Antipsychotic medications are often prescribed for people living with dementia who display aggression or signs of psychosis (Alzheimer's Society, 2017)—however, it is estimated that these drugs are inappropriate for about two-thirds of these people (Social Care Institute for Excellence, 2015).
Beyond behaviour
Imagine a patient who has dementia (or someone who you may not even know has dementia) begins shouting as you move closer to them or begins removing their clothing and touching their private parts. This may make you uncomfortable, and will likely signal that there is another issue at play if the person's dementia is not already known. It may also prompt the prescription of medications to make them easier to manage. However, outside of trying to address the behavioural symptoms, it is worth asking why this person is behaving in this way in the first place.
Could they be uncomfortable in the hospital and frightened that you are coming near them when you haven't introduced yourself, or when they can't recall you doing so? Could they be feeling warm, hence removing their clothing; or need to use the toilet, hence touching their private parts? The person may be struggling to find the words to express their unmet needs, and not simply ‘acting out’ because they are aggressive and need sedating.
Often the hospital ward is a hectic environment where there isn't time to ponder why a person is behaving a certain way, nor the necessary training and resources to do anything about it. However, an awareness is needed around the condition of dementia, the people behind this label, and what their symptoms are trying to communicate before drugs are used.
A case against medication
Since research has revealed the risks of taking antipsychotic medication, other drugs have been presented as alternatives (Passmore et al, 2008). Antipsychotic medications have been found to increase the risk of stroke and cerebrovascular events, while more recent research has revealed that the risk is even greater than previously thought, with mortality increasing and rising further with the dose (Woolerton, 2002; Maust et al, 2015). Other drugs, such as trazodone, have been considered as alternative medications (Halliday et al, 2017). However, older people in long-term care faced a higher risk of falls and fractures on this medication (Watt et al, 2018). Medication is perhaps a last resort and cannot replace listening to a person, trying to understand their needs and providing individualised care.
Looking forward
Working to communicate with the person, meeting their needs in the way that is appropriate to their condition, and involving them in their care is essential. But there are other experiences that can enhance their stay in hospital and lives once discharged.
For example, music can help people with dementia to reconnect with memories and provide an increased sense of wellbeing (Mendes, 2015a). Optimal nutrition is integral to a person's health outcomes and wellbeing (Mendes and Palmer, 2016a) and exercise can maximise a person's independence, improve health, and bring enjoyment and even companionship (Mendes, 2015b). Artistic stimulation can boost mood and wellbeing, and improve memory (Mendes, 2015c); and dolls, as well as animals, whether real, stuffed, or robotic have been shown to provide benefit despite controversy (Mendes, 2016a; 2016b; Mendes and Palmer, 2016b).
The list of non-pharmacological interventions that can improve the condition of a person with dementia is long and cannot be covered in this article in full. Information about these, as well as relevant local resources, should be shared with patients and their carers on discharge, and maximised where possible on the acute ward. However, the number one factor in caring for a person with dementia on a hospital ward, as with any patient, is to treat the whole person and connect with them, addressing their symptoms second.