DICE Method for Handling Agitation & Aggression in Dementia

DICE Method for Handling Agitation & Aggression in Dementia

A new technique called “DICE” empowers caregivers, patients & health providers to work together to reduce behavioral problems in people with dementia. Learn how it can reduce the use of antipsychotic drugs and make life easier for everyone.

ANN ARBOR, Mich. — A new approach to handling agitation, aggression and other unwanted behaviors by people with dementia may help reduce the use of antipsychotics and other psychiatric drugs in this population, and make life easier for them and their caregivers, a team of experts says.

The new DICE model – for Describe, Investigate, Evaluate, and Create – seeks to reduce psychotropic medication use in dementia patients.

Publishing their recommendations under the easy-to-remember acronym of “DICE”, the panel of specialists in senior mental health hope to spark better teamwork among those who care for dementia patients at home, in residential facilities and in hospitals and clinics. In fact, the federal agency that runs Medicare and funds much dementia-related care has made the DICE approach an official part of its toolkit for reducing the use of antipsychotic drugs and other mental health medications in people with dementia. Though these drugs may still help some patients, the new paper in the Journal of the American Geriatrics Society says, many non-medication approaches could also help reduced unwanted behaviors, also known as neuropsychiatric symptoms of dementia. But it will take teamwork and communication to do it. Most people with Alzheimer’s disease and other memory-affecting conditions also get aggressive, agitated, depressed, anxious, or delusional from time to time, says senior author Helen C. Kales, M.D., head of the U-M Program for Positive Aging and Geriatric Psychiatry at the University of Michigan Health System and investigator at the VA Center for Clinical Management Research . Or, they might have delusions, hallucinations, or lose inhibitions. “Often more than memory loss, behavioral symptoms of dementia are among the most difficult aspects of caring for people with dementia. These symptoms are experienced almost universally, across dementia stages and causes,” she 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 often prescribe these patients medications often used in patients with mental health disorders, despite little hard evidence that they work well and despite the risks they can pose — including hastening death. Meanwhile, studies have shown promise from non-medication approaches to changing dementia patients’ behavior and reducing triggers for behavioral symptoms in their environment and daily life. But too few health teams are trained in their use. Kales and her colleagues Laura N. Gitlin, Ph.D. and Constantine G. Lyketsos, M.D. from Johns Hopkins University authored the new paper on behalf of a group of experts, called the Detroit Expert Panel on the Assessment and Management of the Neuropsychiatric Symptoms of Dementia, who developed the DICE approach. Sponsored by Kales’ program, the national multidisciplinary panel of experts met in Michigan to create a comprehensive approach to behavioral management. Dubbed “DICE” for Describe, Investigate, Evaluate, and Create, it details key patient, caregiver and environmental considerations with each step of the approach and describes the “go-to” behavioral and environmental interventions that should be considered. Briefly described, the components are:

  • D: Describe – Asking the caregiver, and the patient 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 health provider look into all the aspects of the patient’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 patient, including everything from changing 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. 
  • The authors say that doctors should prescribe psychotropic drugs only after they and the patient and caregiver have made significant efforts to change dementia patients’ behavior through environmental modifications and other interventions, with three exceptions related to severe depression, psychosis or aggression that present risk to the patient or others.  Now, the authors say, health providers of all kinds who care for dementia patients should familiarize themselves with the DICE approach – as should the spouses, adult children and others who care for dementia patients at home. “Innovative approaches are needed to support and train the front-line providers for the burgeoning older population with behavioral symptoms of dementia,” says Kales, a professor in the U-M Medical School’s Department of Psychiatry and member of the U-M Institute for Healthcare Policy & Innovation . “We believe that the DICE approach offers clinicians an evidence-informed structured clinical reasoning process that can be integrated into diverse practice settings.”  Gitlin, who directs the Center for Innovative Care in Aging at the Johns Hopkins School of Nursing, adds, “The DICE approach is inherently patient- and caregiver-centered because the concerns of individuals with dementia and their caregivers are integral to each step of the process. DICE also enables clinicians to consider the roles of nonpharmacologic, medical and pharmacologic treatments concurrently.” Lyketsos, chair of the Department of Psychiatry at Johns Hopkins Bayview, stresses that the approach “has tremendous utility in clinical trials of treatments for behavioral symptoms, particularly in testing new medications. DICE can be used to better subtype behaviors, or focus on particular behaviors at randomization coupled with systematic treatment approaches”.
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As a family caregiver, you play a vitally important role in the life of your aging loved one—a role that can also be overwhelming, exhausting and sometimes thankless. As our gift to you this season, and as an encouragement for all of the good work you are doing, we asked professional Home Instead® CAREGiversSM to share their best advice with you. Here are eight of our favorites.

