Professional Documents
Culture Documents
MICHELE THOMAS
Pharmacy Services Manager Virginia Department of Behavioral Health, Developmental Services
ANDREW HECK
Clinical Director Piedmont Geriatric Hospital, Virginia Department of Behavioral Health, Developmental Services
(c) 2013 by the authors, on behalf of the Virginia Geriatric Mental Health Partnership & made possible through a grant from the Virginia Center on Aging's Geriatric Training Education Initiative and supported by the Riverside Center for Excellence in Aging and Lifelong Health, the Virginia Geriatric Mental Health Partnership, and the VCU's Department of Gerontology.
4/18/2013
ABBREVIATION
DETAIL
ADE Adverse Drug Effects ADL Activities of Daily Living ALF Assisted Living Facility BPSD Behavioral and Psychological Symptoms of Dementia CMS Centers for Medicare & Medicaid Services GDR Gradual Dose Reduction LTC Long Term Care LTCF Long Term Care Facility Sx Symptoms
ABBREVIATIONS
4/18/2013
Be able to more clearly describe Behavioral and Psychological Symptoms of Dementia, (problematic behaviors, [BPSD or BPSD Sxs]) and possible triggers;
Learn about appropriate use of antipsychotic medications in individuals diagnosed with problematic behaviors in dementia Become familiar with nonpharmacological strategies for preventing and/or reducing problematic behaviors;
Objectives
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The patient is an 84 year old white female newly admitted to a LTC setting exhibiting the following signs and symptoms: two to three year history of increasing forgetfulness Increased wandering and elopement attempts distractibility repetitive requests calling out for her husband intrusiveness resistance to personal care language deficits.
Over the next few weeks at the LTCF, MT declined. She: no longer recognized her husband exhibited repetitive behaviors verbalized suspicious statements about husbands whereabouts exhibited increased restlessness, and began experiencing persistent nighttime wakefulness.
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Up to 80%
72%
9-63%
48%
46%
Hallucinations
Physical Aggresion
Irritability/Lability
Sleep/Wake Distburbance
Depression/Dysphoria
4-41%
31-42%
42%
42%
38%
Disinhibition
Sundowning
Hypersexuality
Obsessive/Compulsive
36%
18%
3%
2%
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Mood
100 80
Cognition
% patients
60 40 20
Suicidal ideation
-40 -30
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POLL Appropriate Antipsychotic Treatment targets include the following: (Check all that apply)
A. B. C. D. Distressing hallucinations Physically aggressive behavior Delusional jealousy Anger over accepting assistance with ADLs
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MANIA
Euphoria Pressured Speech Irritable
*PSYCHOSIS APATHY
Withdrawn Lacks interest Amotivation Hallucinations Delusions Misidentifications Suspiciousness
DEPRESSION
Sad Tearful Hopeless Low self esteem Anxiety Guilt
Bugden. Antipsychotics and Dementia: Part of the Solution or Part of the Problem, Dementia Care Conf. 2012
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Hiding/hoarding Nocturnal restlessness Repetitive activities e.g., pulling on locked doors, etc. Wandering Unsociability Poor self care Uncooperativeness without aggressive behavior Verbal expressions or behaviors that do not represent a danger Nervousness / fidgeting / Mild anxiety Impaired memory
Bugden. Antipsychotics and Dementia: Part of the Solution or Part of the Problem, Dementia Care Conf. 2012
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No FDA-approved medications to treat dementia-related behavioral disturbances Medications utilized today, prescribed off-label:
Typical & atypical antipsychotics Benzodiazepines Anticonvulsants Cholinesterase inhibitors NMDA receptor antagonist Selective serotonin reuptake inhibitors (SSRIs)
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2005: FDA issued warning: 1.6 1.7 fold increase in mortality in response to analysis of 17 placebo-controlled studies. 2010: Nearly 1/3 of elderly patients with dementia residing in nursing homes are on atypical antipsychotics for BPSD even though..
