PPA Faculty members Amanda Leggett, PhD and Courtney Polenick were recently featured in in the main story on the Population Reference Bureau’s website today which stems from their “Today’s Research on Aging” Click Here to check it out!
PPA Faculty members Amanda Leggett, PhD and Courtney Polenick were recently featured in in the main story on the Population Reference Bureau’s website today which stems from their “Today’s Research on Aging” Click Here to check it out!
In this week’s podcast we talk with Helen Kales, Professor of Psychiatry at the University of Michigan the VA Center for Clinical Management and Research.
We’ve spent a great deal of effort in Geriatrics describing what we shouldn’t do to address behavioral symptoms in dementia: physical restraints, antipsychotics, sedating antidepressants.
Helen Kales was lecturing around the country about all of these things we shouldn’t do a few years back, and people would raise their hands and ask, “Well, what should we do?” She realized she needed to give caregivers tools to help.
Dr. Kales went on to develop the DICE approach to managing behavioral and psychiatric symptoms in dementia. Listen or read the full podcast to learn more! You’d be “crazy” not to! (hint: song choice).
Researchers call for clinicians & patients to ‘begin with the end in mind’ with sedatives like Valium or Xanax for anxiety, sleep issues & more
ANN ARBOR, MI – They may start as well-intentioned efforts to calm anxiety, improve sleep or ease depression. But prescriptions for sedatives known as benzodiazepines may lead to long-term use among one in four older adults who receive them, according to new research.
That’s despite warnings against long-term use of these drugs, especially among older people, because they can increase the risk of car crashes, falls and broken hips, as well as causing other side effects.
The new study, published in JAMA Internal Medicine by a team from the University of Michigan, two VA hospitals and the Perelman School of Medicine at the University of Pennsylvania, looked at benzodiazepine use by low-income older adults in a Pennsylvania program that helps with drug costs.
The researchers say their findings point to a strong need for better education of healthcare providers, and the public, about the risks associated with these drugs.
Of the 576 adults who received their first benzodiazepine prescription in 2008 to 2016, 152 still had a current or recent prescription a year later. The study only included people whose benzodiazepines were prescribed by non-psychiatrists, as the majority of older adults who use benzodiazepines have their prescriptions written by primary care physicians or other non-psychiatrists.
White patients were four times more likely to have gone on to long-term use. Those whose initial prescriptions were written for the largest amounts were also more likely to become long-term benzodiazepine users. For just every 10 additional days of medication prescribed, a patient’s risk of long-term use nearly doubled over the next year.
That rate of long-term use is concerning enough in itself, says Lauren Gerlach, D.O., M.Sc., the lead author of the study and a geriatric psychiatrist at U-M.
“This shows that we need to help providers start with the end in mind when prescribing a benzodiazepine, by beginning with a short-duration prescription and engage patients in discussions of when to reevaluate their symptoms and begin tapering the patient off,” she says. “We also need to educate providers about effective non-pharmaceutical treatment alternatives, such as cognitive behavioral therapy, for these patients.”
Gerlach points to two other concerning findings from the review of records and detailed interviews with program participants. Long-term benzodiazepine users were no more likely to have a diagnosis of anxiety, which is sometimes an indication for long-term use.
Also, long-term users were more likely to say they had sleep problems, despite the fact that benzodiazepines are not recommended for long-term use as sleep aids and may even worsen sleep the longer they are used.
More about the study
Gerlach and her colleagues at the U-M Medical School, VA Ann Arbor Healthcare System, Corporal Michael Crescenz VA Medical Center and University of Pennsylvania used data from the Supporting Seniors Receiving Treatment and Intervention, or SUSTAIN, program.
The program provides a supplement to a Pennsylvania medication coverage program for low-income older adults. The program provides behavioral health and case management services by telephone across the state. All of the patients in the study live at home or in other community settings, so the study does not include patients in nursing homes and other skilled nursing facilities.
This included detailed interviews to screen for mental health issues including anxiety, depression, sleep issues and pain, as well as analysis of prescription records and other clinical data. The researchers calculated a medication possession ratio, based on how many days’ supply of benzodiazepines the person had been prescribed, and how many days remained in the time the prescription was valid. They set a threshold MPR of 30 percent over the course of a year as the definition of long-term use.
On average, the patients were 78 years old when they received their first benzodiazepine prescription – an advanced age for use of the drugs, which national guidelines say should rarely if ever be given to adults over about age 65. Very few had had any sort of psychiatric, psychological or psychosocial care in the past two years.
While treatment guidelines recommend only short-term prescribing, if any, these long-term patients were prescribed nearly 8 months’ worth of medication after their initial prescription.
