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Non-Pharmacologic Interventions Underused in Dementia Patients with Aggression

May 3, 2007

Baylor College of Medicine
By Laura Madden-Fuentes | May 3, 2007

HOUSTON - Psychiatric medications are often prescribed for patients with dementia who also have aggressive behavioral problems. However, some experts say non-pharmacologic interventions such as education or behavioral therapy should be tried first.

“Not enough attention is given to non-pharmacologic approaches,” said Mark Kunik, M.D., associate professor of psychiatry and behavioral sciences at Baylor College of Medicine (BCM) and associate director of the Michael E. DeBakey VA Medical Center Houston Center for Quality of Care and Utilization Studies. “There are many reasons, but I believe usually, it is an issue of time. The easiest thing to do is to give medication. It’s a little more difficult to access and implement non-pharmacologic approaches.”

Dementia is a progressive decline in cognitive functioning from either damage done to the brain or disease and is strongly associated with old age. Millions of Americans suffer from some form of dementia, which can be a byproduct of strokes, Parkinson’s disease or alcohol abuse, among other things. Alzheimer’s disease is the most common type of dementia, said Kunik.

“To best take care of people with Alzheimer’s dementia and other dementias, you really need a team approach,” said Kunik. “There aren’t many places these days that offer a multi-disciplinary team approach.”

Many times, especially in a primary care setting, aggression goes unrecognized, which highlights the need for a multidisciplinary approach. It is uncommon for patients to go to their doctors complaining of dementia and even less so of psychological or behavioral problems—they go for other issues like lung or heart disease, said Kunik.

When aggression is recognized, Kunik says education or psychotherapies should be tried before medication. The FDA warned in 2005 that the use of atypical antipsychotics in dementia patients can increase the risk of death. Also, intervention without medications, such as behavioral therapy, has been shown to decrease aggressive behavior without such an increase in mortality.

Much of Kunik’s research has been about identifying ways to better assess and treat psychological behavioral problems in persons with dementia.

“Historically, the assessment and treatment of these issues has been fairly reductionistic with some type of tranquilizing medication,” said Kunik. “My interest has been to try to better understand what might be leading to these psychological and behavioral problems like aggression and then create better approaches for prevention and treatment.”

Currently, Kunik is analyzing the data from a two- year study that followed over 200 patients with newly diagnosed dementia who did not have aggression issues. Over that time period, Kunik and his collaborators looked to see how many patients developed aggression and what happened in the month or months before.

“We were looking to see if there was something specific that led to the development of the aggression,” he said. “From this, we hope to be able to develop some prevention strategies.”

Kunik emphasizes the psychological and behavioral issues that accompany dementia are treatable, whether by therapy or drugs, and patients and caregivers should not have to live with them.

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