Most episodes of BPSD appear as single episode (~86%) and the average duration of each episode lasts between ~9 to 19 months
BLACK BOX WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS and SUICIDALITY *Antipsychotic drugs have increased risk of death*
Jablow V. Trial. 2008;44:12 Recupero PR et al. J Psychiatric Pract. 2007;13:143
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HHS Initiative: National Partnership to Improve Dementia Care CMSs initial goal to reduce unnecessary antipsychotic medication use in all care settings.
Goal:
Using personcentered and individualized interventions for behavioral health in nursing homes
Antipsychotics are the initial focus of the partnership, however attention to other potentially harmful medications is also part of this initiative.
483.25(l) Unnecessary Drugs Each residents drug regimen must be free from unnecessary drugs (F329)
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This number includes all residents in NHs EXCEPT persons diagnosed with Schizophrenia, Tourettes Syndrome or Huntingtons disease .
23.9%
2012 GOAL . 2013 GOALs? Reevaluate based on 2012 4th quarter findings
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Effective interventions follow thorough assessments aimed at the problems specific cause Management of BPSD must be comprehensive and systematic Successful BPSD management blends reactive and proactive strategies
Treatment of BPSD should begin with nonpharmacological approaches keeping in mind five care goals for the patient with dementia:
to experience pleasure to feel safe
to experience minimal stress with adequate positive stimulation to experience a sense of control
to feel comfortable
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Is it: only problematic for the resident? endangering/irritating/ upsetting to other residents/family members/visitors/staff? interfering with care?
Focus resources towards behaviors that are dangerous or cause marked distress to the resident or others
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OAMING? MMINENT PHYSICAL RISK (fire, falls, frailty?) UICIDE? INSHIP RELATIONSHIP ABUSE/NEGLECT? ELF NEGLECT, SUBSTANCE ABUSE, SAFE DRIVING? Risk Assessment: Taking Inventory
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Static
Presence of delusions Impaired communication Frontotemporal dementia Certain forms of traumatic brain damage
Dynamic
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Answers the what, where, when and how questions Basic functional analyses can be performed by anyone clinically familiar with the resident
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Behavior Description
what specific behavior(s) occurred?
Behavior Prediction
did the behavior(s) primarily occur during specific time periods?
Behavior Functions
What functions did the behavior(s) appear to serve for the person?
were there periods when the behavior(s) consistently did not occur?
What were the consequences that were typically provided when the behavior(s) occurred?
when behavior(s) were occurring, were there setting events or stimuli which were consistently related to their occurrence?
With answers to these questions, along with any baseline data gathered, clinicians may begin to draw conclusions about the cause(s) and treatment of the problematic behavior
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Hunger/Thirst
MEDICAL
Anticholinergic agents
Benzodiazepines Opioids
Antihistamines
Health and Medical Conditions: BPSD Common Causes and Trigger Factors
Bugden. Antipsychotics and Dementia: Part of the Solution or Part of the Problem, Dementia Care Conf. 2012
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POLL Delirium is a state of acute cognitive impairment caused by a medical problem. Three primary cardinal features of delirium are:
A. Acute/onset is days to weeks B. Transient in severity often fluctuating throughout the day for short periods of time C. Reversible state of confusion D. Most often irreversible state of confusion
POLL: Delirium
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The likelihood of developing delirium increases with age Three primary features to look for:
1. 2. 3. ACUTE TRANSIENT (lasts only for a short time) and REVERSIBLE state of confusion.