“This study provides strong evidence that the expectations set out by a provider when they first write a new prescription carry forward over time,” says David Oslin, M.D., of Penn and the Philadelphia VA, and senior author of the paper. “When a physician writes for 30 days of a benzodiazepine, the message to the patient is to take the medication daily and for a long time. This expectancy translates into chronic use which in the long run translates into greater risks like falls, cognitive impairment and worse sleep.”
“Since mental health providers see only a very small minority of older adults who have mental health issues, we need to support primary care providers better as they manage these patients’ care,” says Gerlach. “We must help them think critically about how certain prescriptions they write could increase the chance of long-term use.”
Donovan Maust, M.D., M.S., another U-M geriatric psychiatrist who has studied overuse of benzodiazepine drugs and risks associated with them, is a co-author. He and Gerlach are both members of the U-M Institute for Healthcare Policy and Innovation, and the Program for Positive Aging in the U-M Medical School’s Department of Psychiatry.
Says Oslin, “Benzodiazepines are one of several classes of medications that have a high addictive potential and substantial risks for falls, cognitive dulling, and sleep impairment. From a public health perspective, starting 80-year-old patients on benzodiazepines is a high-risk prospect. In addition to the risks to the individual, there is also risk for greater drug diversion and exposure of these medications to grandkids if not properly stored and disposed.”
The research was sponsored by the Pharmaceutical Assistance Contract for the Elderly of the Commonwealth of Pennsylvania.
Reference: JAMA Internal Medicine, Sept. 10 2018
New research which brings together the views of the world’s leading experts has concluded that non-drug approaches should be prioritised in treating agitation in people with Alzheimer’s Disease.
The research, Published in International Psychogeriatrics and led by the University of Michigan, the University of Exeter and John Hopkins University, provided more specific guidance on the management of behavioural and psychological symptoms in people with Alzheimer’s Disease.
It gives the most specific and targeted treatment for psychosis and agitation. Both symptoms are common in dementia and have a significant impact on individuals, families and carers.
The International Delphi Consensus paper incorporates views of a panel of experts from across the globe, who have both clinical and research expertise. Undertaken as an International Psychogeriatric Association taskforce, it brought together the latest evidence on how best to treat symptoms such as psychosis and agitation, to help get the best treatment for the 40 million people with dementia worldwide.
By ranking available treatments in order of the quality of evidence, the paper provides guidance on the order in which clinicians should prioritize treatments.
For treating agitation in people with dementia, the first four highly ranked treatments were all non-pharmacological approaches. Assessment and management or underlying causes, educating caregivers, adapting environment, person-centred care and a tailored activity programme all ranked more highly than any of the pharmacological treatments. The highest ranked pharmacological treatment was the antidepressant citalopram, which came in at number six.
Of note, of the currently used atypical antipsychotic drugs only risperidone reached consensus as a recommended treatment, at number 7 in the list.
Helen C. Kales MD, Director of the Program for Positive Aging at the University of Michigan and Research Investigator at the VA Center for Clinical Management Research noted: “This research advocates a significant shift from current practice, recommending that non-pharmacological treatments are a first-line approach for agitation in dementia. Aside from risperidone at number 7 in the list, none of the other atypical antipsychotic drugs were recommended. This is a very welcome change, given the known harms associated with these treatments.”
For the treatment of psychosis in people with dementia, including symptoms such as hallucinations and delusions, the panel advocated a thorough assessment and management of underlying causes as the first approach. The atypical antipsychotic risperidone came second, as the only pharmacological treatment with any supporting evidence that it works. This highlights a particular gap in the treatment of psychosis in people with dementia, which is a distressing and disabling symptom, and emphasizes tis as a priority area for further research.
Overall, the DICE (Describe, Investigate, Create and Evaluate) therapy approach, which involves identifying triggers, and using music were both found to be effective in managing symptoms without prescribing drugs.
Clive Ballard, Professor of Age-Related Diseases at the University of Exeter Medical School, said: “Symptoms such as psychosis and agitation can be particularly distressing and challenging for people with dementia, their carers and their families. Many commonly prescribed medications can cause harm, in some cases significantly increasing risk of stroke or death. We now know that non-drug approaches are the best starting points and can prove effective. This research provides more specific and targeted guidance to support clinicians to give the best possible treatment options.”
An international commission states 1 in 3 dementia cases could be prevented by targeting risk factors from childhood onward. A Michigan Medicine expert explains more.
Alzheimer’s and related dementias are the “greatest global challenge for health and social care in the 21st century,” according to a new report from The Lancet Commission on Dementia Care.
A 24-member international commission panel convened last year to examine the diseases’ burden, author the report and share key messages. Recently, representatives from the group, including Helen C. Kales, M.D., a University of Michigan professor of psychiatry and founding director of the U-M Program for Positive Aging (PPA), unveiled their findings at the Alzheimer’s Association International Conference in London.
We sat down with Kales to discuss her take — and what health care providers and policymakers should know.
