Behavioral health care — not drugs — for dementia

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Dr. Eleanor Barbera
Dr. Eleanor Barbera

Antipsychotic medications have proved ineffective at reducing the symptoms associated with dementia. They also have serious side effects in older adults, including restlessness, dizziness, higher likelihood of falls and other problems that can contribute to an increased risk of death.  

Behavioral health interventions, on the other hand, have no such side effects and have been found effective in reducing behaviors such as aggression, care refusal and wandering.

Employing behavioral health techniques with people with dementia becomes increasingly valuable as facilities in this country endeavor to follow the Centers for Medicare & Medicaid Services guidelines and reduce the use of antipsychotic medications.

Global efforts

Dementia care is a pressing issue around the world, and other countries have made headway in shifting from medication to behavioral interventions. Psychologist Paula E. Hartman-Stein, Ph.D., of The Center for Healthy Aging, writes about international programs that implement behavioral health methods in the September/October edition of The National Psychologist.

Dr. Hartman-Stein spoke with Cameron Camp, Ph.D., an expert who consults with long-term care facilities in the United States and abroad.


Dr. Camp reports that the French government pays nursing homes to train their staff in non-pharmacological approaches to dementia. The training includes various strategies, including Montessori techniques such as those described by Dr. Camp in his excellent book, “Hiding the Stranger in the Mirror,” and other publications.


Camp notes that Alzheimer's Australia provides funding to train staff in behavioral health approaches. Its website, Alzheimer's Australia Information for Health Professionals, offers helpful information and brief videos that explain the techniques used.


In Canada, the Canadian Foundation for Healthcare Improvement reports on the success “beyond the team's expectations” of an effort to reduce antipsychotic medications and implement non-pharmacological approaches. The project saved $400,000 in six months across the Winnipeg region.

STAR-VA in the USA

Here in the United States, the Veterans Health Administration, less constrained by the fee-for-service psychotherapy model that plagues the rest of the country, utilizes staff psychologists and other behavioral health professionals in their Staff Training in Assisted Living Residences (STAR-VA) model.

The STAR-VA program, as reported by Michele J. Karel, Ph.D. and others in The Gerontologist, uses a “train-the-trainer” approach with psychologists and psychiatrists acting as “behavioral coordinators” who work in partnership with “nurse champions” to train the staff in behavioral techniques.

These techniques include three core components: identifying and changing factors that contribute to challenging behaviors, creating individualized “pleasant events” that satisfy residents, and establishing realistic expectations and communication skills.

The behavioral coordinators and nurse champions work with the team weekly for six months during the implementation process.

The STAR-VA training showed a significant decline in behaviors such as care refusal or resistance, agitation, aggression, vocalization and wandering, as well as a significant reduction in symptoms of depression, anxiety and agitation.

Reform of requirements for LTC facilities

Despite its effectiveness, using the services of a behavioral health consultant for staff training is not currently reimbursable by Medicare and Medicaid.

There is an opportunity to amend this, however, since CMS is proposing changes to the requirements long-term care facilities must meet in order to participate in its program.

Three major geropsychology organizations — Psychologists in Long-Term Care, the Society of Clinical Gerontology of the American Psychological Association, and the Council of Professional Geropsychology Training Programs — recommend that CMS consider the following as part of section §483.40 Behavioral Health Services:

• Reimbursement regulations for psychologists that, rather than being restricted to direct care services, are “broadened to behavioral health consultation and staff training.”

• Reimbursement for medical team conferences regarding patient care (CPT codes 99366-99368), allowing psychologists to contribute their expertise to team meetings.

• Reimbursement for psychologists for collaborative care services for treating beneficiaries who have common behavioral health conditions. This would enable, for example, consultations between a physician and a psychologist regarding the best approach to take to discuss a necessary surgery with a resistant patient.

Comments on the proposed rule changes are being accepted until midnight Oct. 14 at

Changes such as those recommended above would transform the behavioral healthcare of long-term care residents and create opportunities for facilities in the US to implement programs such as STAR-VA and other models from around the world.

On a personal note, it's always been frustrating to me as a psychologist that I could be reimbursed by CMS for counseling a resident who was aggravated by the way she was being treated by a staff member, but not for training the staff member on how to more successfully interact with the residents.

If CMS implements the changes recommended above, it will be a time of rejoicing for me.

Eleanor Feldman Barbera, PhD, author of The Savvy Resident's Guide, is a 2014 Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is the Gold Medalist in the Blog-How To/Tips/Service category of the 2014 American Society of Business Publication Editors Midwest Regional competition. A speaker and consultant with nearly 20 years of experience as a psychologist in long-term care, she maintains her own award-winning website at


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