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Caring for older adults with dementia is stressful, especially when they become physically or verbally aggressive, wander away from home, develop paranoia or hallucinations, engage in inappropriate or repetitive behaviors, or refuse to let caregivers help them.

This story also ran on The Washington Post. It can be republished for free.

Upward of 95% of patients experience these neuropsychiatric symptoms of dementia, which tend to fluctuate over time and vary in intensity. Theyre the primary reasons people with dementia end up in assisted living facilities or nursing homes. At some point, families and friends trying to help at home simply cant manage.

When people think about dementia, they usually think about forgetfulness and memory impairment, said Mary Blazek, director of the geriatric psychiatry clinic at the University of Michigan. But its behavioral and psychological disturbances that are most disruptive to patients and caregivers lives. About ‘Navigating Aging’

Navigating Agingfocuses on medical issues and advice associated with aging and end-of-life care, helping Americas 45 million seniors and their families navigate the health care system.

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Now, help is available from a first-of-its-kind website created by prominent experts in this field. It offers free training in a comprehensive approach to managing neuropsychiatric symptoms of dementia a method known as DICE based on several decades of scientific research as well as extensive clinical practice.

The websites goal is to give people tools to better manage often-distressing situations, said Helen Kales, chair of the Department of Psychiatry and Behavioral Sciences at UC Davis Health in Sacramento, California, and one of DICEs creators. Users learn that neuropsychiatric symptoms are caused by changes in the brain that increase peoples vulnerability. Nine video modules and two simulations provide comprehensive information and problem-solving techniques.

More than 16 million unpaid caregivers primarily family members and friends help people with dementia live at home. (An estimated 20% of patients live in institutional settings.) The most common form of dementia, Alzheimers disease, affects nearly 7 million Americans 65 and older.

DICE is also designed to help avoid the knee-jerk prescribing of psychoactive medications that have potentially serious side effects, Kales said. Several medical organizations recommend that non-pharmaceutical approaches to troublesome behaviors be tried before drug therapy, but, in practice, this doesnt routinely happen. Email Sign-Up

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Drugs prescribed for dementia include antipsychotic medications, such as Risperidone, which carry a black-box warning noting an increased risk of sooner-than-expected death in elderly patients; anticonvulsants, such as gabapentin, for which use has been on the rise despite concerns about safety; benzodiazepines, such as Ativan, which are associated with an increased risk of falls and, thus, fractures; and Celexa and other such antidepressants that have limited data supporting their effectiveness in easing dementia symptoms.

DICE is a mnemonic a pattern of letters meant to serve as a memory aid that stands for Describe, Investigate, Create, and Evaluate, the four pillars of this approach. At its core is an assumption people with dementia engage in disturbing behaviors for often-unrecognized reasons that can be addressed once they are understood.

Take an example on the website featuring Jennifer, a 55-year-old caregiver for her mother, Betty, 85, whom she tries to bathe daily in the late afternoon. When Betty resists getting into the tub, Jennifer insists, Lets go! I have things to do. Betty responds by smacking her and shouting, Leave me alone. It hurts.

DICE asks caregivers to step back from the heat of the moment and examine issues from three perspectives: the person with dementia, the caregiver, and the environment. All can contribute to distressing situations and all need to be considered in fashioning a response.

Examining the problem by using a who, what, when, how, why prompt can reveal several potential issues: The patient. Betty has arthritis and may experience pain getting in and out of the tub. She may feel tired and overwhelmed in the late afternoon. The caregiver. Jennifer may become easily frustrated when she encounters resistance adopting a scolding and commanding tone rather than breaking down what Betty needs to do in simple steps. The environment. The bathroom tends to be cold, with overly bright lights, tepid bathwater, and no grab bars around the tub.

Some possible solutions discussed on the website: Offer Betty an over-the-counter pain reliever before her bath. Try baths in the morning, not the afternoon. Relax expectations that shell have a daily bath and offer sponge baths several times a week. Install grab bars around the tub, and make sure the water temperature is comfortable. Use a nicely scented soap and play music to help Betty relax. Speak calmly, making simple statements.

