Use DICE method for dementia

Caregivers, and healthcare professionals,here is some great information

Here is a great dementia resource for caregivers and healthcare professionals,

Your residents will love the Amazon Kindle Fire

Here is information on being the best caregiver you can be

Here is a way for nurses administrators, social workers and other health care  professionals to get an easyceu or two

Follow alzheimersideas on twitter
The Dementia Caregiver's Little Book of Hope [Kindle Edition]

SOURCE:
University of Michigan
An innovative technique called "DICE" empowers caregivers, patients & professionals to work together and reduce dementia's behavioral problems. Learn how it can help cut antipsychotic drugs and make life easier for everyone. 

---

ANN ARBOR, Mich. — A novel approach to handling agitation, aggression and other unwanted behaviors by people with dementia may help reduce the use of antipsychotics and other psychiatric drugs in this population, and make life easier for them and their caregivers, a team of experts says.

The new DICE model - for Describe, Investigate, Evaluate, and Create - seeks to reduce psychotropic medication use in dementia patients.

Publishing their recommendations under the easy-to-remember acronym of “DICE”, the panel of specialists in senior mental health hope to spark better teamwork among those who care for dementia patients at home, in residential facilities and in hospitals and clinics.

In fact, the federal agency that runs Medicare and funds much dementia-related care has made the DICE approach an official part of its toolkit for reducing the use of antipsychotic drugs and other mental health medications in people with dementia.

D: Describe - Asking the caregiver, and the patient if possible, to describe theThough these drugs may still help some patients, the important paper in the Journal of the American Geriatrics Society says, many non-medication approaches could also help reduced unwanted behaviors, also known as neuropsychiatric symptoms of dementia. But it will take teamwork and communication to do it.

Most people with Alzheimer’s disease and other memory-affecting conditions also get aggressive, agitated, depressed, anxious, or delusional from time to time, says senior author Helen C. Kales, M.D., head of the U-M Program for Positive Aging and Geriatric Psychiatry at the University of Michigan Health System and investigator at the VA Center for Clinical Management Research . Or, they might have delusions, hallucinations, or lose inhibitions.

“Often more than memory loss, behavioral symptoms of dementia are among the most difficult aspects of caring for people with dementia. These symptoms are experienced almost universally, across dementia stages and causes,” she says. “Sadly, these symptoms are often associated with poor outcomes including early nursing home placement, hospital stays, caregiver stress and depression, and reduced caregiver employment.”

Doctors often prescribe these patients medications often used in patients with mental health disorders, despite little hard evidence that they work well and despite the risks they can pose -- including hastening death. Meanwhile, studies have shown promise from non-medication approaches to changing dementia patients’ behavior and reducing triggers for behavioral symptoms in their environment and daily life. But too few health teams are trained in their use.

Kales and her colleagues Laura N. Gitlin, Ph.D. and Constantine G. Lyketsos, M.D. from Johns Hopkins University authored the new paper on behalf of a group of experts, called the Detroit Expert Panel on the Assessment and Management of the Neuropsychiatric Symptoms of Dementia, who developed the DICE approach.

Sponsored by Kales’ program, the national multidisciplinary panel of experts met in Michigan to create a comprehensive approach to behavioral management.

Dubbed “DICE” for Describe, Investigate, Evaluate, and Create, it details key patient, caregiver and environmental considerations with each step of the approach and describes the “go-to” behavioral and environmental interventions that should be considered.

Briefly described, the components are: 

• 1. Who
  2. What
  3. When
  4. Where
  of situations where problem behaviors occur and the physical and social context for them. Caregivers could take notes about the situations that led to behavior issues, to share with health professionals during visits.

• I: Investigate – Having the health provider look into all the aspects of the patient’s
  1. health
  2. Dementia symptoms
  3. Current medications
  4. Sleep habits
  that might be combining with physical, social and caregiver-related factors to produce the behavior.

• C: Create – Working together, the patient’s caregiver and health providers develop a plan to prevent and respond to behavioral issues in the patient, including everything from
  1. Changing the patient’s activities
  2. Adjusting the environment
  3. Care education
  4. Support for the caregiver.

• E: Evaluate – Giving the provider responsibility for assessing
  1. How well the plan is being followed
  2. how it’s working
  3. What might need to be changed.

