4/18/2013

Behavioral Disturbances of DEMENTIA: Interventions to Reduce the Use of Psychotropic Medications

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.

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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

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By the end of the presentation, participants will:

Be able to more clearly describe Behavioral and Psychological Symptoms of Dementia, (problematic behaviors, [BPSD or BPSD Sx’s]) 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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Ms. Take (MT)

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.

Patient Intake & History

Over the next few weeks at the LTCF, MT declined. She: • no longer recognized her husband • exhibited repetitive behaviors • verbalized suspicious statements about husband’s whereabouts • exhibited increased restlessness, and • began experiencing persistent nighttime wakefulness.

Case of Ms. Take (MT)

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Common BPSD/Behaviors in Dementia
Aggression/Agitation Apathy Delusions Anxiety Psychomotor Disturbance

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%

Jeste D, et al. Neuropsychopharmacology. 2008;33:957 Spalletta G, et al. Am J Geriatr Psychiatry. 2010;18:1026

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Early(~0-3yrs) Mild-Mod(~3-5yrs) Severe(~6yrs)

Mood
100 80

Cognition

Behavior / Function Agitation

% patients

60 40 20

Depression Social withdrawal

Diurnal rhythm Irritability Wandering Aggression

Anxiety Mood change Paranoia Accusatory behavior
-20 10 0

Suicidal ideation
-40 -30

Hallucinations Socially unacceptable behavior Delusions Sexually inappropriate behavior
10 20 30

months before dementia diagnosis / months after dementia diagnosis

Estimated Timeline of BPSD in Dementia
Jost BC, Grossberg GT. J Am Geriatr Soc. 1996;44:1078-1081 Brodaty et al. 2003. J. Clin Psychiatry 64:36. http://www.ucc.ie/en/

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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 ADL’s

POLL: CMS “Approved” Indications for LTC Facilities

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BPSD Clusters & Antipsychotic Medications
PSYCHOMOTOR AGITATION *AGGRESSION
• Physically aggressive • Verbally aggressive • Aggressive resistance to care • • • • • Pacing Restlessness Repetitive actions Dressing/undressing Sleep disturbance

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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Apathy Calling out e.g., screaming

Most common BPSD NOT amenable to medication/ antipsychotic medication

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)

BPSD and Psychotropics
Lawrence RM et al, Psychiatric Bulletin. 2002;26:230

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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 • CMS’s initial goal to reduce unnecessary antipsychotic medication use in all care settings.

• Goal:
Using personcentered and individualized interventions for behavioral health in nursing homes

By improving dementia care

Unnecessary medication use will decrease.

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 resident’s drug regimen must be free from unnecessary drugs (F329)

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National prevalence rate of antipsychotic medication use in long-stay residents

Initiative: Reduce the national rate by 15%

This number includes all residents in NH’s EXCEPT persons diagnosed with Schizophrenia, Tourette’s Syndrome or Huntington’s disease .

23.9%

2012 GOAL . 2013 GOALs? Reevaluate based on 2012 4th quarter findings

First Year Goals

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• Effective interventions follow thorough assessments aimed at the problem’s 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

BPSD: Need for Alternative Approaches in Treatment
Buhr GT, White HK. Difficult behaviors in long-term care patients with dementia. J Am Med Dir Assoc. 2006;7(3):181. Ryden MB, Feldt KS. Goal-directed care: caring for aggressive nursing home residents with dementia. J Gerontol Nurs. 1992;18(11):35-42.

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Why is this behavior a problem?

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

First Question in Identifying & Describing BPSD Behaviors

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PRIORITY RISK AREAS

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

Depression Low serotonin levels Psychosis; esp. Irritability

command hallucinations and thought disorganization

Dynamic

BPSD Example: Aggression Risk Factors
Heck, A. Aggressive behavior in the elderly: prevention and management. Cross Country Education Seminar, 2006.