These embody strategies shown to improve neuropsychiatric symptoms associated with dementia: recognizing and addressing underlying medical issues such as pain, infections, or delirium; simplifying the tasks a person with dementia is expected to perform; and establishing daily routines that give structure to the day.

Other important steps: Engage the person in activities that are meaningful to them, including social interactions. Reduce clutter and the potential for overstimulation in the environment. Make sure the person is using hearing or vision aids, if needed. Get them outside and exposed to light.

If safety, psychosis, or major depression are urgent concerns, then consider using psychoactive medications after consulting a physician.

Of course, this isnt a comprehensive list of recommendations. Nor is it prescriptive. What works for one person with dementia may not work for another.

Using DICE is an iterative process that involves creativity and frequent evaluation to assess whether strategies are working, Kales said. If not, new interventions should be tried.

Although this is the first time family caregivers can access the DICE toolkit, the program has been available to health care professionals for a while. Notably, all of Wisconsins dementia care specialists have been trained in DICE over the past few years (every county in that state has a specialist who helps families with dementia).

Its a really pragmatic approach thats put together in a very thoughtful fashion, said Art Walaszek, a professor of psychiatry and medicine at the University of Wisconsin School of Medicine and Public Health whos been involved in that effort.

Other dementia training programs are available, some of which review behavioral and psychiatric symptoms in less depth, and they, too, are increasingly available online. Another valuable resource, Best Programs for Caregiving, launched in March, lists evidence-based programs across the country and their availability. Enter a ZIP code to find information that previously hasnt been assembled in one place. This site, too, is very much worth consulting.

Were eager to hear from readers about questions youd like answered, problems youve been having with your care, and advice you need in dealing with the health care system. Visitkffhealthnews.org/columniststo submit your requests or tips.

Judith Graham: khn.navigatingaging@gmail.com, @judith_graham Related Topics Aging Navigating Aging Caregiving Dementia Nursing Homes Contact Us Submit a Story Tip

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Joe Biden allows Ukraine to begin firing US rockets deep into Russia – as politician warns it ‘risks World War Three’

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Joe Biden allows Ukraine to begin firing US rockets deep into Russia - as politician warns it 'risks World War Three'

Joe Biden has authorised Ukraine to begin firing US-supplied rockets deep into Russia – as Sir Keir Starmer prepares to push for “further support” for Kyiv at the G20 summit.

Mr Biden’s policy shift means Kyiv will now be able to use Army Tactical Missile Systems (ATACMS) for long-range attacks, two American officials have told Sky News’ US partner network NBC News.

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Ukraine plans to conduct its first such attacks in the coming days, the sources said, without revealing details due to operational security concerns.

The US has eased restrictions on the use of ATACMS, which have a range of up to 190 miles, after Russia began deploying North Korean ground troops to supplement its own forces in the conflict.

Kremlin spokesman Dmitry Peskov said such a move would deepen America’s involvement in the war.

“It is obvious that the outgoing administration in Washington intends to… continue adding fuel to the fire and provoking further escalation of tensions around this conflict,” Peskov said.

President Joe Biden meets with Ukrainian President Volodymyr Zelenskyy in the Oval Office in September last year. Pic: AP
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Joe Biden meets with Volodymyr Zelenskyy in the Oval Office in September last year. Pic: AP

The development was also condemned by Biden officials as a possible expansion of the war.

A Russian politician and the son of President-elect Donald Trump have both likened the move to risking a third world war.

Maria Butina told the Reuters news agency: “These guys, Biden’s administration, is trying to escalate the situation to the maximum while they still have power and are still in office.

“I have a great hope that Trump will overcome this decision if this has been made because they are seriously risking the start of World War Three which is not in anybody’s interest.”

Meanwhile, Donald Trump Jr wrote on X: “The Military Industrial Complex seems to want to make sure they get World War 3 going before my father has a chance to create peace and save lives… Imbeciles!”

