Careful Consideration of Supportive Strategies Over Behaviour-Modifying Drugs for Dementia Residents
By Jo Crossland, Head of Dementia Care, Avery Healthcare (www.averyhealthcare.co.uk)
Mood-altering or behaviour modifying medication to treat ‘behaviour’ in dementia care has long been a contentious subject.
The Banerjee report [2009] provided a sobering reminder of the dangers of people with often severe cognitive impairment being routinely prescribed powerful antipsychotic medication. This should have led to widespread change in how we regard the distressed actions and reactions experienced by individuals living with dementia.
Undoubtedly, creating national reporting requirements to monitor antipsychotic use was a positive development, which subsequently caused a reduction in the number of these drugs being prescribed to residents with dementia living in Care Homes.
However, other mood-altering or behaviour modifying medication continues to be prescribed, often with apparent little regard to the root cause of a person’s distress, and frequently without thoroughly considering the potential impact of what can be significant side effects to that individual.
For example, Lorazepam (also known as Ativan) is one of the groups of drugs known as Benzodiazepines, which can be clinically effective as a short-term treatment for several conditions, including anxiety and anxiety-induced insomnia [https://bnf.nice.org.uk]. Despite being recommended to be taken for no more than four weeks, due to the high risk of tolerance and dependence, in reality, Lorazepam is frequently prescribed to residents in care homes for long-term use. It is often administered to ‘manage’ distress in people with dementia on an ‘as required’ basis, without exploring underlying reasons for distress or considering alternative non-pharmacological treatment options.
Common side effects of this drug and other Benzodiazepines include feeling sleepy or tired in the daytime, increased confusion, dizziness, and problems with coordination and controlling movements which can increase the risk of falls [https://bnf.nice.org.uk]. In addition, paradoxical effects of Lorazepam can include restlessness, agitation and feeling angry, risking making everyday life harder than ever for a person coping with cognitive decline.
When supporting a person with dementia who has become distressed or is experiencing frequent and unpleasant actions and reactions, the cause of the distress should always be investigate, with non-pharmacological care interventions attempted first, before Benzodiazepines or antipsychotic medication to treat distress is considered.
There could be any number of reasons as to why a resident with dementia may be experiencing distress, for example; physical causes, including pain and infection, or external triggers including unfamiliar or overcrowded environments or apparently unrealistic demands being made by others – common occurrences for a person with dementia living in a care home.
Addressing underlying physical or external factors or conditions and using life story work to understand a person’s established and preferred way of living must be thoroughly considered by care teams working to support residents with dementia. This will provide alternative strategies to understand triggers for an individual and enable suitable approaches to be put in place to support a person during periods of distress. For example, avoiding situations that the team know a resident with dementia cannot cope with and exploring alternative options that the person finds more tolerable.
Of course, we should never say never to mood-altering and behaviour modifying drugs – at the right time, for the right reasons, these medicines can be the difference between well-being and despair for an individual. However, they should never be the first line of treatment. People living with dementia deserve better than that.
References:
Banerjee, S. (2009) The use of antipsychotic medication for people with dementia: Time for action. Department for Health, London.
BNF British National Formulary – NICE
