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High Risk, Low Benefit
The powerful drugs may be prescribed because clinicians have had few other choices or because the risks were not fully understood.
“Unfortunately, there are limited nonpharmacologic treatments and limited expertise with these treatments, although some are effective, and the ones that exist can be resource intensive,” Gellad said.
“In some cases, the benefits may actually outweigh the risks of treatment, but it’s clear that many clinicians in the past were underestimating the actual risks and perhaps overestimating the benefits,” he added.
A number of studies have shown that antipsychotics are not efficacious in alleviating behavioral issues in patients with dementia. At the same time, they are associated with an increased risk of mortality. In 2005, the Food and Drug Administration (FDA) issued a warning for atypical antipsychotics that stressed the risk of increased morality associated with their use in the elderly with dementia. In 2008, the FDA extended the warning to include all antipsychotics.
Gellad noted that study data “was collected prior to these warnings, so we cannot draw conclusions about whether they make a difference in current practices.”
Prior to the study period, however, “reports had already appeared in print about the risks of these drugs,” he said.
More recently, however, the VA has tested a patient-centered, nonpharmacological approach to management of dementia-related behaviors. In 2010/2011, the VA introduced Staff Training in Assisted Living Residences (STAR-VA) to 17 CLCs. The program adapts an interdisciplinary approach developed by Linda Teri, PhD, and colleagues at the University of Washington.
In the STAR-VA intervention, a doctoral level mental-healthcare provider (usually a psychologist) serves as a behavioral coordinator working closely with other interdisciplinary staff in the development and implementation of an individualized behavioral intervention plan.
According to Karel, who also is with the Harvard Medical School Department of Psychiatry, the program trains interdisciplinary teams to provide effective care for veterans with challenging dementia-related behaviors and improve clinical outcomes for participating veterans.
So far, the nonpharmocologic interventions appear to be working.
“Program evaluation data from the STAR-VA pilot revealed that veterans enrolled in STAR-VA demonstrated significant reductions in the frequency and severity of challenging dementia-related behaviors. In addition, these veterans exhibited decreases in symptoms of depression and anxiety,” Karel told U.S. Medicine.
The benefit extends to the CLC staff as well, she added.
“CLC mental-health providers participating in the pilot reported, overall, that STAR-VA helped them and their teams to better manage challenging behaviors, including agitation, disruptive vocalization, physical aggression and resistance to care,” Karel said.
1. Hanlon JT, Wang X, Castle NG, Stone RA, Handler SM, et al. Potential underuse, overuse and inappropriate use of antidepressants in older veteran nursing home patients. J Am Geriatr Soc. 2011 August; 59(8): 1412–1420.
2. Karel, M. J., Gatz, M., & Smyer, M. A. Aging and Mental Health in the Decade Ahead: What Psychologists Need to Know. American Psychologist. 2011 Sept 26. Advance online publication. doi: 10.1037/a0025393
3. Gellad WF, Aspinall Sl, Handler SM, Stone RA, Castle N, et al. Use of antipsychotics among older residents in VA nursing homes. Med Care. 2012 Nov;50(11):954-960.
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