Alternatives to Antipsychotic Medications

Module 7 - Lesson 1 of 3

Introduction

Antipsychotic medications are often prescribed when a person with dementia is showing signs of behavioral distress. The family, aides, nurses, nurse practitioners and doctors want to help. Often they don't know there may be more effective and less risky ways to reduce suffering or to prevent the distress signals altogether. Nonpharmacologic approaches have received more attention since the Centers for Medicare and Medicaid Services (CMS) launched the National Partnership to Improve Dementia Care.

Dig In

The Problem

The Food and Drug Administration (FDA) issued its first black box warning about antipsychotic use for agitation in persons with dementia in 2003. The FDA had found an increased risk of death and stroke in persons with dementia who had been prescribed one of the newer antipsychotics. By 2008, the warning was extended to ALL antipsychotics. In addition to increasing the risk of strokes and dying, antipsychotics increased the risk of falling, getting upper respiratory infections, oversedation, and worse mental functioning. It has also been found that the antipsychotics don't work very well, except by sedating people. For these reasons, non-pharmacologic ('no drugs') are considered best practice.

Alternatives

Non-pharmacologic interventions have been shown to improve quality of life, reduce depression, apathy, sleep problems, agitation, and aggression.

The first step in adopting non-pharmacologic practices is to take the time to get to know the people in your care. This happens spontaneously with people who have pleasant and outgoing personalities and can talk about their interests. Make the same effort with people with dementia who may not be able to initiate conversation, but who have the same basic needs for engaging with others.

The following guidelines are from the National Partnership to Improve Dementia Care in Nursing Homes. They can be used in any care setting, including assisted living communities (ALs) and home-based care.

  • Get to know the person, including their history and family life, and what they previously enjoyed. Learn their life story. Help them create a memory box.
  • Provide for a sense of security.
  • Play to their strengths.
  • Offer choices.
  • Encourage independence.
  • Apply the 5 Magic Tools (Knowing what the care recipient likes to See, Smell, Touch, Taste, Hear).
  • Bring in pets, children, and volunteers.
  • Involve the family by giving them a task to support the care recipient.
  • Assess for pain. Use a validated pain assessment tool to assure non-verbal pain is addressed.
  • Provide consistent caregivers.
  • Screen for depression and possible interventions.
  • Reduce noise (paging, alarms, TVs, etc.).
  • Be calm and self-assured.
  • Identify unmet needs that may be expressed in certain behaviors.
  • Understand events or actions.

Antipsychotic Medication and Person-Directed Care

If, despite careful attention to identifying and addressing unmet needs, a person with dementia continues to experience extreme distress, and, all non-pharmacologic interventions have been unsuccessful, an antipsychotic may be prescribed.

Follow these guidelines:

  • Complete a pain assessment.
  • Consider a two-week trial of a non-opioid analgesic prior to initiating other drug therapies.
  • Involve both the care recipient, and family in the decision, and be sure to discuss both the risks and benefits.
  • Document the rationale for using the antipsychotic medication if the primary decision-maker approves it.
  • Decide how to determine that the medication is effective.
  • Always use the lowest most effective dose.
  • Carefully monitor the person for side effects.

If the medication has the desired effect, continue use for up to 12 weeks. There is no evidence that giving antipsychotic medication for longer than 12 weeks has any benefit.

If at any time the risks begin to outweigh the benefits, stop the use of the medication.

Document!

Document the rationale for the medication and its effectiveness, the consent (if applicable), and any side effects.

Caregiver behavior (Module 4) and caregiving practices (Module 5) can have a significant impact on reducing inappropriate medication use.

Changing Behavior

Caregiver behavior can escalate or de-escalate most situations. De-escalation is usually possible, and it's a very valuable skill to practice. Monitoring our body language and our own fear response can help avoid triggering a fear response in a person with dementia.

Wrap Up: Lesson 1

Changing Practices

  • Make sure the environment supports a sense of safety and comfort.
  • Think about behaviors as communication of unmet needs. (The Oasis program and the Green House project are two examples.)
  • Anticipate and meet core human needs—physical, social, spiritual and psychological— to reduce unnecessary distress behaviors.
  • Address the realities of boredom, helplessness, and hopelessness that continue to plague many individuals, especially those living in facilities.
  • Create individualized service, support and care plans that reflect a person’s wishes and emphasize strengths and choice.
  • Address stress in caregivers.