Behavioral therapies better than antipsychotics for dementia patients, nurses say

More than 20 percent of American nursing home residents with Alzheimer’s-related illness are on antipsychotic medications, despite the fact that this is an off-label use for the drugs and that dementia patients who take them are more likely to be hospitalized or to die. Medicaid spends more on this class of drugs than any other — including antibiotics, AIDS drugs or medicines to treat high blood pressure.

Ecumen, a Minnesota care organization, used behavior modification and other alternative techniques to reduce the use of antipsychotic drugs by 98 percent in 1,200 patients across its 16 nursing homes, saving $200,000 to $350,000 a month in Medicare and Medicaid spending on the medications and making patients more alert and active.

On Monday, two Ecumen nurses, Shelley Matthes and Maria Reyes, will be in the District to receive the Excellence in Dementia Care award from LeadingAge, an association of nonprofit aging-services providers, for their program, Ecumen Awakenings, which is set to expand to 40 assisted-living communities. We spoke with Matthes and Reyes about their program.

Why are dementia patients given antipsychotic medications, and why is it a problem?

SM: Everybody wants something to alleviate the misery and the suffering, so it’s natural that they would turn to a medication. But it doesn’t reduce their levels of anxiety; it just reduces their ability to express it. It puts people in a stuporous state.

MR: In the early ’80s we used to physically restrain our clients because we didn’t want them to fall and suffer a fracture. As health care has evolved, physical restraints are a thing of the past. But antipsychotic medications really could fall into the category of a chemical restraint. The behavior really doesn’t go away; it’s just that the client is sedated. It doesn’t improve quality of life.

What are some examples of behavior modification you used?

MR: The staff will not correct the client or be confrontational. If a client thinks that a staff member is their mother, then that staff member is their mother. The idea is that for every behavior there is an unmet need. If you are wandering, it’s because you are looking for the bathroom, you are looking for your job, you are looking for your children, you are looking for something to do. We need to know who our clients are, what they did in their past lives, what their interests are. One client who was wandering, pulling at his pants, kind of agitated, was a farmer. We could interpret that he was probably looking for the outhouse. He was unable to recognize the door with the sign on it; what he was looking for was a wood door with a moon on it. So a door was papered to look like a wood plank door with a moon.

SM: The key is having those personal stories, because when you lose your memory you’re not able to find them on your own. We have to have the family’s input, so we know about the blue ribbon pickles that Sally used to make.

What other therapies have you found to be effective?

MR: A marriage of holistic and western medicine. Aromatherapy, music therapy. They may not know the name of their loved ones, but once you start singing the songs from church that they grew up with, they know every word, they know every beat, you see the joy and relaxation come over their face. Also, when you have dementia you revert to your primary language. With one client who spoke Finnish, the staff learned a few words and phrases in Finnish — good morning, how are you — and that made a big difference.

It seems like such an approach would require a lot more investment of time and money into staff training.

SM: It’s about quality of life. And with the medications, there is a higher incident of stroke and heart attack. It’s a lot to care for somebody who is in a sedated state as well. And these meds are horribly expensive.

What difference do you see in clients who are on the medications and those who are not?

MR: It was really the lack of interaction from clients who were under the medications’ effects. The minute you reduce the medications, there’s a difference. They smile and say good morning to you, or take a few extra steps.

SM: They began eating and just became more alive and more awake, and that’s why we called it Awakenings. It keeps them healthier longer, certainly. It’s not stopping the disease’s progress, but it’s improving the quality of life for the person, and the quality of the family experience as well.

Tara Bahrampour, a staff writer based in Washington, D.C., writes about aging and mental health.
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