I am pleased to
introduce you to Rachel Wynn, MS CCC-SLP is speaker, writer, activist, and
speech-language pathologist specializing in geriatric care. I invited her to share some of her thought about about medications and dementia. She blogs at Gray Matter Therapy, which strives to provide information about
geriatric care including functional treatment ideas, recent research, and
ethical care. Find her on Facebook, Twitter, or hiking with her dog in Boulder, CO.
Let me just state my
bias up front. In my personal life, I avoid taking medications. Rather than
take pain reliever for a headache, I drink water. The headache is likely due to
dehydration (which is common at high altitude) or sinus distress (and water thins
mucous being produced). I avoid medications, but I am not anti-medications. In
fact, I take a medication every day and will likely for the rest of my life,
because my body requires it. Personally, I believe medications aren’t often
necessary, especially as the first intervention.
As a speech-language
pathologist, it is not within my scope of practice to give recommendations
regarding medications. However, it is within my scope of practice to understand
how medications affect the body, especially when there may be side effects
impacting cognition or swallowing.
Medications but no therapy?
One of the things I have
found quite concerning is meeting someone new to my care community and seeing
the list of medications they are on. They may be on a cholinesterase inhibitor
and antipsychotic medications for dementia, but they have never participated in
any therapy (speech-language pathology, occupational therapy, or
neuropsychology). This is concerning, because there are so many benefits to therapy
throughout the course of dementia.
In the earlier stages,
therapists develop individualized compensatory strategies and routines to help
people maintain their independence as long as possible. In the middle to late
stages of dementia, therapists work on changing the environment to increase a
person’s independence and quality of life. These interventions don’t cure
dementia (but neither do any of the current medications on the market);
however, they are individualized to help improve quality of life, independence,
and safety without side effects.
Antipsychotic medication effects in the elderly
Antipsychotic
medications are not without side effects. Common side effects of antipsychotics
in the elderly include [1]:
- anticholinergic reactions
- parkinsonian events
- tardive dyskinesia
- orthostatic hypotension
- cardiac conduction disturbances
- reduced bone mineral density
- sedation
- cognitive slowing
We rightfully spend
great time and energy on fall prevention efforts. How many of those antipsychotic
side effects would contribute to an increased risk for falls? Most of them.
Besides falls, in people with dementia sedation and cognitive slowing would
complicate matters. Yet, these are very common side effects.
CMS sets goal to move away from antipsychotics
Given my stance on
medication, especially in the treatment of dementia, I was very pleased
to see this
press release from the Centers for
Medicare & Medicaid Services [2]. The press release states the goal CMS set
to reduce use of antipsychotic medications in nursing homes by 25% by the end
of 2015 and 30% by the end of 2016. This is excellent news.
Want even better news?
Patrick Conway, MD and CMS chief medical officer said, “In partnership with key
stakeholders, we have set ambitious goals to reduce use of antipsychotics
because there are - for many people with dementia - behavioral and other
approaches to provide this care more effectively and safely.” (emphasis
mine).
As an advocate for
person-centered healthcare, Dr. Conway’s words make my heart happy. He said,
“Ultimately, nursing homes should re-think their approach to dementia care,
reconnect with the person and their families, and use a comprehensive
team-based approach to provide care.”
Way to go CMS! Now let’s
chat about how CMS reimburses for these therapy services that can achieve
excellent results without the side effects of antipsychotic medications…
References:
- Masand, P.S. (2000). Side effects of antipsychotics in the elderly. Journal of Clinical Dementia Care Exceeds Goal to Reduce Use of Antipsychotic Medications in Nursing Homes: CMS Announces New Goal. Newsroom Center. CMS.gov, 19 Sept. 2014. Web. 19 Sept. 2014.Psychiatry, 60(8), 43-49.
- Centers for Medicare & Medicaid Services. National Partnership to Improve