1. Take a break without feeling guilty. Maggie, a Home Instead CAREGiver, says, “The one thing I would advise a family caregiver is to allow themselves respite time, at least a couple times each month, without feeling guilty. A refreshed caregiver is a much better provider of care when they themselves have taken a much needed break.”

2. Helping your loved one look good can help them feel good, too. CAREGiver Theresa says, “Washing their hair, getting a trim or a haircut can vastly improve how they feel and see themselves. Update their clothes as their size changes or they lose a lot of weight. Purchasing two or three brightly colored, patterned ‘senior bibs’ or ‘painting smocks’ that can be put on and washed every day can also extend the life of their clothes.”

3. Give them the freedom to forget. CAREGiver Lori says, “Do not assume your family member remembers even the simple parts of life they’ve always known. Do not assume they like what they’ve always liked: music, television, current events, travel, past favorite foods, visiting in large groups of people. Do not assume they remember the person in church greeting them, or the neighbor next door, or even you. Allow them the space to remember and forget at their own pace.”

4. Call or visit regularly. CAREGiver Renee says, “In my years as a caregiver, I have found that most seniors who do not get out much usually experience loneliness. Their phone seldom rings and the television is often left on all day for company. They want to hear the sound of other voices but that doesn’t take the place of visiting with other people or spending time out in public.” Renee suggests setting a specific day and time each week to call, to give your loved one something to look forward to. A simple letter or greeting card to let them know they are missed and loved can make their day and remind them that someone cares.

5. Allow them to change and accept when they do. “Whether it’s a physical incapability or behavioral, realize that it is okay that your loved one is not the person you remember. Step back and realize the only way they can get peace is to let them be.” – Jeannie, Great Lakes Region 2012 CAREGiver of the Year

6. Never make them feel incapable, or say “no” outright. Jeannie also advises, “Be considerate about things that may be embarrassing to them (e.g., helping them out of a wheelchair). Be as creative as you can be. If they’re confused about what is going on, ease the confusion by asking questions about their past and suggesting activities like going for a drive and pointing out all their favorite locations. Do what you can to make it feel like they weren’t denied anything.”

7. Be patient and respectful. Mariana, Central Region 2012 CAREGiver of the Year, says: “Regardless of the reasons they need care, it is important to provide loved ones care in ways that are respectful of their dignity and independence. You need to be patient.”

8. Accept help. “You need to take care of yourself to take care of someone else. If people offer to help, accept the help.” – Mariana


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Such a beautiful song and so true…

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A trip to the Hospital…to maintain health ???

lake healthSeniors often avoid hospitals. For many, the hospital is a place to be avoided at all cost, that if they enter, they’ll never come out.

Instead of addressing health concerns, they might allow the little issues to pile up. They might also ignore symptoms, or hide them from friends and family.

For example…

They might avoid seeking treatment for an arthritic knee, or another treatable malady, until something happens. Perhaps a fall from the sore knee? The knee could have been addressed with medication or exercises. But due to the fall, there is a broken hip, surgery to repair it and then a rather lengthy recovery from surgery. And probably a stay in a rehab facility.

Worse, the injured party was not at optimal strength, because they reduced their activity level prior to the fall. Those little issues that piled up, started a slow decline. Maybe they stopped getting up to cook meals, eating properly, going  grocery shopping, or even going out to pick up medications.

Many times, we don’t realize a loved one is in this place, until they are taken to the hospital after a catastrophic event sends them to the emergency room.

We can help our loved ones before this type of situation occurs…


Or at least your local hospitals website.

In Lake County, Ohio we have TriPoint Medical Center and Lake Health West Medical Center, both part of Lake Health. Also part of Lake Health, there are urgent care, physical therapy, diagnostics and other healthcare locations scattered throughout Lake County.

What type of information is on Lake Health’s website?

