Erratic Behavior and Memory Loss

A recent article in The Elder Law Report by John Roberts discusses the erratic behavior among people with dementia and the challenges it brings to their loved ones and caregivers.

Nursing homes often resort to powerful antipsychotic medications to control the behavior of residents with memory loss, dementia, and Alzheimer’s. A national survey found that in 2004 about one-quarter of residents were being administered these drugs, and data collected by the Centers for Medicare and Medicaid Services in 2010 shows that up to 20% of nursing residents who are given antipsychotic medications do not have a psychotic condition. Nursing homes that have frequently employed antipsychotic drugs in the past are more likely to administer them to newly admitted residents, according to a 2010 University of Massachusetts Medical School study.

The use of antipsychotic drugs (such as Abilify, Haldol, Risperdal, Seroquel, and Zyprexa) to quell dementia’s behavioral symptoms can cause serious side effects beyond the chemical “fog” they often induce. In 2005 the U.S. Food and Drug Administration began requiring manufacturers of “atypical” antipsychotic (including Risperdal, Seroquel, and Zyprexa) to include black box warnings of increased mortality risk for older patients with dementia, and in 2008 the agency extended the requirement to conventional antipsychotic drugs. Since then, doctors who treat elderly patients outside of nursing homes have cut back on prescribing antipsychotic drugs for dementia patients, but the practice persists in nursing homes.

Nursing home administrators are becoming aware of the problem. For example, in November 2010, the Massachusetts Bureau of Health Care Safety and Quality launched a campaign to educate administrators about non-pharmacological strategies to address erratic behavior in dementia and Alzheimer’s patients. A similar educational effort is needed for elder law attorneys, for financial planners who influence long-term health care planning decisions, and for family members of elders with memory loss and dementia. Elder law attorneys must be knowledgeable about the progressing needs of memory loss patients and the available non-chemical alternatives to help protect each client’s quality of life. Without this perspective, Medicaid planning and efforts to protect or set aside assets will be, at best, incomplete.

At worst, asset-protection advice acted on without a sound understanding of the needs of a memory loss patient who is still able to live at home or in assisted living may cause the family to withhold or hoard financial resources that would otherwise have prevented a nursing home admission and reliance on antipsychotics.

Safer and less intrusive alternatives to antipsychotic medication are available to families and caregivers who want to do everything possible to prevent the erratic behavior that causes a crisis nursing home admission, and to avert the use of chemical restraints in a nursing home.

Causes for such erratic behavior can be:

• Physical ailments (arthritis, dental problems, urinary tract infections, etc.)
• Memory loss patient’s environment
• Overstimulation – Noisy? Intrusive roommate? Staff rushing in and out?
  o Understimulation – Is the patient occupied with tasks that challenge him/her? Is he/she exposed to adequate sensorimotor stimulation?
  o Do people or objects trigger stressful memories, drives or feelings?
  o Are there unmet needs?

When family members understand how a memory loss patient’s unmet needs can drive behavior, they have taken the first step toward solutions that may prevent a nursing home admission or the unnecessary use of antipsychotic medications.