Dementia Care Experts Urge Replacing Psychiatric Drugs With DICE

Many people think of memory loss as the most challenging change brought about by Alzheimer's disease. But according to Dr. Helen C. Kales of the University of Michigan Health System, "Often, more than memory loss, behavioral symptoms are among the most difficult aspect of caring for people with dementia. These symptoms are experienced almost universally, across dementia stages and causes."

Behavior-related symptoms might include irritability, agitation, anxiety, depression, aggression, apathy and sleep problems. Dr. Kales says, "Sadly, these symptoms are often associated with poor outcomes, including early nursing home placement, hospital stays, caregiver stress and depression, and reduced caregiver employment."

Doctors sometimes prescribe psychiatric drugs such as antidepressants and antipsychotics to control these symptoms and to calm patients. But many recent studies question the safety and effectiveness of these medications for this use. Dr. Kales says that the side effects of these drugs can be serious, even raising the risk of death for people with dementia.

Dr. Kales and her team have been studying non-drug approaches for addressing dementia patients' behavioral issues. Their approach emphasizes caregiver interactions and interventions that remove triggers for distressed behaviors.

Assessment and Intervention

The first step is to assess and understand the underlying causes of behavior changes in a person with dementia. According to the National Institutes of Health, it's important to realize that these behaviors are expressions of the person's needs, as distorted by the effects of the disease. The person might be hungry, thirsty, frustrated or bored, but unable to express these feelings. Dr. Kales and her team also say that many hidden medical problems, such as pain, urinary tract infection, constipation, dehydration or drug interactions, can lead to behavioral issues.

The next step is to make changes in the person's life to meet their needs and minimize triggers. Dr. Kales says these might include de-cluttering the environment, using music or simple activities that help engage a person with dementia, and better communication techniques, such as using a calm rather than confrontational voice. Adhering to a familiar routine can help. And Dr. Kales reminds families, "Making sure that caregivers get breaks from their responsibilities and take care of themselves, especially in the home, can help them avoid burnout and taking their frustration out on patients."

The DICE Program

Dr. Kales, who is head of the university's Program for Positive Aging and Geriatric Psychiatry, worked with experts from Johns Hopkins University to create a new approach to behavioral and environmental interventions. Published under the easy-to-remember acronym of DICE, the program consists of these four steps:

  • D: Describe—Asking the caregiver, and the person with dementia if possible, to describe the "who, what, when and where" of situations where problem behaviors occur and the physical and social context for them. Caregivers could take notes about the situations that led to behavior issues, to share with health professionals during visits.
  • I: Investigate—Having the person's health provider look into all aspects of the person's health, dementia symptoms, current medications and sleep habits, that might be combining with physical, social and caregiver-related factors to produce the behavior.
  • C: Create—Working together, the patient's caregiver and health providers develop a plan to prevent and respond to behavioral issues in the person with dementia, including everything from enhancing the patient's activities and environment, to educating and supporting the caregiver.
  • E: Evaluate—Giving the provider responsibility for assessing how well the plan is being followed and how it's working, or what might need to be changed.

Dr. Kales cautions that while the DICE intervention has been found to be very effective, "drugs still have their place, especially where the safety of the person with dementia or family caregivers may be at risk." But in the majority of cases, a behavior approach is more effective and safe. Says Dr. Kales, "The evidence for nonpharmaceutical approaches to the behavior problems often seen in dementia is better than the evidence for antipsychotics, and far better than other classes of medication."

Why are many people with dementia still prescribed these drugs? Dr. Kales says, "The issue and the challenge is that our healthcare system has not incentivized training in alternatives to drug use, and there is little to no reimbursement for caregiver-based methods. There needs to be a shift of resources from paying for psychoactive drugs and emergency room and hospital stays to adopting a more proactive approach."

Visit the University of Michigan Health System website to learn more about the DICE approach, and to read about the Program for Positive Aging. Research on the DICE intervention also appeared in the journal BMJ and the Journal of the American Geriatrics Society.

The information in this article is not intended to replace the advice of a person's healthcare provider. Consult the doctor before discontinuing or changing the use of any medication.


Right at Home, Inc. is a national organization dedicated to improving the quality of life for those we serve. We fulfill that mission through a dedicated network of locally owned providers of in home care services.