Reduce Off-Label Meds for Dementia by Modifying the Home

As family and professional caregivers struggle to alleviate the difficult behaviors associated with Alzheimer’s or dementia, they often turn to off-label medications.

When a drug is used for a disease that it hasn’t been approved to treat, it’s considered off-label.

In dementia care, off-label medications often include antipsychotics, antidepressants, antianxiety, and other mood stabilizers—all of which change brain function and result in alterations in perception, mood, or consciousness.

Antipsychotics are the most common medications used to address difficult behaviors and symptoms.

These medications are a class of psychiatric drug primarily used to manage psychosis, which is characterized as a disconnection from reality—in particular schizophrenia and bipolar disorder.

When off-label medications are prescribed for people with dementia, it’s generally for agitation, aggression, anxiety, sleeplessness, depression, hallucinations, and delusions.

This is because these medications have a calming and sedative effect. Unfortunately, this decreases the individual’s quality of life, as they are no longer able to fully engage in activities, or with other people.

The list of potential side effects is extensive, and in 2005 the FDA issued a black-box warning citing an increased risk of death 1.6 to 1.7 times greater than for those taking a placebo. The FDA issued an appended alert in 2008.

As such, the goal should always be to use these drugs as a last resort, at the lowest dose, for a minimal duration, and only after non-drug interventions have been exhausted.

Since most undesirable behaviors, which are often medicated for, are triggered by the environment, it’s most effective to focus on improving the environment first.

There are four primary elements of the environment that must be addressed to reduce the need for antipsychotics and other off-label medications:

1. Safety
2. Function
3. Stimulation
4. Negative Triggers 

These four elements must be in balance to create an Alzheimer’s and dementia friendly environment. 

Safety promotes independence and individualism while helping family members and other caregivers have peace of mind.

The goal is to prevent issues and accidents from occurring, and very importantly, to be prepared to respond in case there’s an injury or illness.

It’s important to address physical hazards that may cause harm. Clutter and extension cords are two examples among many. Here are some DIY modifications you can make to increase safety.

Functionality empowers a person to complete tasks on their own or with minimal assistance, thereby turning potential failures into successes.

The goal here is to create an environment that prolongs the person’s ability to perform activities of daily living such as household chores, preparing meals, bathing, dressing, etc.

Strategies that help create successful outcomes promote autonomy by increasing confidence, prolonging independence, and maintaining a sense of purpose.

Examples include reminder systems, using labels on cabinets, and using color and contrast to improve wayfinding.

Stimulation brings joy, lifts one’s spirit, and results in feelings of purpose and accomplishment.

The goal of using stimulation is to foster an enjoyable environment where the individual stays mentally and physically active and engaged. And hopefully, everyone smiles more. ☺ 

A stimulating environment should include activities that the person enjoys and wants to do. These activities can be passive such as bird watching with another person, or active such as dancing.

The environment should create an opportunity for exercise and movement, as well as provide sensory stimulation through smells, sounds, touch, and taste.

A focus on safety, function, and stimulation reduces and often eliminates many of the environmental triggers that cause difficult behaviors.

Negative triggers result in difficult and undesirable behaviors. A trigger is something such as an action, event, or stimuli that initiates or precipitates a reaction or series of reactions. This results in either a positive or negative outcome. 

The goal is to learn how to identify the trigger, or triggers, that are negatively affecting the individual’s behavior.

The way a person behaves, whether they have dementia or not, is affected by their environment. Physical aspects as well as the behavior of people around them can be triggers.

These triggers often result in confusion, frustration, overwhelm, anger, and even depression. And these feelings cause a reaction.

Instead of looking at the reaction, or negative behavior, as bad, look for how the context or environment is out of sync for the individual, and explore what can be changed to make it better.

By bringing these four elements into balance to improve the environment for the individual, the need for off-label medications can be reduced and often times completely eliminated.