Behavior Challenges May Need Loving Care AND Medications For The Most Humane Approach

On March 18, I came across a  post for older adults on a blog written by a California-based geriatric psychologist and an elder care lawyer. In this post, these the authors put forward a view that is commonplace in geriatrics: If you solve the underlying issues—whether they be related to health, boredom, routines or whatever—you usually can solve the behavioral problems of dementia. If you can’t fix troublesome behaviors, the thinking goes, then you’re just not trying hard enough.  I would heartily agree that engaging an elder, assisting them to pursue their interests and decreasing over-stimulation and boredom is crucial, and that is all the more true if the elder has dementia. Sometimes you can fix an elder’s acting out by fixing an underlying health complaint, or by bargaining with them, as suggested in the post I read, or by taking them to do some favored activity like dancing or playing a round of golf, as also suggested by those two experts. By all means, try those things first. But don’t blame yourself, don’t berate the nursing home staff or the home health care aides if those strategies don’t work.  Sometimes it is from the underlying dementia changes, or the medications the patient has been given, Ativan, Detrol, Keppra, Sinemet, Tylenol PM.....

In my rounds doing geriatric house calls in the San Francisco Bay Area, I find that when behavioral strategies don’t work, we need to look to medication to decrease the anger or paranoia or fear. I would not endorse: If your elderly loved one continues to climb out of windows, or to attack her caregivers, or to be sexually inappropriate in his nursing home, then you just aren’t loving that elder well enough. You just aren’t managing that elder’s life effectively.

I think this unfairly blames families who have been loving and trying to engage their elder for a problem that may be medical: After all, dementia has its roots in brain malfunctions that result from small strokes or plaques on brain neurons or other medical issues. At a conference, I once heard a psychologist make it sound like agitation in dementia was always the fault of the family not providing proper care.  I think that’s as wrong-headed as the doctors of yore who used to think that Schizophrenia resulted from a cold mother.

Sometimes, when you’ve tried everything else( including stopping the medications that can make behavior worse and treating pain, engaging the elder in activities they enjoy) , it’s OK to use medications with dementia patients who have overwhelming anxiety or other behavior problems. But in geriatrics, there is a strong prejudice against using any psychotropic drugs in dementia patients. For instance, in the blog mentioned above, the experts say, “using drugs may appear more humane, but it doesn’t solve the problems that caused the agitation.”  Those medications can cause a lot more problems, we would never use them to sedate.   We would use them when behaviors, despite vigorous behavioral interventions, do not relieve the aggressive and distressing behaviors.   Of course we first have a full discussion of the risks of the antipsychotics ( if they are needed, for the specific behaviors as a last resort), that they are not FDA approved, that they have a 2% increased stroke risk and a 1% sudden death risk; they can lead to a faster decline.  They must be monitored closely and tapered as soon as possible.

I have also heard that the psychoactive medications only work 20% of the time, "Would you use an antibiotic for pneumonia 20% of the time?"I would say a better analogy is Parkinson's Disease; the medications do not fix the disease, but they improve function.  That is what behavior medications should do in dementia.

If you use the correct medications, and if you start them in small doses, only increasing until you find the smallest effective dose, you can make huge improvements in an elder’s quality of life. I have found that using anti-psychotics judiciously  doesn’t just appear more humane, it IS more humane if it addresses the paranoid and delusional thinking that lead to the angry, aggressive behavior that keeps an elder thinking that their spouse or child is trying to poison them, control them.   (This is not to downplay financial elder abuse- in which often the family may try to control the elder- more on that later.)

 

In the  push to avoid anti-psychotic drugs like Haldol and Seroquel and Risperdal, geriatric experts have given the green light to short-acting tranquilizers like Ativan/Lorazepam, Xanax/Alprazolam. The idea seems to be that because they’re short-acting, these “benzodiazepine” or “benzos” tranquilizers, or sleeping pills like Ambien are OK. But I find that they often make problem behaviors worse, or that they simply stupefy a patient into docile silence for a time, then the patient will be more uninhibited, angry and aggressive.

Ativan  may be useful in an emergency when a patient is a danger to herself and others, or when a person is actively dying. Otherwise, I don’t use it. Actually, I call Xanax the “crack of benzos.” It’s addictive, contributes to anxiety and has a very difficult withdrawal once you start it, sometimes as little as 3 days.

On our website, here,  I have a section on the various “psychoactive medications” such as Seroquel, Risperdal, Depakote, Lexapro and the like. It’s written in English, not “medical-ese.” In it, I outline what problems these drugs can address. I outline what common side effects these drugs have. Again and again, I have seen carefully selected medications make it possible for elders to have a better quality of life, whether that means staying at home, or just engaging with family and friends.  It is always preferable to use more simple medications, such as Citalopram, Gabapentin, or some prefer Trazodone.

In more than a  two decades of treating dementia patients—as an assistant professor at UC San Francisco, as a hospice medical director, and as a private practitioner doing house calls— I have found that dementia can cause changes that do not respond to the most loving and engaging of environments. When these changes cause problems, they need to be treated. That’s the most humane approach.