When we think of Alzheimer's disease or other dementias, we think of the loss of memory or the inability to recognize familiar faces, places, and things. But for caregivers, the bigger challenge often is coping with the other behaviors common in dementia: wandering, sleeplessness and anxiety or aggression.
Using antipsychotic drugs to try to ameliorate these symptoms has been common. According to a report released Monday from the Government Accountability Office, 1 in 3 dementia patients in nursing homes receives antipsychotics. Outside of nursing homes, 1 in 7 dementia patients are prescribed the drugs.
This is despite a warning from the Food and Drug Administration saying that antipsychotics increase the risk of death for people with dementia.
And antipsychotics are much less effective than non-drug treatments in controlling the symptoms of dementia, according to a study published Wednesday in the British Medical Journal. Dr. Helen Kales, a psychiatrist who directs the University of Michigan's Program for Positive Aging, examined more than two decades of scientific studies, along with her coauthors, Laura N. Gitlin and Dr. Constantine Lyketsos, both of Johns Hopkins University. They say the treatments that showed the best results were the ones that trained caregivers how to communicate calmly and clearly, and to introduce hobbies or other activities for the patient. The treatments also followed up with caregivers.
"Why I think the caregiver interventions work is because they train caregivers to look for the triggers of the symptoms," says Kales. "And when [caregivers] see the triggers of the symptoms, they train them to manage them...It's inherently patient- and caregiver-centered."
The study showed that antipsychotic drugs were only about half as effective as the caregiver interventions. While antipsychotics can be useful in emergency situations, Kales says their risk of deadly side effects increases over time.
"The risk is small if you look over the short term," Kales says. So over the course of 12 weeks, the risk of increased mortality would be 1 to 2 percent. But at six months, the risk of death rises to 4 to 7 percent with commonly used antipsychotics like haloperidol, risperidone and olanzapine. It continues to rise after that, she says.
Health care providers use antipsychotics, says Kales, partly because they haven't been trained to use non-drug approaches. And even if they did know how to use them, they're rarely reimbursed for doing so by Medicare or private insurance.
RENEE MONTAGNE, HOST:
One issue at the end of life, the overuse of antipsychotic drugs in nursing homes. Those drugs are used to curb the challenging symptoms of Alzheimer's and other types of dementia. But the FDA says the drugs can be lethal to the very patients they're meant to treat. Now a study in the British Medical Journal finds that antipsychotics are much less effective than treatments that don't use drugs. NPR's Ina Jaffe reports.
INA JAFFE, BYLINE: The study examined more than two decades' worth of clinical trials of drug and non-drug treatments for curbing anxiety, wandering and other behaviors that go along with dementia. Actually, University of Michigan psychiatry professor Helen Kales, the lead author of the study, doesn't really like the term non-drug treatment.
HELEN KALES: Because it's named for what it isn't.
JAFFE: Better terms would be behavioral or environmental therapy. The treatments that work are the ones that train caregivers...
KALES: To look for the triggers of the symptoms and when they see the triggers that they train them to manage them.
JAFFE: Kales' study shows antipsychotic drugs to be only about half as effective as non-drug interventions. Antipsychotics can be useful in emergency situation, she says, but their risk of deadly side effects increases over time.
KALES: The number of people that would die if they took the drug over something like a year seems to be in the rate of 10 to 15 percent.
JAFFE: Kales says health care providers use antipsychotics because they haven't been trained in the non-drug approaches, and they're usually not reimbursed for using them. Ina Jaffe, NPR News. Transcript provided by NPR, Copyright NPR.