How to manage psychological changes in individuals with dementia?

Managing Psychological Changes in Individuals with Dementia: The DICE Approach

The DICE approach (Describe, Investigate, Create, Evaluate) should be the first-line strategy for managing psychological changes in dementia, with non-pharmacological interventions attempted before considering medications. 1, 2

Understanding the Problem

Neuropsychiatric symptoms (NPS) in dementia are nearly universal, affecting 98% of individuals at some point in their disease course 1. These symptoms include:

• Aggression and agitation
• Depression and anxiety
• Delusions and hallucinations
• Apathy and disinhibition

These symptoms significantly impact quality of life, increase caregiver burden, and often lead to earlier nursing home placement 1.

The DICE Approach to Management

Step 1: DESCRIBE

Thoroughly characterize the behavior and context:

• Ask caregivers to describe the NPS "as if in a movie"
• Identify antecedents, specific behaviors, and consequences
• Understand what aspect is most distressing to patient and caregiver
• Document triggers and patterns in diaries or logs 1

Step 2: INVESTIGATE

Examine potential causes:

Patient factors:

• Pain or discomfort
• Medical conditions (UTI, constipation, dehydration)
• Medication side effects
• Sensory deficits
• Psychiatric conditions 1, 2

Caregiver factors:

• Communication approach
• Expectations
• Caregiver stress or burnout 1

Environmental factors:

• Overstimulation (noise, lighting)
• Unfamiliar surroundings
• Lack of routine 1, 2

Step 3: CREATE

Develop a management plan:

Non-pharmacological interventions (first-line):

• Create dementia-friendly environments with adequate lighting, reduced sensory stimulation
• Ensure effective communication techniques
• Address basic needs (food, hydration, toileting)
• Provide meaningful activities and social engagement
• Train caregivers in dementia care techniques 2
• Consider reminiscence therapy, behavioral approaches, and support groups 3

Pharmacological interventions (only if necessary):

• Use only after non-pharmacological approaches have been attempted
• Consider only if the patient poses substantial harm to self or others
• Use lowest effective dose for shortest possible duration 2

Medication options (if needed):

• For agitation/aggression: Atypical antipsychotics preferred over typical antipsychotics
• For mood disturbances: SSRIs as first-line pharmacological treatment
• For pain-related behaviors: Acetaminophen as first-line 2

Step 4: EVALUATE

Assess effectiveness of interventions:

• Use quantitative measures like Neuropsychiatric Inventory Questionnaire (NPI-Q)
• Monitor for medication side effects
• Reassess at least every 6 months
• Discontinue ineffective medications 2

Important Considerations and Pitfalls

Safety warnings:

• All antipsychotics carry increased mortality risk in elderly patients with dementia
• Benzodiazepines should not be used as first-line treatment (except for alcohol/benzodiazepine withdrawal)
• Avoid medications with high anticholinergic burden 2

Common mistakes to avoid:

• Using medications before trying non-pharmacological approaches
• Continuing medications longer than necessary
• Using excessive doses in elderly patients
• Failing to monitor for adverse effects
• Not addressing underlying medical causes of agitation 2

Special considerations:

• For Parkinson's disease: Quetiapine is preferred
• For cardiac issues: Avoid medications that prolong QTc
• For diabetes/obesity: Avoid clozapine and olanzapine 2

By following this structured approach, clinicians can effectively manage psychological changes in dementia while prioritizing patient safety and quality of life.