Transcript Managing Difficult Behaviors in the Home and LTC Facility
Approaches to behavioral and psychological symptoms of Dementia
Marie-France Rivard, MD, FRCPC Division of Geriatric Psychiatry University of Ottawa
Objectives
Describe the causes of common psychological and behavioral symptoms in dementia (BPSD)
Introduce the purpose of the PIECES program
Identify appropriate interventions
Advise on the role of pharmacotherapy
Disclosure slide
Over last 28 years, received honoraria for Continuing education activities from most pharmaceutical companies and some grants for research. Over last 7 years, no direct funding for research or Continuing Education: honoraria by organizing committees who may have, in turn, received un-restricted grants. Currently Chair, Seniors Advisory Co to MHCC, mostly volunteer work.
Prevalence of BPSD
90% of patients affected by dementia will experience Behavioral and Psychological Symptoms of Dementia (BPSD) that are severe enough to be labeled as a problem during the course of their illness.
Agitation (75%) Wandering (60%) Depression (50%) Psychosis (30%) Screaming and violence (20%) are most common
Impact of BPSD
50 – 90% of caregivers considered physical aggression as the most serious problem they encountered and a factor leading to institutionalization. (Rabins et al. 1982) Front-line staff working in LTC report that physical assault contributes to significant work related stress (Wimo et al. 1997) Agitation, depression, anxiety, paranoid ideation cause significant suffering.
BPSD Symptom Clusters
Aggression Agitation Apathy Physical aggression Verbal Aggression Aggressive resistance to care Pacing Repetitive actions Dressing/undressing Restless/anxious Withdrawn Lacks interest Amotivation Sad Tearful Hopeless Guilty Anxious Irritable/screaming Suicidal Euphoria Pressured speech Irritable Mania Hallucinations Delusions Misidentification Suspicious Psychosis Depression Adapted from McShane R. Int Psychogeriatr 2000;12(suppl 1): 147
Causes of BPSD What is P.I.E.C.E.S.
Person-centered assessment and care planning approach, using the care team to develop hypotheses and test the implementation of possible solutions. An acronym that conveys the individuality and importance of the various factors that contribute to BPSD in dementia.
These factors are: Physical, Intellectual, Emotional, Capabilities, Environment and Social
P.I.E.C.E.S.
Taught in Ontario since 1998 to LTC registered staff From 1999-2007 expanded to include administrators of LTC, unregistered staff, acute care hospitals, CCAC case managers 2007-08: PIECES program for physicians: Soon available for distribution To be tested with family health teams and utilized by Peer Presenters and Preceptors of Ontario’s Alzheimer strategy
Why use the P.I.E.C.E.S. approach?
Identification of target behaviors which present risk or urgency Flags possible delirium Framework for synthesis of non pharmacologic approaches Nutrition, comfort, hydration, sleep, etc… Environment, personhood, social, stimulation Guide the pharmacologic approach
PIECES Template
The Three Question Template 1. What has changed?
2. What are the RISKS and possible causes (using the PIECES framework)?
3. What is/are the action (s)?
P -
Physical
Drugs Anticholinergics, benzos, Include OTC, alcohol Disease Atypical presentations, hypoxia, pain, infections Delirium – 30% mortality if undetected Hypoactive and hyperactive Basics Hydration, bowels, bladder, fatigue, sleep
I – infectious
Delirium
W - withdrawal A – acute metabolic, dehydration, renal, bowels T –toxins, drugs C – CNS pathology H – hypoxia, D - deficiencies E - endocrine A – acute vascular T - trauma H – heavy metals
Delirium work up and intervention
History and physical Bowel/bladder/pain/mobility Caregivers re what has changed Review medications including prns Investigations to identify and correct underlying causes: Vitals, O2 sat, glucose, chest X-ray CBC, Na, K, Creatinine, Albumin, Drug levels, Ca, Mg, TSH, B12, Folate, Urine, etc….
CT head if warranted
Intellectual/cognitive changes
Memory loss, Amnesia:
Annoying repetitive questioning.
Accusing others of not telling them about upcoming events.
Being “uncooperative” with previous requests.
Agnosia
Accusing family member of being an imposter when cannot quite recognize face… Failing to recognize one’s image in the mirror.
Utilizing objects inappropriately.