The outgoing Biden administration’s move comes as there are concerns about the level of support the Trump White House may be willing to give Ukraine.

Mr Trump has previously vowed to limit US support for Ukraine and end its war with Russia.

In an evening address after Kyiv was given permission to fire deep into Russia, Ukrainian President Volodymyr Zelenskyy said: “Today, there’s a lot of talk in the media about us receiving permission for respective actions. But strikes are not carried out with words. Such things are not announced. Missiles will speak for themselves. They certainly will.”

Back in September, Russian President Vladimir Putin said if the US were to lift the ban on long-range missile use it would be seen as NATO’s “direct participation” in the war.

He added: “This, of course, will significantly change the very essence, the very nature of the conflict.”

The US military tests an early version of an Army Tactical Missile System in 2021. Pic: AP
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The US military tests an early version of an Army Tactical Missile System in 2021. Pic: AP

Meanwhile, the UK prime minister has said he has “no plans” to speak with the Russian president as world leaders gather for the G20 summit in Rio de Janeiro.

Mr Putin will not be attending the two-day summit which starts on Monday after saying in October that his presence would “disrupt the normal work of this forum”. Russia’s foreign minister Sergei Lavrov will be attending instead.

It will take place days after German Chancellor Olaf Scholz spoke to Mr Putin on what was the Russian leader’s first publicly announced conversation with the sitting head of a major Western power in nearly two years.

Asked if he had any plans to make a similar call, Sir Keir said: “It’s a matter for Chancellor Scholz who he speaks to. I have no plans to speak to Putin.”

Read more:
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Firefighters work at the site of a residential area hit by a Russian missile strike in the Lviv region of Ukraine. Pic: Reuters
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Firefighters work at the site of a residential area hit by a Russian missile strike in the Lviv region of Ukraine. Pic: Reuters

Speaking to reporters while on his way to the summit, he added: “We are coming up to the 1,000th day of this conflict on Tuesday.

“That’s 1,000 days of Russian aggression, 1,000 days of huge impact and sacrifice in relation to the Ukrainian people and recently we’ve seen the addition of North Korean troops working with Russians which does have serious implications.

“I think on one hand it shows the desperation of Russia, but it’s got serious implications for European security […] and for Indo-Pacific security and that’s why I think we need to double down on shoring up our support for Ukraine and that’s top of my agenda for the G20.

“There’s got to be full support as long as it takes and that certainly is top of my agenda, shoring up that further support for Ukraine.”

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One of Russia’s ‘largest air attacks’

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The latest developments come after Russia launched a large-scale attack on Ukraine on Sunday, with Mr Zelenskyy claiming Moscow had launched a total of 120 missiles and 90 drones.

Two major strikes, which left a total of 18 people dead, hit a residential building in the northeastern city of Sumy as well as energy infrastructure across Ukraine, prompting emergency power cuts.

Hours later, Moscow mayor Sergei Sobyanin said Russia’s air defence units had destroyed a drone heading towards the city.

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It’s a stunning shift in US policy – but Biden’s announcement will trigger fury and fresh threats from Moscow

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It's a stunning shift in US policy - but Biden's announcement will trigger fury and fresh threats from Moscow

Joe Biden’s belated decision to allow Ukraine to use US-supplied, long-range missiles inside Russia will be cheered by Kyiv and will almost certainly prompt the UK to follow suit.

But the stunning shift in US policy – just weeks before Donald Trump takes over as US president – will also trigger fury and fresh threats from Moscow at a time of increasing uncertainty about the future course of its war.

President Vladimir Putin has warned the West they would be playing with fire if they allowed Ukrainian forces to launch Western-supplied cruise and ballistic missiles at Russia, saying it could even trigger a global conflict.

British and US officials, though, have repeatedly advised their respective capitals not to be intimidated by Moscow’s sabre rattling.

Ukraine war latest: Biden lifts ban on Russia strikes

Yet there has been hesitancy, particularly in Washington, over the unleashing of US Army Tactical Missile System (ATACMS) ballistic missiles beyond the borders of Ukraine.

