Proposal: Managing most troubling symptoms of dementia, lessen use of drugs

Publishing their recommendations under the easy-to-remember acronym of “DICE”, the panel of specialists in senior mental health hope to spark better teamwork among those who care for dementia patients at home, in residential facilities and in hospitals and clinics.

In fact, the federal agency that runs Medicare and funds much dementia-related care has made the DICE approach an official part of its toolkit for reducing the use of antipsychotic drugs and other mental health medications in people with dementia.

Though these drugs may still help some patients, the new paper in the Journal of the American Geriatrics Society says, many non-medication approaches could also help reduced unwanted behaviors, also known as neuropsychiatric symptoms of dementia. But it will take teamwork and communication to do it.

Most people with Alzheimer’s disease and other memory-affecting conditions also get aggressive, agitated, depressed, anxious, or delusional from time to time, says senior author Helen C. Kales, M.D., head of the U-M Program for Positive Aging and Geriatric Psychiatry at the University of Michigan Health System and investigator at the VA Center for Clinical Management Research. Or, they might have delusions, hallucinations, or lose inhibitions.

“Often more than memory loss, behavioral symptoms of dementia are among the most difficult aspects of caring for people with dementia. These symptoms are experienced almost universally, across dementia stages and causes,” she says. “Sadly, these symptoms are often associated with poor outcomes including early nursing home placement, hospital stays, caregiver stress and depression, and reduced caregiver employment.”

Doctors often prescribe these patients medications often used in patients with mental health disorders, despite little hard evidence that they work well and despite the risks they can pose -- including hastening death. Meanwhile, studies have shown promise from non-medication approaches to changing dementia patients’ behavior and reducing triggers for behavioral issues in their environment and daily life. But too few health teams are trained in their use.

Kales and her colleagues Laura N. Gitlin, Ph.D. and Constantine G. Lyketsos, M.D. from Johns Hopkins University authored the new paper on behalf of a group of experts, called the Detroit Expert Panel on the Assessment and Management of the Neuropsychiatric Symptoms of Dementia, who developed the DICE approach.

Sponsored by Kales’ program, the national multidisciplinary panel of experts met in Michigan to create a comprehensive approach to behavioral management.

Dubbed “DICE” for Describe, Investigate, Evaluate, and Create, it details key patient, caregiver and environmental considerations with each step of the approach and describes the “go-to” behavioral and environmental interventions that should be considered.

Briefly described, the components are:

• D: Describe - Asking the caregiver, and the patient if possible, to describe the “who, what, when and where” of situations where problem behaviors occur and the physical and social context for them. Caregivers could take notes about the situations that led to behavior issues, to share with health professionals during visits.

• I: Investigate – Having the health provider look into all the aspects of the patient’s health, dementia symptoms, current medications and sleep habits, that might be combining with physical, social and caregiver-related factors to produce the behavior.

• C: Create – Working together, the patient’s caregiver and health providers develop a plan to prevent and respond to behavioral issues in the patient, including everything from changing the patient’s activities and environment, to educating and supporting the caregiver.

• E: Evaluate – Giving the provider responsibility for assessing how well the plan is being followed and how it’s working, or what might need to be changed.

The authors say that doctors should prescribe psychotropic drugs only after they and the patient and caregiver have made significant efforts to change dementia patients’ behavior through environmental modifications and other interventions, with three exceptions related to severe depression, psychosis or aggression that present risk to the patient or others.

Now, the authors say, health providers of all kinds who care for dementia patients should familiarize themselves with the DICE approach – as should the spouses, adult children and others who care for dementia patients at home.

“Innovative approaches are needed to support and train the front-line providers for the burgeoning older population with behavioral symptoms of dementia,” says Kales, a professor in the U-M Medical School’s Department of Psychiatry and member of the U-M Institute for Healthcare Policy & Innovation. “We believe that the DICE approach offers clinicians an evidence-informed structured clinical reasoning process that can be integrated into diverse practice settings.”

Gitlin, who directs the Center for Innovative Care in Aging at the Johns Hopkins School of Nursing, adds, “The DICE approach is inherently patient- and caregiver-centered because the concerns of individuals with dementia and their caregivers are integral to each step of the process. DICE also enables clinicians to consider the roles of nonpharmacologic, medical and pharmacologic treatments concurrently.”

Lyketsos, chair of the Department of Psychiatry at Johns Hopkins Bayview, stresses that the approach “has tremendous utility in clinical trials of treatments for behavioral symptoms, particularly in testing new medications. DICE can be used to better subtype behaviors, or focus on particular behaviors at randomization coupled with systematic treatment approaches”.