Transcript Facility Level Interventions - Ohio Medical Directors Association

Dementia Behavioral Dilemmas:
Facility Level Interventions
Monica Tegeler, MD, CMD
Assistant Professor of Clinical Medicine,
Indiana University Geriatrics
[email protected]
OMDA 2016 Conference
October 22, 2016
Speaker Disclosure

Dr. Tegeler has disclosed that she has no
relevant financial relationship(s).
Objectives






Describe the evidence for cholinesterase inhibitors in
patients with DAT and PDD.
Categorize different types of behaviors associated
with dementia.
Utilize behavior interventions for different types of
behaviors associated with dementia including
psychosis, agitation, and repetitive statements.
Name 3 categories of non-pharmacologic approaches
to behavior management of patients with dementia.
Identify residents who may be appropriate for a GDR
of an antipsychotic.
Describe key factors that suggest a resident is not
appropriate for a GDR of an antipsychotic.
Case 1
72 y/o WF c/o bugs coming into the
chimney and believes husband is having an
affair, cries all the time
 Clothes are on backwards and inside out
 Gait is normal, wears glasses, no hearing
aids
 Gradual decline over the past 2 years per
spouse

Cross-section Alzheimer’s brain
https://www.alz.org/braintour/healthy_vs_alzheimers.asp
Treatment of Alzheimer’s

Acetyl cholinesterase inhibitors
◦ Donepezil/Aricept
◦ Rivastigmine/Exelon
◦ Galantamine/Razadyne



Improvement of 1-2 points on a research
scale, does NOT necessarily translate to
improved clinical function
Significant side effects: diarrhea, weight loss,
abnormal dreams
Memantine/Namenda – questionable benefit
w/o cholinesterase inhibitor, better tolerated
Treatment of DAT, cont.

Cochrane review of rivastigmine
◦ 0.74 pt improvement on MMSE
◦ 10 trials of 12-52 wk duration
◦ twice as likely to dropout of trial as placebo
due to GI side effects
◦ “uncertain clinical importance”
Initial trials were very short
 Patients in trials tend to be younger than
general population with dementia

Hallucinations, Paranoia, Delusions
Hallucinations – usually visual or auditory
◦ Bugs crawling on skin (not seen by others)
◦ If not bothersome to pt, best
ignored/accepted
 Paranoia – unrealistic, blaming beliefs
◦ Pt believes someone stole her purse/his wallet
(when in fact he/she hid it & can’t locate now)
 Delusions – beliefs contrary to fact
◦ Pt states faithful spouse is having an affair
◦ Don’t confront person or play along; give a
noncommittal answer

Suggestions for
Hallucinations/paranoia/delusions
Avoid denying the person’s experience or
directly confronting him/her or arguing
with the person.
 Increase lighting, glasses on (hearing aids)
 Respond to general feelings of loss
 Distractions – music, exercise, cards,
photos, pets, drawing, social activities

Paranoia: Management
Understand that this is not behavior the
patient can control.
 Do not confront the patient or argue
about the truthfulness of the complaint.
 Distract the patient with other activities.
 Consider medication intervention.

Antipsychotic for Case 1?
Approved for delusions, visual
hallucinations, paranoia IF
 Presents danger to self/others – in this
case crying all the time
 AND behavior interventions tried and
failed

Case 2
75 y/o AAF s/p CVA with Lt hemiparesis,
HTN, CAD
 Abrupt cognitive decline after CVA 6 mos.
ago but short term memory relatively
good
 Repeatedly asks “Where is Jane?”(her
daughter)

Vascular Dementia - MRI
Severe
Moderate
Mild
http://www.alzheimerstreatment.link/severe-vascular-dementia/
Repetitive Actions/Words
Parts of bodies, other people, objects can
represent significant people or events from past
 May be trying to express a feeling
 Body movements replace speech
 Need to link the need to the behavior
◦ Former carpenter banging fist is hammering
nails

Repetitive Actions/Words
Avoid:
◦ Telling her to stop
◦ Asking why she is doing it
 Suggestions:
◦ Occupy the person’s hand with an activity,
doll, stuffed animal, ball
◦ Give her full attention and respond to
emotional needs (affection, loneliness)
◦ Distract with food, music, exercise

Treatment of Vascular Dementia

Similar to cardiovascular disease
◦ Aspirin
◦ Cholesterol lowering medications

Acetyl cholinesterase inhibitors are often
prescribed but 2 Cochrane Reviews found
rivastigmine & galantamine - significantly
higher rates of vomiting, nausea, diarrhea
and anorexia and withdrawals
from treatment AND questionable benefit
Antipsychotic for Case 2?