Intellectual/cognitive changes
Apraxia
Dressing inappropriately —upset with assistance provided/required
Needing assistance to eat
Aphasia
Frustration/anxiety Inappropriate requests/comments Reacting concretely to abstract concept
Intellectual/cognitive changes
Anosognosia
Not recognizing that one is no longer knows about or how to do some things, being unaware of deficits and need for help
Impaired executive functions:
poor planning/initiation
unable to appreciate consequences of things said or done before saying/doing them, impulsive behavior
Return to a place back in time
Intellectual/cognitive changes
Perceptual difficulties (distances, depth, time elapsed, gaps)
Resisting a bath or toileting, running over others.
Apathy and “perseveration”
May be confused with depression or “ill-will”.
Return of primitive reflexes, perseverative behaviors
Grabbing caregiver’s clothing or body part and being unable to let go.
E - Emotions
Delusions/Hallucinations/agitation Dopamine and cholinergic mediated Depression/irritability/anxiety Serotonergic, adrenergic, cholinergic mediated.
Adjustment Disorder Reactivation of past psychiatric illness with stress of dementia, placement Emotional Memory, past trauma, losses
C - Capabilities
Balance of Physical Demands and Capabilities Capacities too low to do a task?
Resistive behaviours, Frustration Catastrophic reactions Withdrawal Able to do more but assumed incapable Boredom, “attention-seeking” behaviors Be sensitive to changes in function Acute change – rule out reversible component Gradual change – Adapt care to progression of dementia
E - Environment
Environmental structure
design, lighting (glare), physical space, temperature
Ambience
Sounds, smells, colour, noise
Familiarity Noise
– excessive, distressing, confusing, unfamiliar Over/under stimulation Changing environment Relocation, routines, caregivers
S - Social
Life story, life accomplishments
‘All about me’, personhood
Social network
Relationships of family
Lifelong coping strategies
Interactions with caregivers who may not know you as a person
Interaction with other residents, roommates, others with dementia…
P.I.E.C.E.S. tools
Daily Observation Sheet (DOS), A-B-C charting Shows frequency, severity, patterns of behaviours, can be individualized Cohen Mansfield Agitation Inventory (CMAI) Identifies behaviours and severity over 7 day period Confusion Assessment Method (CAM) Delirium screen MMSE, MOCA, Clock Sig: E Caps, Cornell Depression Scale
DOS Behavior Map
SAT Time 6am 7am 8am 9am 10a 11a 12p 1pm 2pm 3pm 4pm MON TUE WED THU FRI SUN
Other Common Tools
Scale Assessment
CMAI
The Cohen-Mansfield Agitation Inventory
NPI-NH
Neuro-psychiatric Inventory Nursing Home Version
BEHAVE-AD
The Behavioral Pathology in Alzheimer’s Disease Rating Scale 29 agitated behaviors rated by caregiver on 7 point frequency scale 12 items rated by caregiver on a 4 point frequency and a 3 point severity scale 25 symptoms rated by caregiver on a 4 point severity scale
Caregiver Scales
Useful for patients in the community Self report can be used in office setting or home visit Allow caregivers to identify behaviours they may not be comfortable talking about in front of their loved one ie - Kingston Behavioural Assessment
Pharmacological treatment
Clear indication, potential benefits
Expected time to response
Risks associated with and without Rx
Appropriate dose range
Monitoring for side effects and response
When to consider dose reduction, discontinuation.
Top Ten Behaviors not (usually) responsive to medication
Aimless wandering Inappropriate urination /defecation Inappropriate dressing /undressing Annoying perseverative activities Vocally repetitious behavior Hiding/hoarding Pushing wheelchair bound co-patient Eating in-edibles Inappropriate isolation Tugging at/ removal of restraints
Top Ten Behaviors responsive (perhaps!) to medication
Physical aggression Verbal aggression Anxious, restless Sadness, crying, anorexia Withdrawn, apathetic Sleep disturbance Wandering with agitation/aggression Vocally repetitious behavior Delusions and hallucinations Sexually inappropriate behavior with agitation
Pharmacological treatment: When (indications)
Behaviors that have not responded to non pharmacological treatment.
