Alternatives to Antipsychotic Use of Behavior Problems of Dementia

The purpose of this paper is to address alternatives to antipsychotic use for the behavioral problems associated with dementia patients. Due to changes in personality and the psychotic features of dementia, antipsychotics typically are the first line of treatment. Overuse of antipsychotics in the treatment of behavioral problems of dementia has many risks which include decreased cognition, extrapyramidal motor symptoms, and increased mortality rates. The goal of this paper is to identify the dangers and concerns associated with antipsychotic use and identify the available alternative treatments.

Antipsychotic Use in Dementia Patients

Antipsychotic medications are commonly used in patients with dementia to treat and reduce psychological symptoms. The behavioral and psychological symptoms of dementia include agitation, aggression, sleep disturbance, depression, and psychosis. “Delusions are present in 25% of people with dementia in clinical settings” (Ballard, 2007, p. 913). It has been demonstrated that antipsychotics provide an effective treatment to reduce these symptoms, providing relief for the patient, increasing quality of life, and reducing caregiver stress. While antipsychotics have largely been successful in controlling behavioral symptoms, their prolonged and excessive use have notable risks.

Banjeree (2009) observed that antipsychotics are used inappropriately and frequently and that the risks outweigh the benefits. Banerjee also reported that some 180,000 people in the United Kingdome alone are treated with antipsychotic medications. The risks for prolonged antipsychotic use are associated with increased mortality rates. While other treatments are available, the use of antipsychotics is still consistent as they serve a critical purpose.

Removing antipsychotics from the available treatment options is a difficult task. But, with training and education, nurses, clinicians, and primary care providers can offer alternative and complementary treatments to families. This would allow families to attempt treatment without the dangers antipsychotics pose. Additionally, a multidisciplinary approach utilizing different medications such as anticonvulsants, acetylcholinesterase inhibitors, antidepressants, and anxiolytics may prove to be additional effective treatments without the associated risks.

Literature Review

The widespread use of antipsychotics in the treatment of behavioral and psychological symptoms in dementia has become a worldwide concern, thus prompting researchers to develop alternative treatments.

Nazarko (2011), observed that behavioral and psychological symptoms of dementia are challenging and in some cases dangerous to the patient and caregiver. It was also mentioned that caregiving environments can be modified or changed to reduce challenging behaviors. Nazarko (2011), also reported that excessive use of neuroleptic drugs can also decrease the quality of life and increase the risk of death. Recommendations for alternative treatments included cholinesterase inhibitors that can improve memory and function in dementia patients. Safety concerns were also addressed and that more focus should be placed on the patient’s environment.

In another study, van Marwijk and Speigel (2009), report that “antipsychotic drugs should be used as a considered second-line treatment when other non-pharmacological approaches have failed” (p. 193). The authors go on to discuss the need for a multidisciplinary team that would include case management. This type of collaborative care can foster a team-based approach that would include geriatric nurses, psychiatrists, and physicians. They emphasize the importance of nurses completing medication reviews to assist in the treatment process.

In yet another study, Rayner, O’Brien, and Schoenbacher (2006), it was observed that patient behavior modification, use of sensory interventions, environmental changes, sleep monitoring, and incorporating daily routines should be the first approach in treating psychological symptoms. The authors recommend educating the caregiver about the disease process and coping skills. The key to their discussion was to ensure the caregiver understood the lack of intentionality of the patient’s behaviors. One example recommended calls for behavior approaches that include distraction and asking closed-ended questions.

In another study by Schneider, Dagerman, and Insel (2006), it was noted that dementia patients treated with antipsychotics were at risk for adverse events such as extrapyramidal motor system effects and increased risk of death resulting from cardiovascular causes. The authors recommend the use of cholinesterase inhibitors to manage symptoms. They also recognized that more research and analysis would benefit providers.

In a study by Ballard (2007), it was observed that psychological interventions can include alternative treatments that include essential oils. Ballard (2007), noted that due to reliance on antipsychotics that alternative treatments are not utilized. Ballard (2007), offered some additional alternatives to treating dementia patients with other pharmacological treatments that include cholinesterase inhibitors, menantine, carbamazepine, and antidepressants. He offered that lower mortality rates are associated with these pharmacological treatments. The author agreed that antipsychotics are effective medications, but due to the risks involved, alternative treatments should be investigated and pursued.

In yet another study, O’Connor, Ames, Gardner, and King (2009), reported that due to concerns raised by psychogeriatricans, alternative treatments can reduce or relieve symptoms. One treatment recommended was psychosocial treatment. Due to the low cost and ease of application, these treatments might be adequate for some patients, but the recommendation was for clinicians to work closely with providers to develop a multi-pronged strategy. This strategy called for the inclusion of music therapy, staff reinforcing positive behaviors, and providing creative, engaging activities for patients.

