April 21, 2014 | University of Michigan Health System
Publishing their recommendations under the easy-to-remember acronym of DICE (Describe, Investigate, Evaluate, and Create), a 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.
“Often more than memory loss, behavioural symptoms of dementia are among the most difficult aspects of caring for people with dementia,” she said. “These symptoms are experienced almost universally, across dementia stages and causes. 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’ behaviour and reducing triggers for behavioural issues in their environment and daily life, but too few health teams are trained in their use.
Asking the caregiver, and the patient if possible, to describe the “who, what, when and where” of situations where problem behaviours occur and the physical and social context for them. Caregivers could take notes about the situations that led to behaviour issues, to share with health professionals during visits.
Having the health provider look into all the aspects of the patient’s health, dementia symptoms, current medications and sleep habits, that might be combining with physical, social and caregiver-related factors to produce the behaviour.
Working together, the patient’s caregiver and health providers develop a plan to prevent and respond to behavioural issues in the patient, including everything from changing the patient’s activities and environment, to educating and supporting the caregiver.
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.
The authors said that health providers who care for dementia patients should familiarise themselves with the DICE approach.
“Innovative approaches are needed to support and train the front-line providers for the burgeoning older population with behavioural symptoms of dementia,” said Dr. Kales. “We believe that the DICE approach offers clinicians an evidence-informed structured clinical reasoning process that can be integrated into diverse practice settings.”