The authors say that doctors should prescribe psychotropic drugs only after they and the patient and caregiver have made significant efforts to change dementia patients’ behavior through environmental modifications and other interventions, with three exceptions related to severe depression, psychosis or aggression that present risk to the patient or others. 

Now, the authors say, health providers of all kinds who care for dementia patients should familiarize themselves with the DICE approach – as should the spouses, adult children and others who care for dementia patients at home.

“Innovative approaches are needed to support and train the front-line providers for the burgeoning older population with behavioral symptoms of dementia,” says Kales, a professor in the U-M Medical School’s Department of Psychiatry and member of the U-M Institute for Healthcare Policy & Innovation . “We believe that the DICE approach offers clinicians an evidence-informed structured clinical reasoning process that can be integrated into diverse practice settings.” 

Gitlin, who directs the Center for Innovative Care in Aging at the Johns Hopkins School of Nursing, adds, “The DICE approach is inherently patient- and caregiver-centered because the concerns of individuals with dementia and their caregivers are integral to each step of the process. DICE also enables clinicians to consider the roles of nonpharmacologic, medical and pharmacologic treatments concurrently.”

Lyketsos, chair of the Department of Psychiatry at Johns Hopkins Bayview, stresses that the approach “has tremendous utility in clinical trials of treatments for behavioral symptoms, particularly in testing new medications. DICE can be used to better subtype behaviors, or focus on particular behaviors at randomization coupled with systematic treatment approaches”.

MORE INFORMATION:

Reference: Journal of the American Geriatrics Society, Volume 62, Issue 4, pp 762–769, April 2014

Learn more about the U-M Program for Positive Aging , including its resources for health care providers to assist with management of behavioral aspects of dementia

Calm disturbing dementia behavior without drugs

Caregivers, and healthcare professionals,here is some great information

Here is a great dementia resource for caregivers and healthcare professionals,

Your residents will love the Amazon Kindle Fire

Here is information on being the best caregiver you can be

Here is a way for nurses administrators, social workers and other health care  professionals to get an easyceu or two

Follow alzheimersideas on twitter
The Dementia Caregiver's Little Book of Hope [Kindle Edition]

University of Michigan Health System

ANN ARBOR, Mich. — Doctors write millions of prescriptions a year for drugs to calm the behavior of people with Alzheimer’s disease and other types of dementia. But non-drug approaches actually work better, and carry far fewer risks, experts conclude in a new report. 

The new DICE model - for
Describe, Investigate, Evaluate, and Create -
seeks to reduce psychotropic medication use in dementia patients.

In fact, non-drug approaches should be the first choice for treating dementia patients’ common symptoms such as irritability, agitation, depression, anxiety, sleep problems, aggression, apathy and delusions, say the researchers in a paper just published by the British Medical Journal.

The best evidence among non-drug approaches is for those that focus on training caregivers — whether they are spouses, adult children or staff in nursing homes and assisted living facilities — to make behavioral and environmental interventions.

The researchers, from the University of Michigan Medical School and Johns Hopkins University, reviewed two decades’ worth of research to reach their conclusions about drugs like antipsychotics and antidepressants, and non-drug approaches that help caregivers address behavioral issues in dementia patients.

They lay out their findings along with a framework that doctors and caregivers can use to make the most of what’s already known. Called DICE for Describe, Investigate, Evaluate, and Create, the framework tailors approaches to each person with dementia, and as symptoms change.

“The evidence for non-pharmaceutical approaches to the behavior problems often seen in dementia is better than the evidence for antipsychotics, and far better than for other classes of medication,” says first author Helen C. Kales, M.D., head of the U-M Program for Positive Aging at the University of Michigan Health System and investigator at the VA Center for Clinical Management Research . “The issue and the challenge is that our health care system has not incentivized training in alternatives to drug use, and there is little to no reimbursement for caregiver-based methods.”

Coincidentally, a new U.S. Government Accountability Office report published the same day as the BMJ paper addresses the issue of overuse of antipsychotic medication for the behavior problems often seen in dementia.  It finds that one-third of older adults with dementia who had long-term nursing home stays in 2012 were prescribed an antipsychotic medication -- and that about 14 percent of those outside nursing homes were prescribed an antipsychotic that same year.