Not indicated for repetitive actions/words
when not causing danger to self or others
Case 3
65 y/o WM disrobes in hallway, urinates
on floor, difficulty following simple
commands,
 walks quickly with head down, doesn’t
speak

Fronto-Temporal Dementia
http://medlibes.com/entry/frontotemporal-dementia
Inappropriate Sexual Behavior Management
Separate male & female residents during social
interactions
 Consider same gender staff for personal care
 Educate family and encourage physical affection
(hugging, hand holding, etc.)
 Don’t overreact. Lead pt calmly out of the area
or provide a robe & help put it on.

Inappropriate Sexual Behavior: cont.
Clothing that opens/closes in the back
and pants that pull on versus zipping in
the front. These can often stop undressing
or fidgeting with clothing.
 For masturbation: provide patient privacy
or attempt to distract the patient by
giving him/her a different activity.

Antipsychotic for Case 3?
Not first line treatment for FTD or sexual
behaviors and in general not effective
 Consider SSRIs (side effect is sexual
dysfunction) or medoxyprogesterone
acetate – both are off-label use – if
behavior interventions ineffective and
danger to others

Case 4
65 y/o AAM frequently requests key to
leave building and buy cigarettes and
alcohol
 intermittently agitated, CNA attempts to
remove clothing protector while standing
behind him and he hits her
 Later – CNA finds pt w/ fecal INC in
room, offer to assist is refused, CNA
backing out when pt pulls plastic glove
box holder off wall and throws it at her

Cross-section Alcoholic Dementia
http://www.protect-and-boost-your-brain.com/Alcohol-Brain-Damage.html
Suggestions for Anger/Agitation
Scenario 1 was provoked agitation
(preventable)
 Speak with a reassuring and gentle voice to
the patient.
 Approach slowly & calmly from the front. Tell
the person what you are going to do and try
not to startle them.
 Use non-threatening postures when dealing
with an agitated patient, try to be at the
patient’s eye level.

Angry/Agitated
People with dementia can sense a
caregiver’s anger/frustration and react
accordingly
 Often a sign that the person is feeling loss
of control of his/her life
 If during personal care, leave room and
return in few minutes with different
approach.

Antipsychotic for Case 4?
Not indicated if agitation was provoked
(startling patient).
 Could be indicated if agitation not
provoked (scenario 2) and danger to self
or others and behavior interventions
unsuccessful.

Case 5
82 y/o WM sees small animals like rabbits
and snakes in his room (bothered by
snakes, not rabbits)
 Gradual cognitive decline per family
 Propels self down hallway repeatedly
during the day and sometimes at night
 Cogwheeling of both arms

Parkinson’s features
ADAM, Inc.
http://johnsonspinalcare.com/parkinsons-disease-and-contact-sports-and-upper-neck-injuries/
Treatment of PDD & LBD

2014 systematic review of PDD and LBD
◦ Small increase CGIC (-0.4 to -0.65) with
cholinesterase inhibitors and memantine
◦ Cholinesterase inhibitors improved MMSE
1.04-2.57
◦ Heterogeneity with PDD and LBD together
◦ 10 trials - only 4 addressed LBD
 2 memantine, 1 rivastigmine, 1 donepezil
 12-24 wks duration
• Clinical significance?
Treatment of PDD & LBD, cont.
Use of Parkinson’s medications
(carbidopa/levodopa) can worsen
psychiatric symptoms and confusion
 Use of antipsychotics (haloperidol) cause
worsening cognition, sedation, worse
parkinsonism

