There is a large unmet medical need in long-term care settings for the diagnosis and management of NPS in dementia, including: psychosis, wandering, sleep issues, agitation, depression, apathy, and aggression. Effectively managing or preventing behaviors that disturb and cause harm to self and others is valuable to residents, family caregivers, and payors. While cognitive impairment is regarded as the hallmark indicator of dementia, neuropsychiatric symptoms are nearly as universal, with one or more symptoms affecting nearly all people with dementia over the illness course.
Among people with Alzheimer’s disease (AD), depression is the earliest observable symptom in at least one-third of cases. Milder agitation may manifest early and increase in prevalence and severity with worsening of dementia, often leading to an increase in caregiver burden, greater morbidity, poorer quality of life, increased cost of care, early institutionalization, and rapid disease progression. For long-term care staff caring for residents with depression, agitation, and other NPS, these disorders are associated with decreased quality of care, injury, increased workload, lost days of work, burnout, and staff turnover.
While antipsychotics have been used to treat NPS since the 1950s, people with neurodegenerative disorders were previously excluded from trials of psychotropic medications in general, and antipsychotics specifically, despite the fact that both brain changes and biological aging may impact psychotropic dosage needs and response, carrying significant risks.
There are no disease-modifying treatments for dementia; therefore, clinicians focus on decreasing patients’ suffering and improving their quality of life.
Nearly all patients with dementia will develop at least one NPS. Because of this complexity, treatment should begin with an assessment to rule out potentially reversible causes of NPS. For mild to moderate NPS, short-term behavioral interventions, followed by pharmacologic interventions, are used. For moderate to severe NPS, pharmacologic interventions and behavioral interventions are often used simultaneously. New ICD-10 codes for dementia-related psychosis and other NPS symptoms should be considered to help prescribers with more accurate diagnosis and provide clearer guardrails for appropriate use. Assessing triggers and selecting strategies, however, is time-intensive and reflects a paradigm shift necessitating a reorganization of dementia care.
As part of Project PAUSE’s work to educate lawmakers and interested stakeholders on appropriate use of antipsychotic medications in long-term care (LTC) settings, our coalition has conducted an in-depth look at clinical best practices and how federal regulations and public-private partnerships define current antipsychotic utilization rates. This analysis and the coalition’s recommendations for improvement are outlined in “Project PAUSE: Effective Solutions for Improving Clinical Care in Long-Term Care Settings.”