percentage of individuals with dementia who have persistent and distressing psychotic symptoms or physically aggressive symptoms that pose a significant danger to themselves or others. Before and during the use of any medication to impact symptoms of dementia, behavioral approaches should be used, informed discussions with the individual and family about risks and benefits should occur, and ongoing monitoring for effectiveness and side effects should be present.
Safe reductions in the use of antipsychotics can occur only when family and professional caregivers have access to education and coaching on the use of effective non-pharmacological alternatives. While there is some evidence about the effectiveness of behavioral interventions, results vary, and the use of these techniques is not a one size fits all approach. Obtaining the financial resources to test behavioral interventions in real world settings is challenging and clinical improvements are often modest at best. Knowledge of the person with dementia, the promotion of physical activity, and trial and error are often our best teachers when using behavioral approaches.
If we are serious about improving the behavioral health of individuals with dementia, we must devote time and resources to caregivers who face the daily challenges of understanding and managing behavioral symptoms. We must also reserve the option for appropriate short term use of pharmacological interventions when symptoms are severe enough to warrant their use.
Elizabeth Galik, Baltimore
The writer is an assistant professor at the University of Maryland School of Nursing.