Delirium
http://www.nlm.nih.gov/medlineplus/ency/article/000740.htm
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DRUGS, DRUGS, DRUGS! EYES, EARS POOR HEARING AND VISION = RISK FACTORS L OW O STATES (MI, CHF, COPD, acute respiratory distress syndrome) I NFECTION, IMMOBILZATION RETENTION (URINE/STOOL), RESTRAINTS ICTALSEIZURES CAN CAUSE DELIRIUM UNDERHYDRATION, UNDERNUTRITION METABOLIC ABNORMALITIES (s)UBDURAL, SLEEP DEPRIVATION
2
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MT
84 year old white female newly admitted to LTC setting exhibiting signs & symptoms of: wandering elopement attempts distractibility at mealtime repetitive requests for husband intrusiveness resistance to personal care, and language deficits.
MTs Husband Staff talked with MTs husband. He noted she appeared more worried, apprehensive, fearful and she no longer recognized him during their daily visits
MTs current medications Docusate 100mg bid constipation. Oxybutynin 10mg XL daily incontinence.
Adherence Prior to admission, Mr. Take reported that his wifes dose of oxybutynin had been increased from 5mg to 10mg but, he also stated that his wife rarely took her medications, let alone on a regular basis...
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4/18/2013
MT became more and more challenging exhibiting increasing exit seeking behaviors; daytime restlessness and pacing increased to where it became extremely difficult for staff to redirect her
Ms. Take
She had periods of feeling exhausted, appearing overly sedated or subdued; this resulted in frequent daytime napping. MT also began exhibiting increased distractibility and began refusing to eat. As a result, MT had an eight pound weight loss.
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Orthopedic issues / arthritis: feet (e.g., poorly fitting shoes), shoulder, back, knee, etc
Is there Pain?
Eyes: Corneal abrasion?
Sensory deficits?
Evaluation: Are there any Physical Causes or Medication Adverse Effects (ADE)?
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**DELIRIUM**
PE Labs: CBC, electrolytes & U/A Delirium Assessment performed: MT was Positive Acute onset Sxs, fluctuating in course, and
U/A >> BUN relative to SCr >> Sp. Gravity>> 3+ leuks & WBCs in urine
a change in cognition,
(increasing difficulty in focusing attention).
MT: Evaluation/Findings
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Definition:
ANY ASPECTS OF AN INDIVIDUALS SURROUNDINGS THAT INFLUENCE BPSD
Both cognitively impaired and cognitively intact individuals can be very sensitive to even minor environmental irritants or changes Irritant/change + behavioral dyscontrol = potentially harmful reaction! Environmental changes are recommended in most circumstances
No adverse effects Easy to implement
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Common examples:
Physical elements
Highly patterned wallpaper Mirrors
Space issues
Frequent room changes/redesign Relocation (within or between facilities) Lack of adequate physical space
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4/18/2013
Liberally attempt different environmental changes (being sensitive to the amount of change the residents can tolerate)
Try using soothing sounds (ocean waves, babbling brooks, even white noise)
Scheduled walking or exercise programs have demonstrated effectiveness in preventing and addressing BPSD
Exposure to bright light can also be effective (avoid in patients with a history of Bipolar Disorder)
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Individualized music
Aromatherapy
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4/18/2013
69 year old male with Alzheimers disease Has refused to leave room in past month; swings out at staff who try to get him to come out for meals, activities Often observed to walk up to doorway, look at floor beyond threshold, and retreat into room Staff discovered janitorial staff had recently changed to a shinier wax for the hallway floors (looks slick?) Mr. Faller Timing of change coincided with the emergence of Mr. Fallers behaviors Less shiny wax used, Mr. Faller was able to leave the room with minimal difficulty soon afterward
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Definition:
THE METHOD(S) BY WHICH INDIVIDUALS ARE ADDRESSED BY THEIR CAREGIVERS THAT CAN INFLUENCE BPSD
Caregiver attitude/reactions
Verbal approaches
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4/18/2013
Emphasize lack of intentionality of resident behaviors Educate about signs and symptoms of dementia
Staff training
Teach communication skills (below) Train on proper physical approach to physical contact-based tasks (e.g., ADLs) Use short phrases that express one major idea at a time Use closed-ended rather than open-ended questions