Wandering
May be due to searching for a part of life
lost to disease or for a person, place,
object of past
 May be coping mechanism to relieve
stress and tension
 Might reflect former schedule or routine

Suggestions for Wandering





Direct person to labeled rooms (bedroom,
toilet)
Decrease noise levels and number of people
interacting at one time
Exercise/walk daily
Redirect with food, conversation, activity
rather than directly confront.
“Bob, where have you been? I have been
looking all over for you.”
Antipsychotic for Case 5?
Visual hallucinations common with
LBD/DLB and side effect of some
Parkinson’s medications
 Antipsychotics often make LBD worse
 Not indicated for VH that don’t bother
the patient
 Not indicated for wandering – no danger
to self or others

Using Antipsychotics for Dementia?
Current Model
Poor Caregiver
approach
Nurse Calls
provider
Antipsychotic
medication Rx’d
• Timing, context
• Negative pt response, more staff respond
• Responds to staff frustration
• Lack of knowledge of behavior approaches
• Side effects – confusion, falls, death, etc.
• State tags, financial penalties, “poor care”
Severity of Behavior
Minimal Risk or rarely socially disruptive:
anxiety, safe wandering
 Slight risk or sometimes socially
disruptive: throwing food, mild verbal
abuse
 Moderate risk or often socially disruptive:
intrusive, wandering unsafely
 Major risk or always socially disruptive:
defecating in public, violent

Behavioral or Psychological Sxs of
Dementia (BPSD)


Symptoms present danger to resident
(fear, continuous yelling/screaming/crying,
weight loss, skin breakdown) or others
(violent, sexual aggression )
AND one or both:
◦ Sxs identified as being due to mania or
psychosis (hallucinations, delusions, paranoia)
◦ Behavioral interventions attempted and
included in plan of care (except emergencies)
Inadequate indications
Wandering
 Restless/fidgeting
 Apathy
 Impaired memory
 Mild anxiety/nervousness
 Insomnia
 Refusal of personal care
 Verbal expressions/behaviors not a danger
to self or others

Care Plan Documentation
Indication/rationale for use – specific
target behaviors & expected outcomes
 Dosage, duration, plans for GDR
 Monitoring for efficacy and/or adverse
reactions
 Rule out potential medical causes

Surveyors expect care plans which:
Prevent or mitigate behaviors
 Seek to understand behaviors as a form
of communication
 Are individualized (cognitive & physical
function, personality, interests, preferred
routines)
 Are consistently carried out

Care Plan Example
Bob is a former mechanic who loves
working with his hands
 Being in large crowds causes him to become
anxious and tear his shirt
 He likes chocolate chip cookies, apple juice,
and Snickers.
 He prefers to sleep in until 0800 and go to
bed at 2200.
 He prefers female caregivers and showers
not baths.

Suggested interventions for Bob
Avoid large crowds – place near door for
activities
 Offer chocolate chip cookies when upset
 Distract with hands on activities –
removing bolts from board, tabletop pool
table, etc.

Ongoing documentation
Document (checklist by shift) presence or
absence of specific behavior
 If none documented for 3-6 mos.,
consider GDR or clearly document why
not doing a GDR (multiple failed
attempts, required inpt psych stay, etc.)
 If no improvement in specific behavior
with addition of medication, medication
should be d/c’d

Evidence or Lack of


FDA issued Black Box warning on antipsychotic
use in pts with dementia in 2005
Schneider 2006 – CATIE-AD trial (largest nonindustry study of antipsychotics for psychosis or
agitation)
◦ 15 randomized double blind trials (5 aripiprazole, 5
olanzapine, 5 risperidone, 3 quetiapine)
◦ 11 done in NH, most 10 week long studies
◦ 87% Alzheimer’s, 70% female, ave age 81 y/o
◦ NNT 6-14, overall average treatment effect 18%
◦ NNH 87 (for every 9-25 patients helped, 1 will die)
Statins for high cholesterol – NNT 27, NNH 197
ASA for primary MI prevention – NNT 1667, NNH 233
Evidence, cont.

