A new review in The Cochrane Library finds that education and social support for staff and caregivers can reduce the use of antipsychotics in nursing home patients with dementia. Improved staff training and education, communication between personal and professional caregivers and support for everyone involved in the patient's care are effective non-pharmacological methods to try before using antipsychotic medications.
It has been estimated that over 60 percent of nursing home residents world-wide suffer from dementia. Dementia often produces disturbing behavioral effects, including wandering, shouting or displays of agitation or aggression. Antipsychotic drugs are regularly used as the first line of treatment for this challenging behavior in nursing homes, despite the fact that they can have serious side effects including over-sedation, falls and cardiovascular problems.
"Antipsychotics should not be the first choice of treatment for people with challenging behavior or behavioral and psychological symptoms of dementia," said study author Sascha Kopke, Ph.D., of the Institute of Social Medicine at the University of Lubeck in Germany. "Nursing homes should try non-pharmacological approaches and get everyone involved—nursing home staff, physicians and relatives."
The review analyzed data collected from four studies published in the 1990s, which involved 4337 male and female nursing home residents. Across the four studies, the staff interventions reduced the use of antipsychotic medications.
"Despite the limitations in the effectiveness of antipsychotic medications for the behavioral and psychological symptoms of dementia and the significant concerns about safety and tolerability, there is limited evidence-based guidance on non-pharmacological interventions for the treatment of behavioral symptoms in patients with dementia," said Brent Forester, M.D., director of the geriatric mood disorders research program and assistant professor of psychiatry at Harvard Medical School.
He added the risks of antipsychotic medications need to be weighed against benefits in acutely agitated patients with dementia and psychosis. "Pharmacological approaches may be required due to acute safety concerns," he said.
"Psychosocial interventions will always be complex interventions but nursing homes should avoid antipsychotic prescriptions and instead establish a culture of care by allowing person-centered care," said Kopke. "Instead of relying on antipsychotics they should implement other appropriate measures like multidisciplinary staff meetings, consultations and regular medication reviews."
But, Forester pointed out, "Despite the reduction in antipsychotic use with the behavioral interventions, none of the four individual studies found significant changes in the behavioral and psychological symptoms of dementia. I agree with the main findings but further research to study the effectiveness of non-pharmacological approaches to managing behavioral symptoms of dementia is sorely needed."
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