Persistent despite P.I.E.C.E.S. approach Imminent and severe risk to self or others
E.g. delirium needing to be investigated Behaviors that can respond to medication: listed previously Target appropriate symptom cluster: depression, anxiety (acute or chronic), difficulty falling asleep, psychosis…
Pharmacological treatment: Choosing best drug
Correct underlying cause, deficiency:
Optimize treatment of dementia, CEIs, memantine Target appropriate symptom cluster:
Depression: Antidepressant Anxiety (longer term): antidepressant Difficulty falling asleep: Trazodone Psychosis: antipsychotic Aggression: antipsychotic Choose least likely to worsen dementia and medical problems
E.g. Least anticholinergic Choose drugs without problematic interaction
Best choices: antidepressants
SSRI for depression or anxiety
Citalopram (Celexa) and Escitalopram (Cipralex)
Sertraline (Zoloft) When noradrenergic properties may be wanted (pain, activation)
Venlafaxine (Effexor XR) *not if unstable BP Bupropion (not if unstable BP) When sedation may be needed urgently
Trazodone *watch for hypotension Mirtazapine (some anticholinergic properties) When important to have a drug well tolerated
Moclobemide (Manerix) * drug interactions
Best Choices - anxiety
Cholinesterase inhibitor particularly for anxiety of early dementia.
SSRIs first line treatment for anxiety disorders will take a few weeks to work check drug interactions. Consider trazodone (watch for hypotension)
Best choices: anti-psychotics
For acute delirium – very short term (days)
Haloperidol (0.5 mg that may be repeated) Loxapine (2.5 mg that may be repeated) For persistent psychosis/agitation
Risperidone (Risperdal): start with 0.25-0.5 mg daily and increase slowly as needed/tolerated over weeks to max. 2 mg per day Olanzapine (Zyprexa): start with 2.5 mg daily and increase slowly as needed/tolerated over weeks, to max 10 mg daily Quetiapine (Seroquel): start with 12.5 mg daily or BID and increase slowly over weeks to max 200 mg daily
Target Symptoms Delusions Hallucination Aggression “Agitation” Sadness Irritability Anxiety Insomnia
Meds for BPSD
Medication Starting Dose (mg/day) Average Target Dose (mg/day) Atypical Antipsychotics:
risperidone olanzapine quetiapine 0.25-0.5
2.5-5 12.5-25 Antidepressants
citalopram
sertraline
venlafaxine
mirtazapine
trazodone 10 25 37.5
7.5
12.5-25 0.5-2.0
2.5-7.5
50-400 10-40 50-100 37.5-225 15-45 50-100
Meds for BPSD
Target symptoms Medication Starting Dose (mg/day) Average Target Dose (mg/day)
Mood swings
Euphoria
Impulsivity
Agitation
Apathy
Irritability
Anxiety (short term use in predictable situations) Mood stabilizers:
valproic acid
carbamazepine 250 50-100 As directed Cholinesterase Inhibitors.
Memantine Anxiolytics:
lorazepam
oxazepam 5 mg daily 0.25-0.5
5-10 500-1000 300-800 As directed 10 mg BID 0.5-1.5
10-30
Risks present when there is no pharmacological Rx
Risks of injury (self and others), exhaustion, severe and prolonged suffering, increased risk of death with depression, etc.
Need to present the risks of not treating with medications to pt or SDM when obtaining informed consent.
Risks associated with pharmacological Rx
Risks of antidepressants:
Hyponatremia Increased agitation/insomnia/suicide in first few weeks GI upset and bleed if previous ulcers Headaches Risks of anti-psychotics
Increase risk of death (all antipsychotics), increased QT, cerebrovascular accident EPS and tardive dyskinesia Worsening of vascular risk factors (increased weight, lipids, diabetes) Risks of benzodiazepines:
Falls, ataxia, worsening dementia, memory, disinhibition
Using minimal effective dose, only for the duration required
Consider dose reduction for antipsychotic as soon as there is clear therapeutic response to prevent development of side effects
Review anti-psychotic medication for possible discontinuation Q 6 months
Maintain full dose of antidepressant but review if still needed after 1-2 years? Only if no prior history of depression
Family physicians are at the core of the treatment team, working with:
Patients and substitute decision makers
Other caregivers (home care, LTC staff)
Community resources (Alzheimer Society, First Link programs)
Consultants such as PRCs, Outreach teams, Specialized geriatric medicine and mental health services
Questions and further readings
Program for physicians should be available in the coming months: distribution strategies?
CCSMH guidelines on LTC issues, depression, delirium and suicide
New Canadian Consensus guidelines on Dementia.