Kales: While the commission’s comprehensive report contains 10 key messages, my focus is on one overarching takeaway, plus three other messages from within the report.
The overarching message is the importance of a focus on dementia care. This focus by a journal as prestigious as The Lancet is at once both critical and revolutionary. A quick look at the AAIC 2017 program reveals that the vast majority of research in dementia is related to cure. Research on the “care” part is far outnumbered. But there is no current cure for dementia, with any such disease-altering treatment at least 10 to 20 years in the future, and there’s an aging population, meaning the prevalence of dementia will triple by 2030. A greater focus on care is imperative. I hear this regularly from families of those with dementia: “We need help now.”
Unfortunately, in the U.S. and in many other countries, access to comprehensive and coordinated services for dementia care often depends on where you live, what resources you have and whom you know. Poorly coordinated, fragmented care leads to inappropriate use of health care in the form of potentially preventable emergency room visits and hospitalizations, rather than having case management so that referrals can be made earlier and often for supportive and outpatient services. It is my hope that The Lancet report will be a change agent.
There are three more subtle messages in the report that I also wanted to focus on.
Kales: The first message I want to focus on is becoming ambitious about prevention.
We do not know the causes of many types of dementia, as detailed in the report, though we are starting to accumulate evidence for risk factors that, if altered, could prevent or delay dementia in up to a third of cases. Many of these are interventions, such as improving social engagement, managing hearing loss and stopping smoking, have general health benefits and minimal risk.
It is believed that the compression of dementia incidence that we are seeing in the U.S. is a result of healthier lifestyles in more recently aging cohorts. So, while we are waiting for more studies on how to implement interventions for these risk factors on a larger scale in our countries, it is certainly worth “preaching” about modifying these risk factors to our middle-aged and older patients in clinical settings. This is really what “positive aging” is about and is clearly a focus of the University of Michigan Program for Positive Aging. With age, most of us will face some combination of medical problems, cognitive changes, anxiety, depression or the stress of being a caregiver. The good news is that much of what comes with aging can be managed — and it is this management that can improve quality of life markedly in later life.
The second message is about individualizing dementia care and caring for family caregivers. Inherently, dementia care must be both person-centered and caregiver-centered. I believe that this message has come through loud and clear throughout the commission’s report. Good dementia care is comprehensive and links medical care with social and supportive care in the community. Contrary to popular belief, most people with dementia are cared for in the community by family caregivers who, as noted in the commission’s report, “are the most important resources available for people with dementia.” We need to treat them as such. Family caregivers are drafted into an unpaid profession without training and are highly prone to depression and anxiety; caregiving can literally cause them to “go down with the ship.”
The commission report underscores the value of these caregivers and the types of resources, education and services they need access to be effective and healthy. We are so proud of the caregiver interventions that we have created and are implementing in the PPA. These include DICE (Describe, Investigate, Create and Evaluate) training for family and staff caregivers and the web-based dementia care tool, WeCareAdvisor, that we have developed and tested successfully in a recent National Institutes of Health-funded trial. The commission’s report gives added impetus to pursue such interventions for caregivers.
The third and final message I would like to highlight is that of assessing and managing neuropsychiatric symptoms. While dementia is thought of as a memory problem, behavioral symptoms occur universally and are among the most complex and challenging symptoms faced by caregivers and providers. The good news is that while we are fairly limited in what we can do for memory at this point, we are accumulating evidence on the ability to improve outcomes and quality of life for people with dementia and their caregivers by managing behaviors. The report outlines the utility of approaches like DICE to assess and manage behaviors through an emphasis on training caregivers as well as health care providers in the treatment of modifiable underlying causes (e.g., pain, negative caregiver communication style or an overstimulating environment), and selection of tailored nonpharmacologic strategies over the knee-jerk use of sedating medications.
Dr. Helen C. Kales, Professor of Psychiatry and Director for the Program for Positive Aging, has been selected to take part in an update of the international expert Lancet commission on Dementia Prevention, Intervention and Care in October 2018 in London. In addition, Dr. Amanda Leggett, Research Assistant Professor of Psychiatry, has been selected to take part in the commission as a promising future researcher in dementia. Amanda currently has a K-award from NIH examining a variety of caregiver well-being and stress measures towards creating profiles of “caregiver styles” (akin to parenting styles). Dr. Kales is her primary mentor. Congratulations Dr. Kales and Dr. Leggett!
Lancet commission on Dementia Prevention, Intervention and Care: http://www.ucl.ac.uk/psychiatry/research/olderpeople/lancet-dementia-commission
Air travelers well know the instruction to “please put on your own oxygen mask before assisting others” in the event of an emergency.
This is, as it turns out, good advice in general for dealing with many of life’s stressful situations: we need to take care of ourselves to more effectively help others. And for the 15 million family members caring for the 5 million people with dementia in the United States, self-care is an absolute necessity – the daily demands placed on these caregivers create distress that can seriously erode their ability to look after their loved ones’ wellbeing.
