To the Editor:
I have been a head nurse on a dementia unit for two years. The treatment I have devised with my staff and the medical director for irreversible dementia consists of many psychosocial interventions along with small doses of neuroleptic drugs. I have found the latter to be important for the optimum psychological fiinction of some patients.
The article "Neuroleptics and Behavior: A Comparative Study" published in the Journal of Gerontological Nursing, 13(6) by Butler, Burgio, and Engle questions the advisability of using neuroleptics and cites the main side effects of sleep problems and/or restlessness. The patients in the study who received neuroleptics experienced these two symptoms to a statistically significant degree. On my unit, these side effects are a signal to decrease the dosage of the drug and we do so. Seven patients are taking haloperidol and the mean dose is 2 . 7mg QD (compared to 3 . 7mg QD in the study). One patient takes 60 mg of thioridazine QD as compared to the mean of 200mg QD in the study. The remaining residents are on no neuroleptics or small doses of miscellaneous neuroleptics. Because of the discreet doses of these drugs, the patients on my unit do not experience untoward side effects AND they are able to socialize, perform tasks, and assist in ADLs which they could not do without the drugs.
The article named above also states that the "side effects can affect a patient's ability and motivation to relearn the complex skills required for his or her return to the community " (p 18). This is an unrealistic goal for elderly, irreversibly demented patients on whom the study was conducted. Dementia is "me global impairment of higher cortical functions including memory, die capacity to solve die problems of day-to-day living, correct use of social skills and control of emotional reactions."1
The literature about dementia agrees that the goal of treatment for tiiese patients is "optimum function" for die stage of illness they are experiencing. Neuroleptic drugs, given in discreet doses to prevent untoward side effects, aid the patients in achieving this more realistic goal.
1 . Bondareff W: Biomedical perspective of Alzheimer's disease and dementia in the elderly, in Gilhooly M, Zarit S, Birren J (eds): The Dementias: Policy and Management, Prentice-Hall, Englewood Cliffs, New Jersey, 1986.
Katharine Kolcaba, MSN, RN
Instructor, University of Akron
Head Nurse, Dementia Unit
Margaret Wagner House
Cleveland Heights, Ohio
We would like to thank you for allowing us this opportunity to respond to Katharine Kolcaba's letter regarding our recent article in JGN. We find that we are in complete agreement with most of Ms Kolcaba's main points; however, she has apparently misinterpreted some of our statements. The general thrust of our article was to emphasize the need for more research into the effects of neuroleptic medication on elderly individuals. In this first study, our specific aim was to use objective measures to detect any behavioral differences between two matched groups of patients, one receiving and one not receiving neuroleptic medications. The study clearly showed that there were differences on specific behavioral indices. However, we were careful to state in the Discussion that our experimental design did not allow us to make inferences of causality regarding the effects of neuroleptic medications. Nevertheless, we felt that the results were suggestive of adverse drug effects and we advised nurses to consider this possibility when recommending pharmacotherapy. We were even more forceful in recommending additional research and in urging nurses to collaborate if not lead in these efforts.
We were most pleased to read about Ms Kolcaba's treatment strategy on her Dementia Unit. We also suspect that a combination of a low dose neuroleptic plus an ongoing psychosocial intervention will be an efficacious treatment for many demented patients (although our clinical experience is that behavior therapy is tlie most effective psychosocial intervention). However, it is one thing to express one's opinion regarding die efficacy of a clinical program, and quite another to present systematic, scientific data for peer review. The data alluded to by Ms Kolcaba are crucial and we urge her to submit them for publication so that maximum benefit can be derived from her experiences.
Finally, although we agree that the goal for demented patients is to establish "optimum functioning" we appear to disagree on what is meant by the term. First, one small point: we did not state in the article that our patients were irreversibly demented. It is unknown how many of our patients were irreversibly demented, and it is quite possible that some of them may have been suffering from a neuroleptic-induced pseudodementia. Everyone who has worked either in a long-term care setting or in an acute service with older adults knows the difficulties of differentiating between dementia and delirium. More importantly, though, it has been repeatedly demonstrated that with the use of systematic training techniques, demented patients can relearn even complex skills.1,2 We believe that with training, some institutionalized elderly patients can be returned to the community, although independent functioning may not be a realistic goal.
Pinkston and Linsk3 have demonstrated that many elderly patients can be maintained in the community for much longer periods of time by instructing family members in the use of behavioral procedures to maintain their elders' ADLs, and to decelerate disturbing behavior problems. Low dose neuroleptic medications will probably play an important role in producing optimum functioning in elderly demented patients in both community and inpatient settings. However, only through much additional research can we learn how to apply optimum treatments to produce such optimum functioning.
1. Baltes MD, Lascomb SL: Creating a healthy institutional environment for the elderly via behavior management: The nurse as a change agent. Int J Nur s Stud 1977; 12:5-12.
2. Hussian RA: Behavioral geriatrics, in Hersen M, Eisler RM, Miller PM (eds): Progress in Behavior Modification: Vol. 6, New York, Academic Press, 1984, pp 159-183.
3. Pinkston EM, Linsk NL: Care of the Elderly: A Family Approach, New York, Pergamon, 1984.
Louis D. Burgio, PhD
Bernard T. Engel, PhD
Frieda Butler, PhD, RN
Gerontology Research Center
National Institute on Aging
Howard University College
Washington, D. C.