DEAR DOCTOR: My mother is suffering from dementia and is increasingly difficult, but I'd hate for her to be given antipsychotics. Isn't there anything else that could be done to keep her calm?
DEAR READER: My heart goes out to you and your family. Dementia is one of the most difficult diseases to deal with -- for both patients and their loved ones. The loss of memory and the inability to incorporate new information is a struggle for many elderly patients. Some are able to cope with the loss of memory, but for others, the chaos of a poorly interpreted world causes agitation, irritability and anger.
Patients often scream about problems that aren't even part of their present reality -- leaving family members and health care staff struggling to manage their seemingly irrational agitation. Nursing homes in particular often request some form of treatment, whether it be restraints or medication, to calm these patients and to protect their employees.
Doctors often prescribe benzodiazepines or antipsychotic medications for such cases, but, of course, they have side effects. Most notably, they sedate patients to such an extent that their perception of reality is further altered. Further, antipsychotic medication has been linked to an increased risk of stroke and death.
There may be a better way. Many nursing facilities are now implementing a new program called Oasis. This program assesses both the biologic and psychological needs of the patient, shifting the emphasis away from a person's disabilities and focusing on his or her personhood. Early results are promising.
A 2017 study assessed the implementation of Oasis in 93 Massachusetts nursing homes, during which program coordinators and two to three staff members were trained in how to communicate with people suffering from memory impairment. These caregivers then helped train others within the nursing facility. Implementation of the Oasis program was verified by staff completion of webinars, trainer support meetings and training modules.
In comparing those facilities to 831 nursing facilities in New York and Massachusetts that didn't implement the program, researchers found that the use of antipsychotic medications dropped by 22.3 percent in the Oasis facilities, compared to a 17.2 percent drop in non-Oasis facilities.
Note that the drop in antipsychotic use appeared to be largely related to national trends, meaning that due to the awareness of side effects, practitioners overall are prescribing fewer antipsychotic medications to nursing home patients with dementia. That said, the Oasis program did show an additional benefit, supporting the idea that better training of staff can reduce some of the behavioral disturbances seen in nursing homes.
Another option for agitated patients is the use of antidepressants known as selective serotonin reuptake inhibitors, or SSRIs. These drugs -- the best studied in this respect is citalopram -- can be comparable in efficacy to antipsychotic medications, but without the significant side effects.
Finally, exercise, music and pet therapy also play a role in decreasing the agitation seen in those with dementia. All of these are worth exploring as you seek to maximize your mother's quality of life.
(Robert Ashley, M.D., is an internist and assistant professor of medicine at the University of California, Los Angeles.)
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