Maher – 2011
◦ 38 trials, 18 placebo controlled
◦ Average 238 patients, follow-up 2 days to 1
year
◦ For EPS side effects, NNH 10 for olanzapine &
20 for risperidone
◦ For CVA, NNH 53 for risperidone
◦ Overall 8% developed EPS and 18% urinary
tract symptoms
Antipsychotics - suggestions





Determine what the pt is trying to communicate
Ask family/caregivers for more info.
Prescribe environmental modifications as 1st, 2nd,
3rd line management (redirect, remove from
situation, change staff member, offer alternative,
offer treat)
If antipsychotics prescribed, use monitoring tools
for benefits, side effects, and GDRs
Use Tylenol approach (use when needed, then d/c
when need is over)
Antipsychotics, cont.
Can’t solve the problem in spite of
everything else (low staffing, etc.)
 Asking the doctor to come up with a
magic solution when doctor is there only
small percentage of time, is ineffective
 Someone in the building needs to come
up with the solution

◦ “I don’t know, ask the CNA”
Prevention – Positive Approach
www.teepasnow.com
 Its All in Your
Approach (DVD)
 Progression of
Dementia - Seeing
Gems - Not Just Loss
(DVD)

nursinghometoolkit.com
Non-Pharmacologic Approaches:
Sensory Stimulation
 Behavior Management
 Cognitive/Emotion Oriented
 Structured Activity
 Social contact
 Environmental modification
 Person-centered care approaches
 Staff Training

Sensory Stimulation Approaches

Goal:
◦ Respond to unmet needs for
stimulation, to enhance the senses
and to achieve therapeutic effects
such as pain control, relaxation and
reduction of anxiety

Music
◦ Short-term efficacy in reducing agitation among
persons with dementia, although overall study findings
have been inconsistent.
◦ No evidence on effectiveness with persons with
severe agitation.
◦ High feasibility, must be individualized to person
Sensory Stimulation, cont.

Massage & Touch Therapy
◦ Moderate effect on BPSD,
specifically agitation
◦ High feasibility, doesn’t need to be licensed
massage therapist

Aromatherapy
◦ Moderate efficacy in reducing agitation,
however more rigorous research is needed
◦ Moderate feasibility, need
to assess for allergies
Behavior Mgmt Approaches






Goal: reinforce appropriate social behavior &
reduce unwanted behavior
Habit training
Communication training
Cognitive-behavioral therapy (CBT)
Individualized behavioral reinforcement
therapies
Inconsistent study results and limited
methodological rigor provide insufficient
evidence to support the use of behavioral
management techniques at this time.
Cognitive/Emotion Oriented
Goal: elicit positive emotional responses
Validation Therapy
Reminiscence therapy
Simulated Presence Therapy (SPT)
Reality Orientation
Currently, evidence does not support the use of
any of these approaches for BPSD.
 Limited and inconsistent evidence regarding the
use of cognitive/emotion-oriented interventions.
 SPT and reality orientation may actually have an
adverse effect & are not recommended for
treatment of BPSD.






Structured Activity Approaches






Goal: develop/stimulate social, cognitive,
physical abilities and reduce boredom
Exercise
Recreation activities
Insufficient evidence to conclude the effects of exercise
interventions or structured activities on BPSD; this is largely
due to methodological limitations of existing studies
Other benefits of exercise programs such as improved sleep
may merit their use depending on individual care needs
Group activities – short term effect on decreasing agitation
in NH residents, but no evidence of long-term effect to
decrease agitation and no evidence to suggest that
individualizing activities further decreases agitation
Social Contact





Goal: improve well-being but decreasing boredom and social
isolation
Pet therapy/Animal assisted therapy
One-on-one interaction
While AAT has demonstrated preliminary positive findings,
the current evidence base is very limited and includes
primarily non-randomized, very small scale studies. Additional
research is needed to understand whether AAT effectively
reduces BPSD.
There is currently an insufficient evidence base to support
the efficacy of one-on-one interaction for reducing BPSD,
however further testing of this approach is merited because
preliminary work suggests that people with dementia benefit
by being engaged in social contact.
Environmental Modification
Goal: maintain autonomy & independence,
create home-like atmosphere & reduce
stress level
 Wandering areas
 Natural/enhanced environments
 Reduced stimulation units
 Environmental modification interventions
have not demonstrated efficacy in
reducing BPSD.

