Transcript Optimizing Treatment and Care for People with Behavioral

OPTIMIZING TREATMENT AND CARE
FOR PEOPLE WITH BEHAVIORAL AND
PSYCHOLOGICAL SYMPTOMS OF
DEMENTIA
LYNN ETTERS, MSN, GNP-BC, ANP-C
ANGELA POPOFF, LMSW
BEHAVIORAL & PSYCHOLOGICAL
SYMPTOMS OF DEMENTIA (BPSD)
“Symptoms of disturbed perception,
thought content, mood or behavior that
frequently occur in patients with dementia”
(IPA consensus group 1999)
INTRODUCTION
• Aging population = Significant increase in the absolute
number of older people with Alzheimer’s disease (AD) &
other dementias
• Dementia is associated with progressive cognitive
decline, a high prevalence of BPSD such as agitation,
depression and psychosis, stress in caregivers, & costly
care
• BPSD are an integral part of the disease process & present
severe problems to patients, their families, caregivers, &
society at large
• Treatment of BPSD offers the best chance to alleviate
suffering, reduce family burden, & lower societal costs in
patients with dementia
PREVALENCE OF BPSD IN DEMENTIA
• Up to 95% of persons with dementia develop BPSD
• Over 80% of BPSD persist over an 18 month period especially delusions, depression and aberrant
motor behavior
• BPSD predicts functional decline, cognitive decline
& institutionalization
• BPSD is not a unitary concept & should be divided
into several or more groups of symptoms reflecting
a different prevalence, course over time, biological
correlate and psychosocial determinants
PREVALENCE OF BPSD
• Most intrusive & difficult BPSD to cope
with are:
• Delusions
• Hallucinations
• Misidentifications
• Depression
• Sleeplessness
• Anxiety
• Physical aggression
• Wandering
• Restlessness
USING THE NEUROPSYCHIATRIC
INVENTORY (NPI)
• Delusions
• Hallucinations
• Agitation/aggression
• Depression/dysphoria
• Apathy/indifference
• Elation/euphoria
• Anxiety
• Disinhibition
• Irritability/lability
• Aberrant motor
behavior
• Sleep
• Appetitie/eating
disorder
WHY ARE BPSD IMPORTANT?
CAUSES OF BPSD
• Biological Factors
• Genetic
• Neurotransmitters
• Structural Changes
• Clinical Factors
• Psychological & Personality Factors
• Social & Environmental Factors
• Caregiver Factors
CLINICAL RISK FACTORS FOR BPSD
• Increased Irritability in higher functioning groups
• Executive impairment early in course of dementia
associated with BPSD & carer stress 3-6 years later
• Frontal symptoms are associated with increased
severity & frequency of agitation & aggression as well
as increased severity of psychosis & depression
• Serious medical comorbidity – increased risk of
agitation, irritability, disinhibition & aberrant motor
behavior
BPSD ARE OFTEN MULTI-FACTORIAL IN
ETIOLOGY
• Few cases of BPSD are due to a single factor
• Must consider a biopsychosocial approach in the
clinical context – medical, psychiatric, behavioral,
cognitive, environmental, social – to identify
treatable factors
DIAGNOSIS AND ASSESSMENT OF
BPSD
• Phenomenology is the basis of diagnosis
• Direct interview
• Direct observation
• Proxy report
• Measurements and scales (NPI)
• Need for accurate descriptions
• Think of physical illness
• Think of sensory impairment
TREATMENT PRINCIPLES
• When treating BPSD, success rates will be
higher if the following principles are
observed:
• Identify what symptom(s) cause most concern
• Describe each symptom in detail
• Specify the Antecedents of Behaviors (the
circumstances that spark them) & their
Consequences (what makes them better or worse)
• This approach is known as the ABC approach
OVERVIEW OF MANAGEMENT OF
BPSD
• Patients with BPSD should be evaluated for delirium
• Consider changes in environment, medication,
fecal impaction, pneumonia, urinary infection, etc.