As the older U.S. population grows, dementia is projected to affect 16 million Americans by 2050, with 98 percent of them impacted by symptoms such as depression, anxiety, delusions, wandering, aggression and sleep problems.
Michigan Medicine’s Helen C. Kales, M.D., U-M professor of psychiatry, and her Program for Positive Aging (PPA) team have been at the forefront of innovation for dementia caregivers, providing reliable and well-evaluated information and training, creating support tools and studying how to enhance self-care.
One web-based caregiver support tool called the WeCareAdvisor, developed by Kales and the PPA with collaborators at John Hopkins University, has been shown to measurably reduce caregiver distress, according to an evaluation recently published in BMC Geriatrics. Future research will identify whether using WeCareAdvisor for longer periods can impact other caregiver and behavioral outcomes; the caregivers in the study used it for one month; future trials plan to evaluate three months of using WeCareAdvisor.
WeCareAdvisor is designed to lead the family caregiver through the assessment, management and monitoring needed to accomplish the following:
Kales will discuss WeCareAdvisor and other PPA-developed products to benefit individuals with dementia and their caregivers at the Precision Medicine World Conference in Ann Arbor, June 6-7.
The bedrock of the WeCareAdvisor tool is the “DICE” approach to dementia behaviors that was developed from a U.S. national multidisciplinary expert consensus panel led by Kales and the PPA in 2011. DICE™ comprises four steps:
The approach promoted by DICE and the WeCareAdvisor, putting behavioral and environmental strategies ahead of drugs in the management of dementia behaviors is consistent with the stance of multiple medical organizations and expert groups as the preferred first-line treatment approach.
Dr. Helen Kales has a new research collaboration with University College London. She and members of the PPA team will be training family caregivers in London on the DICE method as part of UCL’s “New Interventions for Independence in Dementia” grant.
The PPA team trained nearly 100 nurses and social workers May 15 in Lansing on its DICE (Describe, Investigate, Create and Evaluate) training program for caregivers of Alzheimer’s and dementia patients. The training was part of the Michigan Mental Health & Aging Conference at the Kellogg Center. Led by Helen Kales, the PPA team of Mary Blazek, MD, MEHP; Lynn Etters, DNP, GNP-BC, ANP-C, and Laura M. Struble, PhD, GNP-BC provided the training at an all-day session. PPA team members Molly Turnwald, Barb Stanislawski and Bri Broderick coordinated the event.
Two faculty from the Program for Positive Aging will be presenting at next week’s Issues in Aging conference held at Schoolcraft College in Livonia on April 23rd and 24th.
Lynne Etters, DNP,GNP-BC,ANP-C and Gerontological Nursing Leadership Academy Fellow, U-M will present The DICE Approach: We’re on a Roll during the Current Research & Practices for Alzheimer’s Disease & Dementia program. The DICE approach is a nationally and internationally-acclaimed educational and training strategy developed by PPA’s Director Dr. Helen Kales to better assess, identify and resolve behavioral expressions in patients and support caregivers in family and institutional environments.
Donovan Maust, MD, MS, Asst. Prof of Psychiatry, U-M Research Scientist, VA, Ann Arbor Healthcare System will present Understand & Simplify: Psychotropic Prescribing in Older Adults as part of the New Enhancements in Frailty Care program.
The conference is sponsored by Michigan Medical’s Michigan Alzheimer’s Disease Center, the Greater Michigan Chapter Alzheimer’s Association and Wayne State University’s institute of Gerontology.
Tranquilizers, antidepressants, opioids and anti-psychotic medications carry special risks for older people, alone or in combination.
Dr. Donovan Maust, M.D., M.S., assistant professor of psychiatry, brought his research findings and expertise on that subject to the Michigan Psychiatric Society’s Annual Spring Frontiers in Psychiatry event Friday, April 13 at Michigan State’s Kellogg Center.
His presentation will assist fellow psychiatrists and physicians better understand:
Trends in psychotropic prescribing among older adults, both of single agents and combination use.
Understand how the risk-to-benefit calculation for psychotropic prescribing may shift as patients age.
Review evidence from policies that try to reduce specific types of psychotropic prescribing.
Frontiers in Psychiatry is jointly provided by the American Psychiatric Association and the Michigan Psychiatric Society.
Dr. Lauren Gerlach has been chosen from a wide field of applicants to participate in the Cornell University 2018 Career Institute in Mental Health of Aging Summer Research Institute. The Summer Research Institute (SRI) is an effort by the field of geriatric psychiatry to increase the number of talented investigators in the research career pipeline and to broaden the base of geriatric psychiatry research by attracting new investigators.
“It’s an honor to participate in such a meaningful program that aims to mentor and support junior investigators, providing them with the tools needed to succeed in a research career.”