  • Recipes for healthy eating and cooking tips
  • Buttons to connect to Lake Health via social media
  • Classes and Events; skin cancer screenings, music therapy classes to help manage diabetes, kayaking for fitness and fun, classes to quit smoking, and so much more. (Some classes are free, some have fees.)
  • Presentations; Lake Health frequently has staff present on topics of interest, such as joint replacement surgery or heart health.
  • 2013 Arthritis Expo information
  • Details about a new walking path soon to be constructed around the TriPoint facility for both hospital staff, guests, patients and also for community use.


bookA fun event or outing is a nice way of getting everybody out of the house. But it might also help make your local hospital seem less threatening. Which can encourage a loved one to maintain scheduled doctors appointments, or even to feel more comfortable if they do require a hospital stay. The familiar is always more comfortable–less scary.

TriPoint Medical Center presents Growing up:Making the Big Girl Shoes Fit, on Thursday, June 20, 2013 at the Physician Pavilion, 7590 Auburn Road, Concord Township, OH 44077.

                 From Lake Health...

You’re invited to meet Lake Health’s Lori Stevic-Rust, PhD, ABPP, as she shares her book, Greedy for Life: A Memoir on Aging with Gratitude. Learn how her grandmother’s extraordinary lessons of love and living guided Lori on her journey to adulthood.

Discover how her multi-generational family made their big girl shoes fit. The fee of $15 includes a copy of the book.

Bring your mother, daughters and friends to this event and wear your best big-girl shoes!  

The bonus?

Gathering families and friends, or groups of mothers, daughters, sisters, aunts, grandmother’s gets people talking. Sometimes when conversations get started, we find out little pieces of information that can help us to help our loved ones.

For example, maybe we find out our grandmother needs extra help getting to the grocery store and we get the opportunity to arrange for help, instead of allowing her to struggle.


Non-medical home care  can be wonderful. A caregiver can take your loved one to doctor’s appointments, the grocery store, hair appointments and other activities. Sometimes seniors need a little more help and their children must work. At Taylor Made Home Care, its common for caregivers to fill in those gaps.

The old thinking? Staying OUT of the hospital is healthy. But these days, hospitals offer tools to help us maintain our good health. They offer a wealth of resources not only to our elderly, but to all of us.

For more information on services mentioned above or to register for an event by phone, please call the Best of Health Line at 800-454-9800.  

Please click on the provided links, take a look around, and see what services are available. If you haven’t visited these sites recently, you’ll be pleasantly surprised!!

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Check out this newsletter it has a lot of helpful information.


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What Happens After a Fall?

flowerA family friend’s mother was recently admitted into the hospital.

Let’s call her Esther.

Ester is 85, has enjoyed excellent health and lives in her own condo. Fiercely independent, she wants to live at home.  She no longer drives, but she is mobile and sharp as a tack. Esther’s family helps out with grocery shopping and they pick her up to go to lunch, family events, etc.

Last week, Esther fell.  They estimate she was down for at least 12 hours.  A little banged up; she was admitted into the hospital.

During her hospital stay, doctors and family determined that Esther should not be home alone. And yet, that’s exactly where she wants to be. It’s where she’s comfortable and happy.

She was just moved from the hospital to rehab, for now. It gives the family a chance to explore their options and Esther has access to therapy to gain strength.

These situations are common. They happen every day to families. But when it happens in YOUR family, to YOUR loved one, it’s suddenly a very big deal.

What will happen to Esther? Or those in her situation?

She might be placed into a nursing home:  This would be difficult, because like many seniors, this is her greatest fear. She has maintained her independence for 85 years. It would be her nightmare to lose that.

She might need to live with family/relatives: Again, this would be difficult. Esther is lucky enough to have children who would welcome her, but she would still feel that she was a burden. And she would struggle with that type of living situation.

She could go home: This would be dangerous. Esther is a fall risk; she has reached a point where she should not live alone. She would need a family member to stay with her at all times.

She could go home with companion care: This is probably a solution that could work. And work well. Her family would know that she was cared for, that she’s eating regularly while they are at work and that she’s taking her medications. Esther could remain in her home.

With this type of care, Esther could still feel in control of her living arrangements, she wouldn’t feel she was burdening her family. Her caregiver could help her shower, grocery shop, could run the vacuum for her. And when her family was with her, they could enjoy each other and visit.