• Evaluate for needs that the dementia patient is
unable to communicate normally e.g. pain
• Behavioral management or situational manipulation
are the initial strategies of choice for mild to
moderate BPSD
• Pharmacological interventions are useful if
symptoms are severe or do not respond to nonpharmacologic strategies alone
Sleep deprivation
Worsens dementia
Sleep apnea
Impaired memory processing
High body mass, glucose intolerance
KEY MESSAGES
• There is now a substantial body of evidence
supporting the use of non-pharmacological
treatments of BPSD
• Even when BPSD are caused by physical discomfort,
major depression, or psychosis, psychosocial
interventions will prove helpful when offered in
combination with analgesic, antidepressant, or
antipsychotic medications
• Psychosocial approaches are indicated as first-line
approaches to all BPSD
KEY MESSAGES - II
• Psychosocial interventions work best when they are
tailored to people’s backgrounds, interests, &
capacity
• Family & professional caregivers are key
collaborators. It is important to provide them with
necessary information, education, & to support
them as they test & refine their responses to
challenging symptoms
• The physical environment can help prevent or
minimize BPSD by reducing distress, encouraging
meaningful activity, maximizing independence, &
promoting safety
SYSTEMATIC REVIEW OF
PSYCHOSOCIAL TREATMENTS FOR
BPSD
• Only 25 of 118 relevant studies met every
specification
• Treatment proved more effective than an attention
control condition in reducing behavioral symptoms
in only 11 of the 25 studies
• Effect sizes were mostly small or moderate
• Treatments with moderate or large effect sizes
included aromatherapy, ability-focused carer
education, bed baths, preferred music, & muscle
relaxation training
• (O’Connor et al, 2009)
First Line
The Acetylcholinesterases
Tablet
5mg, 10mg
23mg
Tablet
3mg, 4.5mg, 6mg
Patch
4.6mg, 9.5mg
Tablet
8mg, 16mg, 24mg
Great Expectations
• For all AD stages
– Mild
– Moderate
– Severe
• Exelon approved for
Parkinson’s/Lewy body
• Those who took AchEI the
earliest and continued the
longest lived three years longer
than those who
– Never took AchEI
– Stopped the drug
– Started later
• Benefits
– Slows progression
– Improve behavior (hallucinations,
delusions, mood)
• Safest and most specific
treatment for the disease
Side Effects
• Runny nose
• Initial nausea, diarrhea
– Abates without intervention
– Upon first starting or
increasing dose
– If continues, check for other
underlying cause
• Avoid if:
–
–
–
–
COPD dependent on steroids
Active lung infection
Active stomach ulcer
Heart block
Second Line -Namenda
• Moderate to severe AD
• NMDA receptor antagonist
– Slows neuron death
• Add to
Acetylcholinesterase
inhibitors
• Side effects:
– insomnia,
– constipation
– headache
• Drug interactions
– dextromethorphan
Titration pack
10mg twice daily
Potentially Inappropriate Medications for
those with Dementia
Anti-cholinergic Medications
Possible Consequences
•
•
•
•
•
•
Confusion and delirium
Blurred vision
Dry mouth
Urinary retention
Constipation
Increased risk for falls
• Minimize use if possible
• Cancels effects of acetyl
cholinesterase inhibitors
• Benefits vs. disadvantages
ANTICHOLINERGICS
INCREASE RISK FOR DEMENTIA
• In a cross-sectional, prospective study of 1,380
elderly inpatients, researcher found, medication
with anticholinergic properties are associated with
worse cognitive & functional performance in elderly
patients
• There was a dose-response relationship for total
burden score and cognitive impairment.