Implications for Practice

All of the studies in this literature review point to the dangers of using antipsychotics in elderly patients with dementia. The studies emphasize the danger, health risks, and safety concerns raised with continued antipsychotic use. From the above works, the major trends are that the continued use of antipsychotics is dangerous and that there is a significant need for alternative treatments. The studies also point to a shift in paradigm to include alternative methods to treat the behavioral and psychological symptoms associated with dementia patients. The articles reviewed presented compelling arguments to include alternative treatments to reduce side effects and increase mortality. The studies also described the need for increased training for staff at caregiving facilities, nurses, and providers about alternative treatments.

Integration

This literature review helped to increase awareness of alternative treatments for the behavioral symptoms associated with dementia. As noted previously, a multidisciplinary team that focuses on the specific needs and symptoms of dementia patients would improve the quality of life and decrease the need for long-term use of antipsychotics. Treatment plans should include providing psychosocial treatments, improving the environment, addressing safety concerns, and provide training for family caregivers and providers.

At issue is the implementation of training programs for family members. This is a key area where nurses can be at the forefront of the patient’s treatment and work closely with the family to integrate the alternative treatment methods. The benefit is two-fold, the patient’s quality of life is increased and caregiver stress is reduced. Yet, training programs can incur additional expenses that most family members simply cannot afford. Supportive care environments would need to have trained staff to meet the caregiver's needs for training and education. Ameliorating the barriers of cost and staff would benefit all involved.

Recommendations

There have been recommendations for reducing the use of antipsychotics in elderly patients with dementia. In several of the studies mentioned, alternative treatments such as behavior modification, environmental changes, and treatments using essential oils were recommended to manage the symptoms associated with dementia. Identification of symptoms was noted in one of the aforementioned studies as the key to providing the appropriate treatment.

Rayner, O’Brien, and Schoenbacher (2006) state that “Before introducing an intervention, the behavior problem or symptom must be identified and quantified in terms of frequency and severity. Identification and elimination of precipitating causes are essential”. This helps to eliminate the unnecessary use of antipsychotic medications.

Another compelling recommendation by Ballard (2007) was the use of other pharmacological medications that do not have risks associated with increased mortality rates. Ballard (2007), reported that there is emerging evidence that other medications, such as cholinesterase inhibitors, can also improve the behavioral symptoms in patients with dementia. Ballard (2007), also describes emerging studies and several placebo-controlled trials have suggested that aromatherapy is effective.

In addition to changing the type of medication, O’Connor, Amers, Gardner, and King (2009) recommend the implementation of psychosocial programs to alleviate symptoms by preventing potential outbursts. Their recommendations included music therapy, creative activities, and staff providing positive reinforcement.

Finally, another recommendation included the development and implementation of training programs at nursing care facilities to assist family members and caregivers learn about the disease process of dementia. Implementing training programs on reducing caregiver stress would greatly enhance the quality of life for the patient as well as the caregiver. Educating staff about behavioral interventions rather than depending on antipsychotic medications could help physicians reduce the amount and frequency that antipsychotics are used in dementia care.

Conclusion

Due to changes in personality and psychotic features of dementia, antipsychotics are typically the first line of treatment. With developments in alternative treatment and research information, treatment providers can offer these alternative treatments to address the behavioral and psychological concerns associated with dementia. The literature review revealed that alternative treatments include psychosocial interventions, behavior modifications, essential oils, environment modification, and providing education on the disease process for caregivers. The development of a multidisciplinary team would help to improve the quality of life and decrease the need for long-term use of antipsychotics. Implementing training programs for family members and staff would decrease caregiver stress and encourage staff to utilize additional strategies. The integration of caregiver training and staff development pose potential barriers due to the associated costs. Another barrier is the lack of appropriate research studies and controlled trials. Before a treatment plan and interventions can be developed, trained staff must properly identify the symptoms posing the most risk to the patient. Only then can staff implement an effective treatment plan.

References

Banjeree, S. (2009). The use of antipsychotic medication for people with dementia: Time for action. A report for the Minister of State for Care Services. London: Department of Health, 2009.

Ballard, Clive, M.R.C.Psych, M.D. (2007). Agitation and psychosis in dementia. The American Journal of Geriatric Psychiatry, 15(11), 913-7. Retrieved from http://search.proquest.com.library.capella.edu/docview/195985461?accountid=27965.

Nazarko, L. (2011). Dementia: Neuroleptic drugs and alternative treatments. British Journal of Healthcare Assistants, 5(7), 331-334.

O'Connor, D., W., Ames, D., Gardner, B., & King, M. (2009). Psychosocial treatments of behavior symptoms in dementia: A systematic review of reports meeting quality standards. International Psychogeriatrics, 21(2), 225-240.

Rayner, A., O’Brien, J., & Schoenbacher, B. (2006). Behavior disorders of dementia: Recognition and treatment. American Family Physician, 73(4), 647-652.

Schneider, L. S., Dagerman, K., & Insel, P. S. (2006). Efficacy and adverse effects of atypical antipsychotics for dementia: Meta-analysis of randomized, placebo-controlled trials. The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry, 14(3), 191

van Marwijk, H., & Spiegel, W. (2009). Overuse of antipsychotic medication in elderly people with dementia? A view from general practice. Mental Health in Family Medicine, 6(4), 191.