However, it seems that a move by North Korea to send thousands of its troops to fight with Russia has changed US calculations.

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Joe Biden is in Brazil for a G20 summit. Pic: Reuters
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Joe Biden delivered his remarks in Brazil. Pic: Reuters

The New York Times, which was among the US media organisations to break news of the Biden administration’s decision on long-range missiles, reported that the first time the American weapons will be used inside Russia will likely be against Russian and North Korean troops battling a Ukrainian incursion in the Russian region of Kursk.

While a significant step up in support for Ukraine, the ability to use American long-range missiles inside Russia is not a war-winning development.

But it does expand Kyiv’s capacity to hit important military targets deliberately positioned by Russian commanders far back from the frontline. This includes stockpiles of missiles, drones and other ammunition used to strike Ukraine.

Just as important as the military impact, though, is the political signal that the US decision sends to the Kremlin about Washington’s willingness to defy Russian warnings about dire consequences should Mr Biden dare to grant Ukraine the permission it’s so long been seeking.

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‘The missiles will speak for themselves’

The dramatic move by the US comes after months of lobbying by Ukraine’s leader, Volodymyr Zelenskyy.

A key thing to watch now will be how Mr Putin reacts the first time an American missile kills Russian soldiers on Russian soil.

Read more:
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Moscow does not want a direct war with the United States and NATO – nuclear-armed forces with far greater combined firepower – but the Kremlin could well ramp up an already heightened campaign of sabotage and other forms of hybrid warfare across Europe.

Another important reaction to track will be how Mr Trump responds to Mr Biden’s move and whether he continues to allow Ukraine this permission once he takes over as the US commander-in-chief.

The president-elect has vowed to end Russia’s war in Ukraine quickly but he has not said how. Yet he has voiced fierce opposition to the continued gifting of vast quantities of American weapons to the Ukrainian military.

It is a reason perhaps for Ukraine to make use of its new freedoms with US missiles as quickly as possible.

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Vladimir Shklyarov: Russian ballet star dies aged 39 after ‘fall from building’

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Vladimir Shklyarov: Russian ballet star dies aged 39 after 'fall from building'

An acclaimed Russian ballet dancer has died aged 39 after reportedly falling off a balcony.

Vladimir Shklyarov, one of the world’s top male ballet stars, died on Saturday night, according to the Mariinsky Theatre, where he was a principal dancer.

The St Petersburg theatre said: “It is with profound sadness that the Mariinsky Theatre announces the untimely passing of principal dancer Vladimir Shklyarov.

“Shklyarov, a beloved artist and audience favourite, died tragically on 16 November.

“His loss is deeply felt by the entire Mariinsky family and the wider ballet world.”

The Mariinsky Theatre told Sky News Shklyarov had a back injury at the time, and was due to have “complicated spinal surgery” on Monday 18 November. He was “taking serious pain medication”.

A spokesperson for the theatre was reported in Russian media at the weekend as saying he had fallen from the fifth floor of a building.

Vladimir Shklyarov performing in London in 2009.
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Vladimir Shklyarov performing in London in 2009, with fellow dancer Alina Somova. Pic: Reuters

Dancers have been paying tribute to Shklyarov, who was married to fellow company dancer Maria Shklyarov, with whom he had two children.

Former ballerina Irina Bartnovskaya said Shklyarov had been at home, on pain relief, preparing for foot surgery at the time of his death.

In a post on Telegram, she continued: “He went out onto the balcony to get some air and smoke, lost his balance (a very narrow balcony) and fell down (from the 5th floor).

“Stupid, unbearable accident.”

Read more from Sky News:
US allows Kyiv to fire rockets deep into Russia
UK will double aid to Sudan
Police force ends use of strip searches

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Diana Vishneva, a ballerina at the Mariinsky Theatre, was also among those paying tribute.

She said: “This tragedy brings only tears and sadness.”

According to state-run news group RIA Novosti, an investigation has been launched into the death.

The outlet also said that the preliminary cause of death was believed to be an accident.

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