• (Pasina et al., 2013)
IF PHARMACOLOGICAL THERAPY IS
NEEDED:
• Look for symptom complexes such as depression,
psychosis or anxiety to guide initial choice of agent
• In most situations, medications should be given in
lower doses than are typically recommended for an
adult population
• Ideally, use agents with demonstrable efficacy as
first line agents
ANTIDEPRESSANTS IN DEMENTIA
• Effectiveness in treating depression, anxiety and
agitation in dementia is modest
• Meta-analysis by Thompson et al (2007) of
depression in dementia included five DB placebo
controlled studies involving 165 patients and found
antidepressants efficacious with the number
needed to treat being five
• Subsequently, one large RCT of 131 depressed
patients treated with sertraline was found to be
ineffective (Rosenberg et al, 2010)
• SSRIs remain the first choice agents, if only due to
their tolerability
ATYPICAL ANTIPSYCHOTICS FOR BPSD
• Meta-analysis of 13 studies concluded ‘effect sizes
of atypical antipsychotics for behavioral problems
are medium, and there are no statistically or
clinically significant differences between atypical
antipsychotics and placebo’ (Yury & Fisher, 2007)
• Best quality evidence of effectiveness is with
risperidone
ANTIPSYCHOTICS FOR BPSD
• Antipsychotic medications are most effective in the
treatment of psychotic symptoms (hallucinations,
delusions), agitation, and aggression
• Both atypical and typical antipsychotics appear to carry
an increased risk for mortality and stroke in patients with
dementia
• Atypical antipsychotics are preferred over typical
antipsychotics for BPSD
• Side effects include sedation, weight gain, confusion,
parkinsonism
KEY MESSAGES
• In general, non-pharmacological approaches are
first-line treatment for BPSD
• Medication is indicated for BPSD that are moderate
to severe that has impact on a patient’s or
caregiver’s quality of life, functioning, or that pose a
safety concern, often in conjunction with nonpharmacological interventions
• In a person unable to provide informed consent, it
should be obtained from the appropriate proxy &
include the potential risks associated with
pharmacological treatments
• Develop a plan to monitor therapy – aim to cease
medication within 3 months if possible
CONCLUSIONS
• BPSD occurs in up to 95% persons with dementia
• The course of BPSD is now better understood
• Causes of BPSD are multifactorial including
biological, social, psychological, and
environmental factors
• Non-pharmacological treatments should be first line
for all BPSD
• Pharmacological treatments have only modest
efficacy & may have serious adverse effects &
should be reserved for only moderate to severe
BPSD
RESOURCES
• Ames, D., Burns, A., & O’Brian (Eds.), (2010). Dementia (4th Ed.), UK: Hodder Arnold.
• International Psychogeriatric Association (IPA). (2013). The IPA complete guides to
behavioral and psychological symptoms of dementia. Retrieved from
http://www.ipa-online.org
• Pasina, L., Djade, C. D., Lucca, U. Nobili, A., Tettamanti, M., Franchi, C.,…Mannucci,
P. M. (2013). Association of anticholinergic burden with cognitive and functional
status in a cohort of hospitalized elderly: Comparison of the anticholinergic cognitive
burden scale and anticholinergic risk scale: Results from the REPOSI study. Drugs &
Aging, 30(2), 103-112.
• O’Connor, D. W., Ames, D., Gardner, B., & King, M. (2009). Psychosocial treatments
of psychological symptoms in dementia: A systematic review of reports meeting
quality standards. International Psychogeriatrics, 21, 225-251.
• Selkoe, D. J., Mandelkow, E., & Holtzman, D. M. (Eds.), (2012). The Biology of
Alzheimer’s Disease. Cold Spring Harbor, NY: Cold Spring Harbor Laboratory Press.
• Thompson, C. A., Spilsbury, K., Hall, J., Birks, Y., Barnes, C., & Adamson, J. (2007).
Systematic review of information and support interventions for caregivers of people
with dementia. BMC Geriatrics, 27(7), 18.
• Yury, C. A., & Fisher, J. E. (2007). Meta-analysis of the effectiveness of atypical
antipsychotics for the treatment of behavioral problems in persons with dementia.
Psychotherapy & Psychosomatics, 76(4), 213-218.