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• Will want to know the following about the BPSD:
• • • • Type Frequency Intensity Duration

• Functional analysis of behavior:
• an examination of what a behavior’s purpose (i.e., function) serves for the individual

• Answers the “what, where, when and how” questions • Basic functional analyses can be performed by anyone clinically familiar with the resident

Clarifying the BPSD

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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?

if >1 behavior, did any ever occur together?

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

Clarifying the BPSD (cont.)

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ealth and medical conditions nvironment pproach esident factors
• An ordered strategy for examining common sources of a behavior problem

The HEAR method

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B12/Folic Acid Deficiency Infection (UTI/Pneumonia)

Most common and potentially dangerous causes of BPSD Sxs

Hunger/Thirst

MEDICAL

Nocturia Hypercalcemia Pain Hypothyroidism Constipation
Digoxin

MEDICATIONS/DRUG INDUCED DELIRIUM

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 diagnosis is often missed in up to 70% of cases
• This is especially concerning, since up to 60 % of elderly individuals experience a delirium prior to or during a hospitalization

Delirium is Always an Acute Medical Emergency

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 ICTAL—SEIZURES CAN CAUSE DELIRIUM UNDERHYDRATION, UNDERNUTRITION METABOLIC ABNORMALITIES (s)UBDURAL, SLEEP DEPRIVATION
2

Common Causes of Delirium

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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.

MT’s Husband • Staff talked with MT’s husband. He noted she appeared more worried, apprehensive, fearful and she no longer recognized him during their daily visits

MT’s current medications • Docusate 100mg bid constipation. • Oxybutynin 10mg XL daily incontinence.

Adherence • Prior to admission, Mr. Take reported that his wife’s 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...

Case Update: Ms. Take

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• 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.

MT: 30 Day Update

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Orthopedic issues / arthritis: feet (e.g., poorly fitting shoes), shoulder, back, knee, etc

Is there Dehydration/ Nutritional issues?

Constipation, urinary retention / incontinence?

Musculoskeletal: Joint pain?

Is there Pain?
Eyes: Corneal abrasion?

HPE, Vital Signs, Labs as warranted

Is there Infection/ Illness?

Sensory deficits?

Skin: Bed sores/ skin lesions?

Is the resident experiencing ADEs?

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

VS: +orthostatic hypotension; +restlessness, +poor attention

U/A >> BUN relative to SCr >> Sp. Gravity>> 3+ leuks & WBCs in urine

a change in cognition,
(increasing difficulty in focusing attention).

Findings: ANTICHOLINERGIC TOXICITY
"Compliance Toxicity”…due to increase in oxybutynin dose with resultant anticholinergic load/toxicity
oxybutynin dose > oral intake > urinary retention >> bladder infection.

MT: Evaluation/Findings

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• Definition:
• ANY ASPECTS OF AN INDIVIDUAL’S 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

HEAR: Environmental Factors

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• Common examples:
• Physical elements
• Highly patterned wallpaper • Mirrors

• Noise and activity level
• Loud call bells/paging systems • Constant Television Programs (e.g., Soap Operas, CNN)

• Space issues
• Frequent room changes/redesign • Relocation (within or between facilities) • Lack of adequate physical space

Environmental Factors cont.

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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)

Environmental Factors cont.

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Providing space to freely wander

Brief gentle hand massages

Empirically supported interventions to prevent/ manage agitation

Individualized music

Use of “gliding” rockers

Aromatherapy

Environmental Factors cont.
Landreville P et al. Intl Psychogeriatrics 2006;18 Rayner A et al. Am Fam Physician 2006; 73 Camp C et al. In Lichtenberg D et al., Handbook of dementia 2003; NY: Wiley & Sons

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• 69 year old male with Alzheimer’s 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. Faller’s behaviors • Less shiny wax used, Mr. Faller was able to leave the room with minimal difficulty soon afterward

Case Example: Mr. Faller

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• Definition:
• THE METHOD(S) BY WHICH INDIVIDUALS ARE ADDRESSED BY THEIR CAREGIVERS THAT CAN INFLUENCE BPSD

• Can include physical, verbal, nonverbal, schedule/routine issues, etc.
Common examples

Violations of personal space

Caregiver attitude/reactions

Stance and positioning issues

Verbal approaches

Physical touch (esp. during ADLs)

Erratic or unpredictable daily structure

HEAR: Approach Factors

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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

PREVENTION/ MANAGEMENT STRATEGIES:

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

Approach Factors cont.

