The American Psychiatric Association recently released its new “Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients with Dementia.” In 2013, the APA surprisingly took a modest anti-drugging stance regarding the use of antipsychotics to “treat” “behavioral and psychological symptoms” of dementia. The new Guideline gives a much more detailed justification for this stance.
What to like.
The Guideline earnestly encourages non-drug interventions as the first and second-line of treatment for behavioral challenges associated with dementia care and even gives some description of what ought to be considered: pain, the environment, relationships, etc. Additionally, the authors seem to have a bit of reluctance to recommend drug options even as a last resort and advise caregivers to start any antipsychotics with low dosing and use lots of reviews and deliberations going forward.
What to Loathe.
There are a few troubling parts of the Guideline but what makes it loathesome is the framing of the care needs of people with dementia. The old and (frankly) embarrassing medical perspective is pervasive: e.g., labeling expressions of distress “symptoms.” But the worst offense is repeatedly referring to agitation as the CAUSE rather than the RESULT of distress. This framing assumes that agitation is a bio-physiological result of simply having dementia. And then this agitation leads to distress that impairs a patient’s quality of life – so drugs that “calm” the agitation are part of symptom reduction and can improve overall quality of life.
The right framework is the exact opposite. Agitation is borne of distress and distress is completely avoidable if we keep people comfortable, engaged, and happy. People with dementia are no more naturally inclined to agitation than anybody else. What they are naturally more inclined to is memory loss, confusion, and communication problems which of course means they are prone to frustration and distress unless active interventions are made by caregivers to help them navigate the world. Antipsychotics, or any other psychotropic drugs, can’t and don’t resolve the sources of frustration and distress.
The APA’s patently misleading approach comes sharply into focus when we compare the treatment of people with dementia to the treatment of others. When babies are agitated, we don’t think of symptoms, we think of caring for them. When we see a family member or friend agitated, we think of helping them fix their problem. When we see a person with dementia with agitation, we think of symptoms and drugs. Such thinking is not right and it’s not fair and, when used to silence a perfectly reasonable response to distress, it’s rotten.