Pamela A. MacLean
While psychiatrists debate the origins of dementia and Congress probes the abuse of mind-numbing drugs in controlling seniors, some innovative care centers are finding early success with experimental programs that help the elderly cope with dementia while reducing - or eliminating - the use of psychotropic medications.
The 115-year-old Eliza Jennings Senior Care Network, a not-for-profit chain based in Cleveland, is using a Japanese teaching program to slow the symptoms of dementia. In Minnesota, the Ecumen a chain of 15 skilled nursing homes, is calming agitated dementia patients through a natural, one-on-one calming blend of conversation and environmental changes.
Both experiments help dementia patients live more comfortably with little or no use of powerful antipsychotic drugs, a growing problem in senior care facilities nationwide. A government study found that 14 percent of the 2.1 million seniors in nursing homes had at least one Medicare claim for such drugs, and 88 percent of the drugs were given for "off-label" uses considered dangerous by the Food and Drug Administration. A panel of experts warned a U.S. Senate Special Committee on Aging in November that care facilities, hospitals and assisted living centers have turned increasingly to use of dangerous antipsychotic drugs as chemical restraints for agitated dementia patients.
The need for better methods is growing rapidly. Today there are 40 million Americans over 65, but there are 77 million baby boomers just starting to move into their senior years. The percentage of elders requiring professional care also may rise as psychiatrists expand the definition of mental illness in elders next spring when they publish the fifth edition of the "Diagnostic and Statistical Manual of Mental Disorders." The manual, the Bible of diagnosing mental problems, is expected to include new disorders such as bereavement and "mild neurocognitive disorder" that could apply to millions of seniors. Without alternative treatments, the problems now visible in treating mentally ill seniors could multiply, resulting in greater problems and much higher health care costs.
During her testimony to the Senate committee in November, Dr. Cheryl Phillips, a geriatric specialist and senior vice president for advocacy at LeadingAge, warned that people diagnosed with dementia frequently arrive at a nursing home already taking multiple psychoactive medications to manage behavior. The use typically begins in a hospital, assisted living community or as part of a home dementia treatment plan. The nursing facilities merely continue the treatment, she said.
In a recent interview, Phillips praised the Ecumen and Eliza Jennings experiments for their cutting edge work on dementia care without medication. To be sure, the work is early and much remains to be seen. But they are promising steps on the long road of finding practical alternatives to the current problems.
3 Rs for Elders
The Eliza Jennings facilities brought the Kumon Learning program from Japan to two of its Ohio homes. It uses math, reading and writing studies for 30 minutes a day on patients with mild to mid-stage cognitive problems that many consider a precursor to full-blown dementia.
"It is not difficult material, nor is it intended that the participant learns the material," said Deborah Lewis Hiller, president and CEO of Eliza Jennings. "It is an intervention to stimulate the prefrontal cortex of the brain."
Although the results of the six-month experiment will not be published by the Japanese researchers until June, Hiller says, "the outcomes have been very positive, better than anticipated."
Kumon began in 1954 when a high school math teacher, Toru Kumon, wanted to help his son teach himself. He wrote numerous calculations on loose-leaf paper for his son. Today 200,000 students in Japan are enrolled in the program.
The Kumon method was adapted in recent years to help elders with dementia and, since 2010, nearly 5,000 seniors have been using the method at 319 centers in Japan. They use it with the intent to stave off potential dementia.
A 1-on-1 Experiment
The Ecumen program, called Awakenings, began by looking back to a more traditional approach of working one-on-one with patients. It is a three-year program funded by a $3.8 million grant from Minnesota's Department of Human Services.
When the program began more than a year ago, the industry had slipped into using drugs to medicate people with dementia when they acted out or had profound agitation, said Andrea Marboe, the spokeswoman for Ecumen's Awakenings Program in Shoreview, Minn.
The new program trains staff to redirect an agitated resident away from noise, heavy foot traffic or other activities that can be disturbing. The staffers talk with them or walk outside or in a quiet area. They place a bulletin board in each room showing a resident's favorite things, from food, to TV show or just a color. It includes a little biography. The information helps a night shift nurse to redirect a conversation in the middle of the night, if a patient is acting out, Marboe said. They have also added a therapeutic recreation assistant for every 40 to 50 residents.
Within six months, Ecumen's Two Harbors home had weaned all the residents off antipsychotics and decreased antidepressants by 30-50 percent, according to Marboe. The facility turned to therapies that used reminiscence, music, aroma and pets to improve cognitive functions.
Phillips says Ecumen and Eliza Jennings are not alone. "There is a growing body of evidence of models addressing care issues and doing it medication-free with remarkable success." She noted Copper Ridge in Baltimore and Miami Jewish Health Systems have made similar commitments to providing dementia care without these medications.
Phillips says the long-term solution across the country must come from a "sustained campaign that teaches caregivers how to provide real person-centered care alternatives."
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