Communication
Focus on the emotion rather than the content of what is being said (validation) Give directions one step at a time Use distraction rather than logic/reason to calm resident behavior (most often in later dementia stages) Keep predictable schedule (esp. mealtimes and sleep) Use familiar staff whenever possible
Structure
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Resident with 6-year diagnosis of Alzheimers disease Memory unit in ALF: For the past three weeks, every morning Ms. Hurley has been observed to throw her toast from her tray across the room Resident had not previously expressed a dislike for toast, and family said she used to like it
Ms. Hurley
After starting to observe Ms. Hurley from beginning of meal forward, staff noticed that she struggled to apply the sealed butter and jelly packets (sequencing problems) Staff started serving the toast with butter and jelly already spread on it, behavior ceased directly. Example of catastrophic reaction
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Definition:
THE NEEDS, WANTS, DESIRES, OR HABITS OF AN INDIVIDUAL THAT INFLUENCE BEHAVIORAL PROBLEMS
Can also be considered psychological factors These constitute a broad array of potential contributing causes for BPSD
Learned patterns of behavior and/or thinking History of trauma Mood states Emotional discomfort Lack of socialization Boredom Lack of autonomy/privacy/intimacy Distress/feeling abandoned Fear of danger Misinterpretation paranoia
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BEHAVIOR PLANNING
Some residents may benefit from more involved contingency management plans (AKA behavior plans) Works across different levels of cognitive ability Typically developed by a MH consultant, implemented by facility staff (with staff training) Aimed at bringing about desirable behaviors while discouraging or eliminating harmful behaviors
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81 year old woman in psychiatric hospital Cursing and swinging arms Personality disorder and early dementia Plan: could earn treats (coffee, strolls, etc.) every 2 hours if no cursing or striking out Needed frequent reminders of treat opportunities Problematic behavior dropped 66% in 2 months After thinning reinforcement schedule, behavior stopped completely
Mrs. Sweet
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Diagnosis
Were instruments geared toward individuals [national or ethnic] culture? (e.g., normative data, language) Was level of education accounted for?
Shah et al Int Psychogeriatr 2004; 16 Herbert P Can J Neurol Sci 2001; 28 Suppl 1
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Communication difficulties
Taboo topics
Institutional racism Unfamiliarity with sxs of dementia by relatives Sxs of dementia being viewed as a function of old age
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Schizophreniform disorder Psychosis NOS Atypical psychosis Brief psychotic disorder Dementing illnesses with associated behavioral symptoms Medical illnesses or delirium with manic or psychotic
Antipsychotic treatment goal[s]: to stabilize and or improve a residents outcome, quality of life and functional capacity
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JUSTIFY
H
After
E
After
BPSD Sxs must present a DANGER to the person or others or, cause the patient to experience one of the following:
HEALTH
A
After
ENVIRONMENTAL
R
After
APPROACH FACTORS
- inconsolable or persistent distress; - a significant decline in function; - substantial difficulty receiving needed care
RESIDENT FACTORS
SELECT
1. Individualize 2. Initiate monotherapy Start low, go slow 3. Titrate dose to effect, Rule of Thumb: 5-10% dose increases q 4-6 wks 4. If effective, continue few weeks few months 5. STOP drug if INEFFECTIVE (appropriately tapering)
Maixner, et al. J Clin Psychiatry. 1999;60(suppl 8):29. Jibson and Tandon. J Psychiatry Res. 1998;32:215.
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AND Physician has documented rationale for why additional GDR attempts would likely impair the residents function
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In clinical record:
Clear documentation of treatment targets / symptoms
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Explore, identify and address the following potential contributors: Conduct risk analysis
Health/medical factors Environmental factors Approach factors Resident factors
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Michele Thomas, R.Ph., Pharm.D., BCPP michele.thomas@dbhds.virginia.gov Andrew Heck, Psy.D., ABPP andrew.heck@dbhds.virginia.gov
Contact
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