CareGuard shield mark

CareGuard

A Patient Safety Organization listed by AHRQ · PSO P0268

Report a concern

Well-Being and Cognitive Enhancement

Focus on non-pharmacological interventions that enhance cognitive function and improve the emotional and mental well-being of dementia patients.

What replaces the medication

Reducing a medication list without putting anything in its place is not deprescribing; it is withdrawal. The second letter of DWARAA is the substitution: cognitive stimulation, physical activity, social engagement, structure, and an environment that is not fighting the resident all day.

The environment is an intervention

The memory-care section of the safety review checks bright natural lighting, large legible signage, visible clocks and calendars, calm decor without disorienting patterns, temperature control and noise control. Those are not decor decisions. A resident who cannot tell what time it is, in a corridor that looks like every other corridor, under fluorescent light with a television going, is being given six reasons to be agitated before anyone speaks to them.

The memory care items.

Metabolic health is cognitive health

Glycemic control, blood pressure and vascular health are not a separate subject from cognition in an older adult. That is the seam where CareGuard and Measura meet: Measura handles the cardiometabolic and autonomic analysis on the clinical side, and DWARAA handles what the facility does with it. The Measura pairing.

DWARAA is six steps. Back to the overview.

The four levers, and what each one is for

  • Cognitive stimulation. Structured activity matched to what the resident can still do. The review checks that activities are tailored to cognitive ability, because an activity pitched too high produces failure and agitation, and one pitched too low produces disengagement.
  • Physical activity. Safe, enclosed outdoor space and daily movement. Movement is also the single most reliable intervention for the sleep disruption that drives sundowning.
  • Social engagement. Adequate staff-to-resident ratio so that individualized attention is possible at all — an item that sits in the memory-care section rather than in the labor section, because in a memory-care unit it is a clinical variable.
  • Environmental modification. Light, signage, clocks, calm decor, temperature, noise. Six items, all cheap, all skipped.

Why cognition and comfort are not separable

A resident in pain who cannot report pain will present as agitated, and agitation gets treated. The review therefore requires regular pain assessment specifically for non-verbal residents, and non-drug relief — positioning, warmth, comfort items — before anything else. Getting that wrong is how a comfort problem becomes a psychiatric prescription.

And sleep

Consistent daily routine appears twice in the checklist, in Routine & Engagement and again in Behavioral Support. Routine is what a person with failing short-term memory has instead of orientation: it lets the body know what happens next when the mind cannot recall it.

The evidence on antipsychotics in dementia

The mortality signal, and where the label came from

A 2005 meta-analysis of 15 randomized placebo-controlled trials (3,353 patients on drug, 1,757 on placebo) found death in 3.5% of drug-treated patients versus 2.3% on placebo, odds ratio 1.54 (95% CI 1.06 to 2.23). The FDA’s own analysis of 17 placebo-controlled trials, stated in the current approved labeling, puts it this way: “a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group.” The boxed warning followed for atypical antipsychotics in 2005 and was extended to conventional antipsychotics in 2008.

The label also records cerebrovascular adverse reactions, including fatalities, at a significantly higher incidence than placebo in elderly patients with dementia-related psychosis.

And the efficacy side

CATIE-AD randomized 421 outpatients across 42 sites for up to 36 weeks and found no significant difference between treatments in time to discontinuation for any reason. Discontinuation for intolerability ran at 24% (olanzapine), 16% (quetiapine), 18% (risperidone) and 5% (placebo). Its conclusion is one sentence: “Adverse effects offset advantages in the efficacy of atypical antipsychotic drugs.”

Withdrawal

The DART-AD discontinuation trial in 165 UK care-facility residents found 12-month survival of 70% (95% CI 58 to 80) in those continuing antipsychotics versus 77% (64 to 85) on placebo, hazard ratio 0.58 (0.35 to 0.95). At 24 months the gap was 46% versus 71%; at 36 months, 30% versus 59%.

A Cochrane review of nine randomized trials (606 participants, seven in nursing homes) concluded that “many older people with Alzheimer’s dementia and NPS can be withdrawn from chronic antipsychotic medication without detrimental effects on their behaviour” — with an important exception: two studies of people whose agitation or psychosis had previously responded well to antipsychotic treatment found an increased risk of relapse after discontinuation. Withdrawal is not uniformly safe and is not a policy to apply across a building without individual assessment.

What happened when a country tried it at scale

Antipsychotic use in US nursing homes reached 23.9% of residents by 2011. Following the National Partnership to Improve Dementia Care launched in 2012, use had declined 40.1% to 14.3% by the second quarter of 2019. Notably, sedative-hypnotic use did not rise to compensate — it declined in tandem. The evaluation’s own conclusion about what made it work: “Adequate staffing, particularly of registered nurses, is key.”

The substitution risk a safety review should look for

A repeated cross-sectional study of more than 70,000 Ontario nursing home residents per quarter from 2010 to 2019 found antipsychotic use falling 0.70% per year and benzodiazepine use 1.17% per year — while antidepressant use rose 0.89% per year and anticonvulsant use 1.06% per year. Over the same window the coding of delusions rose from 3.5% to 10.2%, while coded schizophrenia stayed flat.

That last figure is the one an owner should care about. A falling antipsychotic rate can mean better care, or it can mean a different drug class and a different diagnosis code. A review that only reads the headline metric cannot tell the two apart.

References

  1. Schneider LS, Dagerman KS, Insel P 2005. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA 294(15):1934-43. [meta-analysis, 15 trials] · PMID 16234500 · doi:10.1001/jama.294.15.1934
  2. US Food and Drug Administration 2026. RISPERDAL (risperidone) prescribing information, boxed warning and section 5.1. FDA-approved label, effective 2026-05-28. [FDA-approved drug label] · Source
  3. Schneider LS, et al. 2006. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease (CATIE-AD). New England Journal of Medicine 355(15):1525-38. [randomized controlled trial, 421 outpatients] · PMID 17035647 · doi:10.1056/NEJMoa061240
  4. Ballard C, et al. 2009. The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial. Lancet Neurology 8(2):151-7. [randomized discontinuation trial, 165 care-facility residents] · PMID 19138567 · doi:10.1016/S1474-4422(08)70295-3
  5. Declercq T, et al. 2013. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database of Systematic Reviews (3):CD007726. [Cochrane review, 9 RCTs] · PMID 23543555 · doi:10.1002/14651858.CD007726.pub2
  6. Jeste DV, et al. 2008. ACNP white paper: update on use of antipsychotic drugs in elderly persons with dementia. Neuropsychopharmacology 33(5):957-70. [expert white paper] · PMID 17637610 · doi:10.1038/sj.npp.1301492
  7. Crystal S, et al. 2020. National Partnership to Improve Dementia Care in Nursing Homes campaign: state and facility strategies, impact, and antipsychotic reduction outcomes. Innovation in Aging 4(3):igaa018. [national mixed-methods evaluation] · PMID 32699827 · doi:10.1093/geroni/igaa018
  8. Harris DA, et al. 2022. Potential unintended consequences of antipsychotic reduction in Ontario nursing homes. Journal of the American Medical Directors Association 23(6):1066-1072.e7. [repeated cross-sectional, 2010-2019] · PMID 35143749 · doi:10.1016/j.jamda.2021.12.043