March 9, 2015 |

DICE model provides alternative to drugs for dementia

Components of the DICE model:

Describe. Ask the caregiver—and the person with dementia if possible—to describe the “who, what, when and where” of situations where problem behaviors occur and the physical and social context for them. Caregivers could take notes about the situations that led to behavior issues, to share with health professionals during visits.

Investigate. Have the health provider look into all the aspects of the person’s health—dementia symptoms, current medications and sleep habits—that might be combining with physical, social and caregiver-related factors to produce the behavior.

Create. The patient’s caregiver and health providers work together develop a plan to prevent and respond to behavioral issues in the person with dementia, including everything from enhancing the patient’s activities and environment to educating and supporting the caregiver.

Evaluate. Give the provider responsibility for assessing how well the plan is being followed and how it is working, or what might need to be changed.

Researchers from the University of Michigan (U-M) Medical School and Johns Hopkins University shared a behavior-based strategy designed to calm the behavior of those with dementia in a recent issue of the British Medical Journal (BMJ). The model (DICE, for Describe, Investigate, Create, Evaluate—see box) can be used by physicians and caregivers to capitalize on current research and tailor care to patients and residents as symptoms change, they said.

“Behavior-based strategies may take longer than prescriptions,” first author Helen C. Kales, MD, head of the U-M Program for Positive Aging at the U-M Health System and an investigator at the Veterans Affairs Center for Clinical Management Research, said in a statement. “But if you teach people the principles behind DICE, the approach becomes more natural and part of one’s routine. It can be very empowering for caregivers or nursing home staff.” Kales also is a member of the U-M Institute for Healthcare Policy and Innovation.

She and her colleagues from Johns Hopkins, Laura N. Gitlin, PhD, and Constantine Lyketsos, MD, are working with the U-M Center for Health Communications Research to launch a National Institute of Nursing Research-sponsored clinical trial this spring that will test the DICE approach through a computer-based tool for caregivers called the WeCareAdvisor. They hope the tool will help families identify tips and resources in a single computer interface to address behavioral symptoms.

Nonpharmaceutical approaches are more effective at calming the behavior of those with dementia, and are associated with fewer risks, than are pharmacologic approaches, according to their BMJ report. In fact, non-drug approaches should be the first choice for treating common behavioral symptoms in those with dementia—irritability, agitation, depression, anxiety, sleep problems, aggression, apathy and delusions—said the researchers, who reviewed two decades’ worth of research to arrive at their conclusions.

“The evidence for non-pharmaceutical approaches to the behavior problems often seen in dementia is better than the evidence for antipsychotics and far better than for other classes of medication,” Kales said. “The issue and the challenge is that our healthcare system has not incentivized training in alternatives to drug use, and there is little to no reimbursement for caregiver-based methods.”

The study coincidentally was released at the same time as a new report from the Government Accountability Office calling for reductions in the off-label use of antipsychotics to be expanded from nursing homes to other settings, including assisted living communities and homes. Kales, however, cautioned that penalizing physicians for prescribing antipsychotic drugs to these patients/residents could backfire if caregiver-based non-drug approaches are not encouraged.

“There needs to be a shift of resources from paying for psychoactive drugs and emergency room and hospital stays to adopting a more proactive approach,” she and her colleagues wrote in the paper. They added, however, that medication can be appropriate to manage acute symptoms where patient/resident or caregiver safety is at risk. For instance, they said, in some cases, the use of antidepressants is appropriate for use in those with severe depression, and antipsychotic drugs can be appropriate for use when individuals have psychosis or aggression that could lead them to harm themselves or others. Such uses should be monitored and ended as soon as possible, they added.

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