MedicalResearch.com Interview with
Helen C. Kales MD
Professor of Psychiatry
Director, Section of Geriatric Psychiatry and The Program for Positive Aging, University of Michigan
Research Scientist, VA Center for Clinical Management Research
and Geriatric Research Education and Clinical Center
VA Ann Arbor Healthcare System
Please note that this paper is the result of the deliberations of a multi-disciplinary national expert panel, not a specific study.
MedicalResearch.com: What were the main findings of the expert panel?
Dr. Kales: 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, and 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 psychiatric medications like antipsychotics, despite little hard evidence that they work well in this population and despite the risks they pose including hastening death. Meanwhile, studies show promise for non-medication behavioral and environmental approaches (such as providing caregiver education/support, creating meaningful activities and simplifying/enhancing the environment), but too few health providers are trained in their use. The method created by the national multidisciplinary group of experts (DICE which stands for Describe, Investigate, Create and Evaluate) represents a comprehensive approach to assessment and management of behavioral symptoms in dementia. For example, a new report of “agitation” from a caregiver, should be fully understood and described (e.g. who/what/when/where/risk/safety); underlying causes should be investigated (e.g. pain, changes in medications, medical conditions, poor sleep, fear); a treatment plan should be created (e.g. responding to physical problems, working collaboratively with the caregiver and other team members to institute non-pharmacologic interventions); and evaluating whether the interventions tried were effective.
MedicalResearch.com: Were any of the findings unexpected?
Dr. Kales: Given the mixed evidence-base for most psychotropics used for behavioral symptoms of dementia, several of the expert panelists were hesitant recommend first-line treatment with medications under any circumstances. Others noted that lack of homogeneity of behavioral symptoms in prior trials may have been problematic. Given the limitations of the current evidence base, the panel consensus was that psychotropic drugs should only be used after significant efforts have been made to mitigate behavioral symptoms using behavioral and environmental modifications and medical interventions (e.g. treatment of a urinary tract infection that could underlie behavioral changes), with three exceptions. In each of the three “exceptions”, medication use would follow a concern for significant and imminent risk:
· Major depression with or without suicidal ideation
· Psychosis causing harm or great potential of harm
· Aggression causing risk to self or others
If medications are used, close followup is needed to monitor for adverse effects and use should be time-limited as behaviors and symptoms may resolve over time with or without drug intervention.
MedicalResearch.com: What should clinicians and patients take away from this report?
Dr. Kales: The DICE approach offers clinicians an evidence-informed structured approach that can be integrated into diverse practice settings. The 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 enables clinicians to consider conjointly the role of nonpharmacological, medical and pharmacologic treatments.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Dr. Kales: Ultimately, developing technology applications of DICE (e.g. in the form of an “app”) may simplify its use, save time, standardize its application and facilitate evaluation of its effectiveness. Drs. Kales and Gitlin are Co-PIs on a grant from the National Institute of Nursing Research (R01NR014200) creating and testing the approach using technology with the benefit of key stakeholder (patient, caregiver and provider) input.
Management of Neuropsychiatric Symptoms of Dementia in Clinical Settings: Recommendations from a Multidisciplinary Expert Panel
Kales HC1, Gitlin LN, Lyketsos CG; Detroit Expert Panel on the Assessment and Management of the Neuropsychiatric Symptoms of Dementia.
J Am Geriatr Soc. 2014 Apr;62(4):762-9. doi: 10.1111/jgs.12730. Epub 2014 Mar