Success of antipsychotic alternatives in dementia unproven: study

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Nonpharmacologic interventions are not necessarily effective in reducing agitation and aggression in assisted living and nursing home residents who have dementia, despite research suggesting otherwise, according to a newly published study in the Journal of the American Geriatrics Society.

The authors, from the University of Minnesota, searched several scientific databases for clinical trials reporting behavioral outcomes in the care of residents with dementia that did not involve drugs. They found 19 relevant studies addressing caregiver training, dementia care mapping, person-centered care, clinical protocols to reduce the use of antipsychotics and other psychotropic drugs, and emotion-oriented care, as well as 11 other studies that evaluated other interventions.

Evidence was insufficient to prove that any of the nonpharmacological interventions was more effective than usual care in lessening agitation and aggression, the authors wrote, noting that their findings run counter to those of a recent review that found that dementia care mapping and person-centered care do reduce agitation. The design of that study, the authors said, may have biased its results.

“Despite the need for evidence that will help reduce the use of antipsychotics for treatment of agitation and aggression in nursing home and assisted living facility residents with dementia, evidence of the efficacy of nonpharmacological care-delivery interventions in this setting is weak,” they wrote. Researchers must improve the design of studies if they are to prove that such interventions work, the authors said.

In a related editorial, behavioral psychologists John F. Schnelle, Ph.D., of Vanderbilt University and Sandra F. Simmons, Ph.D., of the Veterans Affairs Tennessee Valley Healthcare System in Nashville, said that high staff turnover and insufficient staffing could be lessening the positive effects of interventions, which must be implemented consistently and over time. “This consistency is difficult to accomplish and requires a high degree of training, as well as a therapist or caregiver who knows the person well,” they wrote.

Studies of ways to prevent the development of behavioral disturbances instead of treating them when they occur also are needed, Schnelle and Simmons said.

Despite the findings of the current study, the editorial writers expressed “enthusiasm” for non-drug interventions for those with dementia and said that efforts to implement and evaluate their effectiveness are worthwhile. “In contrast to medications, nonpharmacological approaches should have minimal to no unintended negative side effects and the potential to improve a resident's functioning in multiple domains, including quality of life,” they concluded.

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