Companion care and caregivers aren’t covered by insurance, however many seniors have savings—and can use them for this purpose. Also, family members often help pay for this type of care. With it, they have peace of mind  while they’re at work or tending to their responsibilities, they know their loved one is happy, safe and cared for.

This is why companies such as Taylor Made Home Care are becoming more and more common. Because non-medical home care is a wonderful service for so many who are in Esther’s predicament.

Because we know Esther, my family has talked about the family situation, what the options are available to the family. Because I’ve worked in non-medical home care, have seen this situation every day, I could speak to it. This event started dialog in my family. We talked about how we would handle things.

And that’s a good thing.

Families should talk about their wishes. It’s important to plan for this, or at least know the options so that if your loved one has to make decisions such as Esther and family must make, the best possible decision can be made.

How to know when a loved one needs assistance?

Click here for a blog I wrote last fall entitled “Is your loved one in need of assistance?”

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Alzheimer’s Disease

ALZ-side-info-graphic-sixthI’m 42, so Alzheimer’s Disease was something to worry about in 30 years. It was on my radar, but with teenagers to raise, a job and bills to pay, it wasn’t a concern NOW…

That was my view, until I met Tricia Vidovic, Eastern Region Education and Outreach Specialist at The Alzheimer’s Association and before I worked for Taylor Made Home Care and saw firsthand how Alzheimer’s Disease affected families every day. 

The Alzheimer’s Association

Tricia works tirelessly  to raise awareness for this disease.  She was recently in Columbus, Ohio for Memory Day 2013. It’s an event that supports those living with Alzheimer’s disease and memory loss, by ensuring that our state legislators support vital programs and that there is funding for Alzheimer’s research. Tricia is a charismatic speaker, who manages to explain the disease in a way that it’s more easily understood.

For example, she has a book analogy. When we are very young children, our book has few pages and our story is just beginning. As we get older there are more and more pages/chapters, far more information in our book. The book is our brain. As we age, there’s simply more information to process and remember.

When I heard her speak earlier this year at Kemper House in Mentor, Ohio, Tricia outlined how the brain works. She also did interactive exercises to demonstrate how we remember information, presented statistics, studies, preventative measures to be taken and what’s in the works. She had flyers, websites and other resources both to offer help to families needing support now. Her goal was also to educate us in how we can help in finding treatments and a cure.

From working at Taylor Made…

I learned that caring for a loved one with Alzheimer’s Disease is stressful, emotionally exhausting and expensive . Thankfully, there are a growing number of resources to help; support groups, non-medical caregivers who offer companion care, local councils on aging  that offer such services as Meals on Wheels, local chapters of The Alzheimer’s Association and so much more. At Taylor Made, we provided caregivers, but we always tried to help our families find other resources in the community that might help them.

Alzheimer’s Disease is the 6th leading cause of death—yet nobody knows its cause, there is no treatment and no cure. And yet, there’s hope.

In the works…

National Alzheimer’s Plan is a huge push to help plan for the future of Alzheimer’s; to not only find treatments and a cure, but to plan for caring for those in our country who are afflicted (and will be diagnosed) with Alzheimer’s.

Legislation: The National Alzheimer’s Project Act (NAPA) requires creation of a national strategic plan to address the rapidly escalating Alzheimer’s disease crisis and will coordinate Alzheimer’s disease efforts across the federal government.

What can we do?

Get involved. One thing I did immediately after meeting Tricia, was go online and sign up to be an advocate. That lets those like Tricia know I’m interested in knowing what’s going on. I’ll get emails on the latest legislation, be kept in the loop and maybe be able to help in some small way.

walkWalk to end Alzheimer’s in Lake County Ohio on Sunday, September 29, 2013 at Holden Arboretum. (9550 Sperry Road, Kirtland, OH 44094) The event begins with activities at 8:30 a.m., a ceremony at 9:30 and then a walk of your choice. There is a one mile and a three-mile route.

Click here to find a walk in your area.

As I’ve had the opportunity to learn more about this disease, I realized that I need to do what I can NOW to support those mobilizing to research, treat and cure Alzheimer’s Disease.

It seemed a good idea to pass along information and links to websites, so that others can do the same.

And in September, I’ll be at Holden Arboretum doing the Walk to End Alzheimer’s in Lake County, Ohio.

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