Helen C. Kales, MD
Helen C. Kales, MD, professor of psychiatry, director, section of geriatric psychiatry and Program for Positive Aging, University of Michigan, Ann Arbor. Her study appeared in the Journal of the American Geriatrics Society.
Although we casually think of Alzheimer’s as memory loss, any caregiver will tell you that it’s far more than that—depression, anxiety, agitation, delusions, hallucinations and apathy are all symptoms, and they all can take a great toll on the caregiver. How to cope with this often martyring challenge?
A strategy that goes by the acronym DICE and is forged by a partnership between patient, caregiver and health-care provider has gotten a lot of buzz in the health-care community. The Centers for Medicare and Medicaid Services will include DICE in their training and resource modules for health-care providers. If you are the caregiver of someone with dementia, DICE really can improve life for you and the person you care for.
DICE is a four-step process in which the patient, caregiver and a health-care provider—it could be a geriatrician, geriatric psychiatrist, nurse practitioner or physician assistant, social worker or similar professional trained in dementia care—work as a team to identify the real causes of a patient’s “bad behavior” in any given situation and come up with solutions.
The four steps are…
The caregiver will be directed toward education resources and support groups, and the caregiver and health-care provider will work together to improve communication with the patient, simplify caregiver tasks, create structured routines and establish meaningful activities for the patient (such as revival of a hobby or participation in an adult day-care program) to help minimize his or her boredom, frustration, fear or other difficult emotions.
This example illustrates a problem situation that DICE is meant to address.
Imagine that you’re the caregiver of a relative—maybe your mom—with Alzheimer’s disease. You’re preparing to bathe her and think you are being gentle as you lower her into a tub, but she physically and verbally lashes out at you, exclaiming that she’s in pain. Well, you’ve been through this before with her and think that she’s intentionally giving you a hard time. How could she possibly be in pain? You were handling her with kid gloves!
These misunderstood problem behaviors, also referred to as noncognitive neuropsychiatric symptoms, are often so stressful for caregivers that families sometimes put loved ones in nursing homes much sooner than they really want to.
With the DICE approach, you would relate the event in detail during an appointment with a specialist trained in dementia care. The specialist would get you thinking about what might be causing this repeated problem and would also get your mother’s take on the situation. The specialist would arrange for Mom’s physical and psychiatric evaluation and, in examining her living space, might question you about whether the tub has grab bars, nonslip mats or other fixtures that would make bathing less stressful for her.
Suppose that, during the physical examination, it’s discovered that your mother has arthritis but isn’t on medication for it. The specialist explains that Mom means it when she says she’s in pain. Pain medication is prescribed, and your mother is referred for physical therapy. Meanwhile, you get to work outfitting the bathroom and other parts of the home to make them more user friendly for your mother. The specialist also provides you with educational counseling, reading material and referrals to support resources to help you better understand what your mother is going through…and to help you feel less alone.
The DICE approach is only recently being rolled out in a formal way, with training for health-care personnel being developed and a clinical trial underway. Its real value and feasibility won’t be fully known until its use becomes more widespread and clinical trials are completed to scientifically prove its value, ease of use and cost effectiveness. If you would like to try the DICE approach, start by asking your loved one’s health-care providers whether they are familiar with it—they may be able to refer you to a specialist or a practice that provides a similar service. Also contact a geriatric psychiatrist, whose training makes it more likely that he or she will apply an approach similar to DICE when working with dementia patients and their caregivers. You might even find that some or all of this is covered by insurance, depending on your loved one’s coverage.