Greater Michigan Chapter
25200 Telegraph Road
Southfield, MI 48033
(800) 272-3900
www.alz.org/gmc
Service Territory
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Greater Michigan Chapter Office Locations
 Southfield, MI
 Wayne, Oakland, Macomb, St. Clair, Huron, and
Sanilac Counties
 Midland, MI
 Traverse City, MI
 Marquette, MI
 Grand Rapids, MI
 Alpena, MI
Great Lakes Chapter
 http://www.alz.org/mglc/
HARRY L. NELSON HELPLINE
Overview
1-800-272-3900
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Who is Harry L. Nelson?
What is the Harry L. Nelson Helpline?
The Harry L. Nelson Helpline Provides:
Confidentiality
 Empathetic listening
 Accurate information and referral
 Accessibility (24/7)

Types of Helpline Calls
 Information
regarding
our agency
 Basic information on
dementia
 Program and service
referrals
 Guidance and support
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What does this program provide?
24/7/365 accessibility
 Efficient and safe reunions
 Information to emergency
responders
 Training for emergency responders
 Incident follow up support
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GPS tracking device
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Portable device, device for car
Track location on a secured and
protected website
Allows alerts to assist care partner in
knowing where loved one
Allows a “safe zone” to be set
Pricing may vary, fees include:

Device, activation fee, and monthly fee
CARE CONSULTATION
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Services Include:
- Assessments
- Assistance with planning & problem solving
- Supportive listening
Fee for service is reimbursed through some
insurances, or a sliding scale is utilized.
NO ONE IS TURNED AWAY DUE TO
INABILITY TO PAY
Types of Care Consultation
Programs
 General
Care Consultation
 The Wraparound Program
 Henry Ford Health System
Collaborative
West
Bloomfield
Detroit
Taylor
SUPPORT GROUPS
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Kinds of Support Groups
Caregiver Support Groups
 Dial-in Support Group
 Younger Onset Support Group
 Early Stage Support Groups
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FOR INFORMATION ON THESE GROUPS,
VISIT www.alz.org/gmc
Early Stage Programming
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Ongoing support group
Early Stage Lecture Series
Early Stage Social Club
Living With Alzheimer’s
Pre-assessment required for
registration!
Minds on Art
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Minds on Art is a FREE 6 week program, as
well as providing Saturday drop in sessions.
For people living with Alzheimer’s disease and
other dementias and their care-partners.
Provides unique opportunity for individuals in
the early and mid stages of the disease to create
meaningful memories through art.
Hosted at the Detroit Institute of Arts (DIA)
PRE-REGISTRATION REQUIRED
EDUCATION PROGRAMS
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Provided by instructors or moderators with appropriate
expertise.
Provided for both the community and staff in the field of
dementia care
Types of Education Programs
 Foundations of Dementia Care
 The Basics
 Know the Ten Signs
 Creating Confident Caregivers
Creating Confident Caregivers
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Improving caregiver skill,
knowledge, and outlook
Developing skills for self-care
Strengthening family resources
Strengthening decision making
skills
Improving confidence reduces
sense of distress
RESPITE SERVICES
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What is Respite?
Respite Services Include:
- Adult Day Programs

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Rebecca & Gary Sawka Day Program- Southfield, MI
Robert & RoseAnn Comstock Day Program- Detroit, MI
- Respite Care Assistance Program

Check with regional office for availability
Get Involved
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Hosting a Third Party Event
Attending or assisting at a fundraiser:
 Walk to End Alzheimer’s
 Chocolate Jubilee
Writing letters, emails, making phone calls to local
legislatures
Be a support group facilitator
Be a Harry L. Nelson Helpline Representative
Represent our agency at community health fairs
Be a speaker on our Speaker’s Bureau
Sign up for a clinical trial in your area using Trial Match
Visit our message boards at www.alz.org
CONTACT US!
For more information on our services or to get more
involved:
Call our 24/7 Harry L. Nelson Helpline
1-800-272-3900
Visit our chapter website
www.alz.org/gmc
Visit our National website
www.alz.org