Person-centered care approaches
Goal: focus on person rather than task
 Emphasize abilities and maximize comfort
 Reduces resistance to care behaviors
 Bathing without a Battle

Staff training
Limited sustained improvement in BPSD
and suggest that continual training or
reinforcement are needed to influence
behavior change.
 Inconsistent findings & difficult to evaluate
due to methodological limitations;
insufficient evidence

Additional Resources
References - Music






Cabrera, E, Sutcliffe, C,Verbeek, H, et al. Non-pharmacological interventions as
a best practice strategy in people with dementia living in nursing homes. A
systematic review. European Geriatric Medicine. 2015; 6(2): 134-150.
Chang,YS, Chu, H,Yang, CY, et al. The efficacy of music therapy for people with
dementia: A meta‐analysis of randomised controlled trials. Journal of clinical
nursing. 2015
Konno, R., Kang, H. S., & Makimoto, K. A best-evidence review of intervention
studies for minimizing resistance-to-care behaviours for older adults with
dementia in nursing homes. J Adv Nurs. 2014; 70(10): 2167-2180.
Livingston, G. Kelly, L, Lewis-Holmes, E, et al. Non-pharmacological
interventions for agitation in dementia: systematic review of randomised
controlled trials. Br J Psychiatry. 2014; 205(6): 436-442.
Petrovsky, D, Cacchione, P.Z, & George, M. Review of the effect of music
interventions on symptoms of anxiety and depression in older adults with mild
dementia. International Psychogeriatrics. 2015; 1-10.
Särkämö, T, Tervaniemi, M, Laitinen, S, et al. Cognitive, emotional, and social
benefits of regular musical activities in early dementia: Randomized controlled
study. The Gerontologist. 2014; 54(4): 634-650.
References - Massage
Cabrera, E, Sutcliffe, C, Verbeek, H, et al. Nonpharmacological interventions as a best practice
strategy in people with dementia living in nursing
homes. A systematic review. European Geriatric
Medicine. 2015; 6(2): 134-150.
 Livingston, G, Kelly, L, Lewis-Holmes, E, et al. Nonpharmacological interventions for agitation in
dementia: systematic review of randomised controlled
trials. Br J Psychiatry. 2014; 205(6): 436-442.
 Moyle, W, Murfield, JE, O'Dwyer, S, & Van Wyk, S. The
effect of massage on agitated behaviours in older
people with dementia: a literature review. J Clin Nurs,
2013; 22(5-6): 601-610.

References - Behavior Mgmt


Kong E, Evans LK, Guevara JP.
Nonpharmacological intervention for
agitation in dementia: a systematic review
and meta-analysis. Aging Ment Health.
2009;13(4):512–520.
O'Neil M, Freeman M, Christensen V, et al.
Non-pharmacological interventions for
behavioral symptoms of dementia: a
systematic review of evidence. In: Affairs V, ed.
Washington DC: Evidence-based Synthesis
Program; 2011.
References – Cognitive/Emotion


Cabrera, E, Sutcliffe, C, Verbeek, H, et al.
Non-pharmacological interventions as a best
practice strategy in people with dementia
living in nursing homes. A systematic review.
European Geriatric Medicine. 2015; 6(2):
134-150.
Livingston, G, Kelly, L, Lewis-Holmes, E, et al.
Non-pharmacological interventions for
agitation in dementia: systematic review of
randomised controlled trials. Br J Psychiatry.
2014; 205(6): 436-442.
References – Exercise/Activity
Brodaty H, Arasaratnam C. Meta-Analysis of
nonpharmacological interventions for
neuropsychiatric symptoms of dementia. American
Journal of Psychiatry. 2012;169(9):946–953.
 Cohen-Mansfield J. Nonpharmacologic interventions
for inappropriate behaviors in dementia: a review,
summary, and critique. Am J Geriatr Psychiatry. Fall
2001;9(4):361–381.
 O'Neil M, Freeman M, Christensen V, et al. Nonpharmacological interventions for behavioral
symptoms of dementia: a systematic review of
evidence. In: Affairs V, ed. Washington DC: Evidencebased Synthesis Program; 2011.

