2014-2015 Alzheimer’s and Related Diseases Research Award*

Pharmacologic and Non-pharmacologic Management of Behavioral and Psychological Symptoms of Dementia (BPSD): A Mixed-Method Pilot

VCoA*The Virginia Center on Aging which administers the Alzheimer’s and Related Diseases Research Award Fund for the Commonwealth of Virginia, provides seed money to researchers in Virginia to stimulate innovative research into biomedical and psychosocial aspects of dementia, including cell biology, caregiving, and animal modeling.


Pharmacologic and Non-pharmacologic Management of Behavioral and Psychological Symptoms of Dementia (BPSD): A Mixed-Method Pilot

Jonathan Winter, MD and J. William Kerns, MD

Warren Memorial Hospital

The behavioral and psychological symptoms of dementia (BPSD) are frequently treated with antipsychotic medications which have the potential for dangerous health side effects. For this reason, the Centers for Medicaid and Medicare Services have been purposeful in trying to curb their use in patients with dementia, but with little effect. The potential for severe risks were highlighted by Food and Drug Administration’s ‘black box warnings’ in patients over age 65 with dementia, yet they continue to be prescribed for over 20% of nursing home patients in Virginia. This study will evaluate behavioral health diagnoses and prescribing trends for BPSD over the last decade among nursing home and community dwelling patients in Virginia insured by Medicaid. The data will inform interviews with patients’ families and nursing caregivers about their experiences and perceptions regarding the treatments for BPSD. A better understanding of the perspectives of all stakeholders will be critical in identifying and increasing family, nursing, and physician engagement in shared decision-making regarding treatment options, including non-pharmacologic approaches with or without medication use.

(The investigators may be contacted at 540/631-3700, jwinter@valleyhealthlink.com, bkerns@valleyhealthlink.com)

REPORT:

Because antipsychotic medications (APs) for treating the behavioral and psychological symptoms of dementia (BPSD) can cause rare severe side effects (SE), an FDA Black Box Warning (BBW) was issued to reduce their use.  This mixed methods study explored why roughly 20 percent of Virginia nursing home patients still remain on APs.  Quantitatively, they trended the prescribing rates of all psychotropics in Virginia’s Medicaid dementia population since the FDA BBW.  Not only has AP utilization not decreased, but use of alternative medications for BPSD that have not been shown to be safer or more efficacious are increasing. Qualitatively, they assessed the experiences and perceptions of POAs and nurses (caregivers) about decision-making processes concerning pharmacologic/non-pharmacologic approaches to BPSD management. Caregivers feel that non-pharmacologic strategies (NPS) can work for most BPSD, but have limits. Community POAs also feel “on their own,” in developing and utilizing NPS, with little help from physicians and inadequate supporting resources.  Furthermore, caregivers see pharmacologic strategies as effective, especially if the ‘right’ medication is used in addition to NPS. What’s more, no caregiver reported ever knowingly observing the severe SE of APs described by the BBW. These severe SE of APs were rarely discussed by physicians and poorly understood by caregivers.

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