The GAO calls on the federal government to work to reduce use of these drugs further than it’s already doing, by addressing use in dementia patients outside nursing homes.

Kales, however, cautions that penalizing doctors for prescribing antipsychotic drugs to these patients could backfire, if caregiver-based non-drug approaches aren’t encouraged.

She and her colleagues from Johns Hopkins, Laura N. Gitlin PhD and Constantine Lyketsos MD, note in their paper that “there needs to be a shift of resources from paying for psychoactive drugs and emergency room and hospital stays to adopting a more proactive approach.”

But they also write, “drugs still have their place, especially for the management of acute situations where the safety of the person with dementia or family caregiver may be at risk.” For instance, antidepressants make sense for dementia patients with severe depression, and antipsychotic drugs should be used when patients have psychosis or aggression that could lead them to harm themselves or others. But these uses should be closely monitored and ended as soon as possible,

The authors lay out five non-pharmacologic categories to start with based on their review of the medical evidence. These approaches have been shown to help reduce behavior issues:

• Providing education for the caregiver
• Enhancing effective communication between the caregiver and the person with dementia
• Creating meaningful activities for the person with dementia
• Simplifying tasks and establishing structured routines
• Ensuring safety and simplifying and enhancing the environment around the patient, whether in the home or the nursing/assisted living setting

They also note that many “hidden” medical issues in dementia patients – such as urinary tract infection and other infections, constipation, dehydration and pain – can lead to behavioral issues, as can drug interactions. So physicians should look to assess and address these wherever possible.

Kales, Gitlin and Lyketsos  are working with the U-M Center for Health Communications Research to launch a National Institute of Nursing Research-sponsored clinical trial this spring that will test the DICE approach through a computer based tool for caregivers called the WeCareAdvisor. The tool will help families identify tips and resources in a single computer interface to address behavioral symptoms.  The tips are designed to prevent or mitigate possible triggers for common behavioral symptoms such as pacing, repetitive questioning, restlessness, or shadowing.

"Behavior-based strategies may take longer than prescriptions. But if you teach people the principles behind DICE, the approach becomes more natural and part of one’s routine. It can be very empowering for caregivers or nursing home staff.” -- Helen Kales, M.D.

For instance, de-cluttering the environment, using music or simple activities that help to engage a person with dementia , or using a calm voice instead of being confrontational, could help greatly to reduce behavioral symptoms, Kales says. And making sure that caregivers get breaks from their responsibilities and take care of themselves, especially in the home, can help them avoid burnout and taking their frustration out on patients.

“Behavior-based strategies may take longer than prescriptions,” acknowledges Kales, a member of the U-M Institute for Healthcare Policy and Innovation. “But if you teach people the principles behind DICE, the approach becomes more natural and part of one’s routine. It can be very empowering for caregivers or nursing home staff.”

More research on both new drug options and the best ways to assess and address behavioral symptoms is needed, the authors conclude. But in the meantime, the evidence to date comes down in favor of non-drug approaches in most cases.

THE COMPONENTS OF THE DICE APPROACH ARE:

• D: Describe - Asking the caregiver, and the person with dementia if possible, to describe the “who, what, when and where” of situations where problem behaviors occur and the physical and social context for them. Caregivers could take notes about the situations that led to behavior issues, to share with health professionals during visits.

• I: Investigate – Having the health provider look into all the aspects of the person’s health, dementia symptoms, current medications and sleep habits, that might be combining with physical, social and caregiver-related factors to produce the behavior.

• C: Create – Working together, the patient’s caregiver and health providers develop a plan to prevent and respond to behavioral issues in the person with dementia, including everything from enhancing the patient’s activities and environment, to educating and supporting the caregiver.

• E: Evaluate – Giving the provider responsibility for assessing how well the plan is being followed and how it’s working, or what might need to be changed.

More information

Reference: BMJ 2015; 350 doi: http://dx.doi.org/10.1136/bmj.h369 (Published 02 March 2015)

Funding: National Institutes of Health, NR014200, Johns Hopkins Alzheimer’s Disease Research Center (P50AG005146).

Previous publication - the DICE model: Journal of the American Geriatrics Society, April 2014. Paper