References – Social contact






Bernabei, V, De Ronchi, D, La Ferla, T, et al. Animal-assisted interventions
for elderly patients affected by dementia or psychiatric disorders: a review.
J Psychiatr Res. 2013; 47(6): 762-773.
Cohen-Mansfield J. Turnover among nursing home staff. A review. Nurs
Manage. May 1997;28(5):59–62, 64.
Cohen-Mansfield J, Marx M, Dakheel-Ali M, et al. Can persons with
dementia be engaged with stimuli? Am J Geriatr Psychiatry. Apr
2010;18(4):351–362.
Cohen-Mansfield J, Marx M, Regier N, et al. The impact of personal
characteristics on engagement in nursing home residents with dementia.
Int J Geriatr Psychiatry. 2009;24(7):755–763.
O'Neil, M, Freeman, M, Christensen, V, et al. Non-pharmacological
Interventions for Behavioral Symptoms of Dementia: A Systematic Review
of the Evidence.:VA-ESP Project #05-225. 2011
O'Neil M, Freeman M, Christensen V, et al. Non-pharmacological
interventions for behavioral symptoms of dementia: a systematic review of
evidence. In: Affairs V, ed. Washington DC: Evidence-based Synthesis
Program; 2011.
References - Environmental


Kong E, Evans LK, Guevara JP.
Nonpharmacological intervention for
agitation in dementia: a systematic review
and meta-analysis. Aging Ment Health.
2009;13(4):512–520.
O'Neil M, Freeman M, Christensen V, et al.
Non-pharmacological interventions for
behavioral symptoms of dementia: a
systematic review of evidence. In: Affairs V, ed.
Washington DC: Evidence-based Synthesis
Program; 2011.
References – Staff Training
Ayalon L, Gum A, Feliciano L, Arean P. Effectiveness of
nonpharmacological interventions for the management of
neuropsychiatric symptoms in patients with dementia: A
systematic review. Arch Intern Med. November 13,
2006;166(20):2182–2188.
 Kong E, Evans LK, Guevara JP. Nonpharmacological
intervention for agitation in dementia: a systematic review
and meta-analysis. Aging Ment Health. 2009;13(4):512–520.
 Livingston, G, Kelly, L, Lewis-Holmes, E, et al. Nonpharmacological interventions for agitation in dementia:
systematic review of randomised controlled trials. Br J
Psychiatry. 2014; 205(6): 436-442.
 O'Neil M, Freeman M, Christensen V, et al. Nonpharmacological interventions for behavioral symptoms of
dementia: a systematic review of evidence. In: Affairs V, ed.
Washington DC: Evidence-based Synthesis Program; 2011.

References – Person-centered care
Konno, R, Kang, HS, & Makimoto, K. A bestevidence review of intervention studies for
minimizing resistance-to-care behaviours for
older adults with dementia in nursing homes.
J Adv Nurs. 2014; 70(10): 2167-2180.
 Sloane P, Hoeffer B, Mitchell C, et al. Effect of
person-centered showering and the towel
bath on bathing-associated aggression,
agitation, and discomfort in nursing home
residents with dementia: a randomized,
controlled trial. J Am Geriatr Soc. Nov
2004;52(11):1795–1804.

