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
Apathy
Agitation
Physical aggression
Verbal Aggression
Aggressive resistance
to care
Withdrawn
Lacks interest
Amotivation
Pacing
Repetitive actions
Dressing/undressing
Restless/anxious
Euphoria
Pressured speech
Irritable
Sad
Tearful
Hopeless
Guilty
Anxious
Irritable/screaming
Suicidal
Mania
Depression
Adapted from McShane R. Int
Psychogeriatr 2000;12(suppl 1):
147
Hallucinations
Delusions
Misidentification
Suspicious
Psychosis
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 nonpharmacologic approaches


Nutrition, comfort, hydration, sleep, etc…
Environment, personhood, social, stimulation
 Guide
the pharmacologic approach
PIECES Template
 The
 1.
Three Question Template
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



Disease


Atypical presentations, hypoxia, pain, infections
Delirium – 30% mortality if undetected


Anticholinergics, benzos,
Include OTC, alcohol
Hypoactive and hyperactive
Basics

Hydration, bowels, bladder, fatigue, sleep
Delirium

I – infectious







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)


Apathy and “perseveration”


Resisting a bath or toileting, running over others.
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?




Able to do more but assumed incapable


Resistive behaviours, Frustration
Catastrophic reactions
Withdrawal
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


Cohen Mansfield Agitation Inventory (CMAI)


Identifies behaviours and severity over 7 day period
Confusion Assessment Method (CAM)


Shows frequency, severity, patterns of behaviours,
can be individualized
Delirium screen
MMSE, MOCA, Clock
 Sig: E Caps, Cornell Depression Scale
DOS Behavior Map
Time
6am
7am
8am
9am
10a
11a
12p
1pm
2pm
3pm
4pm
MON
TUE
WED
THU
FRI
SAT
SUN
Other Common Tools
Scale
Assessment
CMAI
29 agitated behaviors rated
by caregiver on 7 point
frequency scale
The Cohen-Mansfield
Agitation Inventory
12 items rated by caregiver
Neuro-psychiatric Inventory- on a 4 point frequency and
a 3 point severity scale
Nursing Home Version
25 symptoms rated by
BEHAVE-AD
The Behavioral Pathology in caregiver on a 4 point
Alzheimer’s Disease Rating severity scale
NPI-NH
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 nonpharmacological treatment.


Imminent and severe risk to self or others


Persistent despite P.I.E.C.E.S. approach
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:


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


Optimize treatment of dementia, CEIs, memantine
E.g. Least anticholinergic
Choose drugs without problematic interaction
Best choices: antidepressants

SSRI for depression or anxiety



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



Citalopram (Celexa) and Escitalopram (Cipralex)
Sertraline (Zoloft)
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
Meds for BPSD
Target
Symptoms
Medication
Starting Dose
(mg/day)
Average Target
Dose
(mg/day)
Delusions
Hallucination
Aggression
“Agitation”
Atypical
Antipsychotics:
risperidone
olanzapine
quetiapine
0.25-0.5
2.5-5
12.5-25
0.5-2.0
2.5-7.5
50-400
Sadness
Irritability
Anxiety
Insomnia
Antidepressants
citalopram
sertraline
venlafaxine
mirtazapine
trazodone
10
25
37.5
7.5
12.5-25
10-40
50-100
37.5-225
15-45
50-100
Meds for BPSD
Target
symptoms
Medication
Mood
swings
Euphoria
Impulsivity
Mood stabilizers:
valproic acid
250
carbamazepine 50-100
Agitation
Cholinesterase
Inhibitors.
Memantine
Apathy
Irritability
Anxiety
(short
term use in
predictable
situations)
Anxiolytics:
lorazepam
oxazepam
Starting Dose
(mg/day)
Average Target
Dose (mg/day)
500-1000
300-800
As directed
As directed
5 mg daily
10 mg BID
0.25-0.5
5-10
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:





Risks of anti-psychotics




Hyponatremia
Increased agitation/insomnia/suicide in first few weeks
GI upset and bleed if previous ulcers
Headaches
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.