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• Resident with 6-year diagnosis of Alzheimer’s 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

Case Example: Ms. Hurley

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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

HEAR: Resident Factors

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PSYCHOTHERAPY (for some residents)
• Individuals with early-state dementia may benefit from some forms of psychotherapy • Gather collateral information—family and others
• “Has your loved one ever shown behavior like this before?” • “Is there anything about these circumstances that may be bringing up bad memories for your loved one?”

• Pass along information and observations to therapist

HEAR: Resident Factors (cont.)

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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

HEAR: Resident Factors (cont.)

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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

Case Example: Mrs. Sweet

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Identification and attribution of behaviors
• Prevalence of BPSD has been found to vary across cultures
• Is behavior culturally normative? (e.g., loudly and constantly praying, high hostility in interpersonal interactions) • Is environment or approach having a disproportionate impact due to cultural factors? (e.g., physical touch during ADL care)

Diagnosis
• Were instruments geared toward individual’s [national or ethnic] culture? (e.g., normative data, language) • Was level of education accounted for?

BPSD: Cultural Considerations for Clinicians

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

Cultural factors that may complicate the diagnosis of dementia

Stigma attached to mental illness Bias and prejudice of clinicians

Institutional racism Unfamiliarity with sxs of dementia by relatives Sxs of dementia being viewed as a function of old age

CULTURAL CONSIDERATIONS: Diagnosis
Shah, AS. CROSS-CULTURAL ISSUES AND COGNITIVE IMPAIRMENT http://www.rcpsych.ac.uk/pdf/Dementia%20%20Culture.pdf

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When is an antipsychotic justified?
Schizophrenia Schizoaffective disorder Delusional disorder Mood disorders (e.g. mania, bipolar disorder, depression with psychotic features, and treatment refractory major depression)

Antipsychotic medication can be used for the following conditions/diagnoses:

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 resident’s 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

and medical causes have been ruled out

“A”
After

ENVIRONMENTAL

“R”
After

treatment strategies have been tried/ implemented

APPROACH FACTORS

- inconsolable or persistent distress; - a significant decline in function; - substantial difficulty receiving needed care

have been evaluated, (training, communication & structure)

RESIDENT FACTORS

have been evaluated

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)

Antipsychotic justification in BPSD

Maixner, et al. J Clin Psychiatry. 1999;60(suppl 8):29. Jibson and Tandon. J Psychiatry Res. 1998;32:215.

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GDR attempts can be omitted if they are “clinically contraindicated.”
For behavioral symptoms related to dementia, “clinically contraindicated” is defined when:
 Resident’s target symptom[s] return or worsen after most recent GDR attempt

AND  Physician has documented rationale for why additional GDR attempts would likely impair the resident’s function

Gradual Dose Reduction : Antipsychotics
Hardesty, JL. Presentation to VHCA, Under the Microscope: The Ever-Increasing Scrutiny of Antipsychotics in LTC, 2012

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In clinical record:
Clear documentation of treatment targets / symptoms

Non-pharmacological interventions tried and/or in use

Pharmacological intervention is prescribed:
• Lowest effective dose is utilized • Time limited duration, (as warranted)

Ongoing monitoring / reporting of efficacy and response
• ADEs clearly being monitored for and supported in documentation • Tolerability & efficacy assessed every 3 to 7 days

GDR attempts are documented
• Reassess for tapering / discontinuation per CMS guidelines

If the drug doesn’t help, stop it!

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Explore, identify and address the following potential contributors: Conduct risk analysis
•Health/medical factors •Environmental factors •Approach factors •Resident factors

Clearly document every step of the way…

Immediately address imminent safety issues

Prescribe medications judiciously
•Start low and go slow!

Conclusions: Managing BPSD

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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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