References






Aarsland D, Ballard C, Walker Z, et al. Memantine in patients
with Parkinson’s disease dementia or dementia with Lewy
bodies: a double-blind, placebo-controlled, multicentre trial.
Lancet Neurol 2009;8:613–18.
Ballard, Lana, Theodoulou, et al. A Randomised, Blinded,
Placebo-Controlled Trial in Dementia Patients Continuing or
Stopping Neuroleptics (The DART-AD Trial). PLoS Med.
2008;5(4):e76.
Birks J1, McGuinness B, Craig D. Rivastigmine for vascular
cognitive impairment. Cochrane Database Syst Rev. 2013.
Birks J, Craig D. Galantamine for vascular cognitive
impairment. Cochrane Database Syst Rev. 2006
Birks JS, Grimley Evans J. Rivastigmine for Alzheimer's disease.
Cochrane Database Syst Rev. 2015
Brackey J: Creating Moments of Joy. Purdue University Press,
2007.
References, cont.






Emre M, Tsolaki M, Bonuccelli U, et al. Memantine for patients with
Parkinson’s disease dementia or dementia with Lewy bodies: a
randomised, double-blind, placebo-controlled trial. Lancet Neurol
2010;9:969–77
Feil N: The Validation Breakthrough: Simple Techniques for
Communicating with People with “Alzheimer’s-Type Dementia.”
Health Professions Press, 2002.
Fitzpatrick AL. Survival following dementia onset: Alzheimer's
disease and vascular dementia. J Neurol Sci. 2005 Mar 15;229230:43-9.
Geriatric Review Syllabus
Jeste, Blazer, Casey, et al. ACNP White Paper: Update on Use of
Antipsychotic Drugs in Elderly Persons with Dementia.
Neuropsychopharmacology. 2008; 33(5): 957–970.
Maher, Maglione, Bagley, et al. Efficacy and Comparative Effectiveness of
Atypical Antipsychotic Medications for Off-Label Uses in Adults: A
Systematic Review and Meta-analysis. JAMA. 2011; 306 (12): 1359-1369.
References, cont.






McKeith I, Del ST, Spano P, et al. Efficacy of rivastigmine in dementia
with Lewy bodies: a randomised, double-blind, placebo-controlled
international study. Lancet 2000;356:2031–6.
McKhann GM, Knopman DS. The diagnosis of dementia due to
Alzheimer’s disease: Recommendations from the National Institute on
Aging-Alzheimer’s Association workgroups on diagnostic guidelines for
Alzheimer’s disease. Alzheimers Dement. 2011; 7(3): 263–269.
Mori E, Ikeda M, Kosaka K. Donepezil for dementia with Lewy bodies: a
randomized, placebo-controlled trial. Ann Neurol 2012;72:41–52.
Oslin, D, Atkinson RM. Alcohol Related Dementia: Proposed Clinical
Criteria. International Journal of Geriatric Psychiatry. 1998; 13: 203-212.
Revised S.O.M. Interpretive guidelines/Surveyor Guidance (2013)
Robinson A, Spencer B, White L: Understanding Difficult Behaviors:
some practical suggestions for coping with Alzheimer’s Disease and
related illnesses. Eastern Michigan University, 1989.
References, cont.
Salzman, Jeste, Meyer, et al. Elderly Patients with Dementia-Related
Symptoms of Severe Agitation and Aggression: Consensus Statement on
Treatment Options, Clinical Trials Methodology, and Policy. J Clin
Psychiatry. 2008; 69(6): 889–898.
 Schneider, Dagerman, Insel. Risk of Death With Atypical Antipsychotic
Drug Treatment for Dementia Meta-analysis of Randomized PlaceboControlled Trials. JAMA. 2005; 294(15): 1934-1943.
 Schneider, Dagerman, Insel. Efficacy and Adverse Effects of Atypical
Antipsychotics for Dementia: Meta-analysis of Randomized, PlaceboControlled Trials. Am J Geriatr Psychiatry. 2006; 14(3): 191-210
 Wang H-F, Yu IJ, Tang SW, et al. Efficacy and safety of cholinesterase
inhibitors and memantine in cognitive impairment in Parkinson’s
disease, Parkinson’s disease dementia, and dementia with Lewy
bodies: systematic review with meta-analysis and trial sequential
analysis. J Neurol Neurosurg Psychiatry 2015;86:135–143
