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

Pharmacy Services Manager Virginia Department of Behavioral Health, Developmental Services

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.



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


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;



4/18/2013 Ms. 2003. 2008. Neuropsychopharmacology. Grossberg GT. MT declined. Case of Ms. J. Clin Psychiatry 64:36. 2010. et al. She: • no longer recognized her husband • exhibited repetitive behaviors • verbalized suspicious statements about husband’s whereabouts • exhibited increased restlessness.ucc. et al. 1996.18:1026 Early(~0-3yrs) Mild-Mod(~3-5yrs) Severe(~6yrs) Mood 100 80 Cognition Behavior / Function Agitation % patients 60 Depression Social withdrawal Diurnal rhythm Irritability Wandering Aggression 40 20 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.ie/en/ 2 . 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. http://www.33:957 Spalletta G.44:1078-1081 Brodaty et al. Am J Geriatr Psychiatry. Patient Intake & History Over the next few weeks at the LTCF. J Am Geriatr Soc. and • began experiencing persistent nighttime wakefulness. Take (MT) 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.

B. Dementia Care Conf. 2012 Apathy Calling out e. C.4/18/2013 POLL Appropriate Antipsychotic Treatment targets include the following: (Check all that apply) A. 2012 3 .g. Antipsychotics and Dementia: Part of the Solution or Part of the Problem. 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. Dementia Care Conf.. etc.g.. screaming Most common BPSD NOT amenable to medication/ antipsychotic medication Hiding/hoarding Nocturnal restlessness Repetitive activities e. D. pulling on locked doors. Antipsychotics and Dementia: Part of the Solution or Part of the Problem. Distressing hallucinations Physically aggressive behavior Delusional jealousy Anger over accepting assistance with ADL’s POLL: CMS “Approved” Indications for LTC Facilities 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.

Trial.13:143 • 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. J Psychiatric Pract. 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. 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. §483. however attention to other potentially harmful medications is also part of this initiative. Psychiatric Bulletin.7 fold increase in mortality in response to analysis of 17 placebo-controlled studies.4/18/2013 • No FDA-approved medications to treat dementia-related behavioral disturbances • Medications utilized today.26:230 • 2005: FDA issued warning: 1. Antipsychotics are the initial focus of the partnership.. 2008. 2002.44:12 Recupero PR et al.6 – 1. • 2010: Nearly 1/3 of elderly patients with dementia residing in nursing homes are on atypical antipsychotics for BPSD even though.25(l) Unnecessary Drugs Each resident’s drug regimen must be free from unnecessary drugs (F329) 4 . 2007.

2013 GOALs? Reevaluate based on 2012 4th quarter findings First Year Goals • 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. Difficult behaviors in long-term care patients with dementia. 1992. J Am Med Dir Assoc. J Gerontol Nurs. White HK. Goal-directed care: caring for aggressive nursing home residents with dementia. Ryden MB.4/18/2013 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.7(3):181.9% 2012 GOAL . Feldt KS. 2006. 23. 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 5 . Tourette’s Syndrome or Huntington’s disease .18(11):35-42.

. Cross Country Education Seminar. • 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. SAFE DRIVING? Risk Assessment: Taking Inventory Static Presence of delusions Impaired communication Frontotemporal dementia Certain forms of traumatic brain damage Depression Low serotonin levels Psychosis. where. 2006. when and how ” questions • Basic functional analyses can be performed by anyone clinically familiar with the resident Clarifying the BPSD 6 . Aggressive behavior in the elderly: prevention and management. esp.4/18/2013 PRIORITY RISK AREAS ROAMING? IMMINENT PHYSICAL RISK (fire. frailty?) SUICIDE? K INSHIP RELATIONSHIP ABUSE/NEGLECT? SELF NEGLECT. A. Irritability command hallucinations and thought disorganization Dynamic BPSD Example: Aggression Risk Factors Heck. function) serves for the individual • Answers the “what. SUBSTANCE ABUSE. falls.

Antipsychotics and Dementia: Part of the Solution or Part of the Problem. clinicians may begin to draw conclusions about the cause(s) and treatment of the problematic behavior Clarifying the BPSD (cont. were there setting events or stimuli which were consistently related to their occurrence? With answers to these questions. along with any baseline data gathered. 2012 7 .) Health and medical conditions E nvironment Approach Resident factors • An ordered strategy for examining common sources of a behavior problem The HEAR method 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. 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.4/18/2013 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. Dementia Care Conf.

COPD. DRUGS! EYES. IMMOBILZATION RETENTION (URINE/STOOL). Three primary cardinal features of delirium are: A.htm DRUGS. Acute/onset is days to weeks B. Most often irreversible state of confusion POLL: Delirium • The likelihood of developing delirium increases with age • Three primary features to look for: 1. EARS –POOR HEARING AND VISION = RISK FACTORS L OW O2 STATES (MI.nlm.nih. Transient in severity often fluctuating throughout the day for short periods of time C. ACUTE TRANSIENT (lasts only for a short time) and REVERSIBLE state of confusion. 3. RESTRAINTS ICTAL—SEIZURES CAN CAUSE DELIRIUM UNDERHYDRATION. CHF. DRUGS. UNDERNUTRITION METABOLIC ABNORMALITIES (s)UBDURAL. Reversible state of confusion D. • Delirium diagnosis is often missed in up to 70% of cases • This is especially concerning. acute respiratory distress syndrome) I NFECTION. 2. SLEEP DEPRIVATION Common Causes of Delirium 8 .4/18/2013 POLL Delirium is a state of acute cognitive impairment caused by a medical problem.gov/medlineplus/ency/article/000740. 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.

Take • She had periods of feeling exhausted. this resulted in frequent daytime napping. MT’s Husband • Staff talked with MT’s husband.. knee. he also stated that his wife rarely took her medications. 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)? 9 . and • language deficits. Vital Signs... etc Is there Dehydration/ Nutritional issues? Constipation.g. He noted she appeared more worried. apprehensive. Case Update: Ms. • Oxybutynin 10mg XL daily incontinence. daytime restlessness and pacing increased to where it became extremely difficult for staff to redirect her Ms. Adherence • Prior to admission. appearing overly sedated or subdued. urinary retention / incontinence? Musculoskeletal: Joint pain? Is there Pain? Eyes: Corneal abrasion? HPE. • MT also began exhibiting increased distractibility and began refusing to eat. As a result. Take • MT became more and more challenging exhibiting increasing exit seeking behaviors. Mr.4/18/2013 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. MT: 30 Day Update Orthopedic issues / arthritis: feet (e. Take reported that his wife’s dose of oxybutynin had been increased from 5mg to 10mg but. fearful and she no longer recognized him during their daily visits MT’s current medications • Docusate 100mg bid constipation. shoulder. MT had an eight pound weight loss. let alone on a regular basis. back. poorly fitting shoes).

(increasing difficulty in focusing attention). Gravity>> 3+ leuks & WBCs in urine a change in cognition. electrolytes & U/A Delirium Assessment performed: MT was Positive Acute onset Sxs. 10 . and VS: +orthostatic hypotension.g.4/18/2013 **DELIRIUM** PE Labs: CBC. CNN) • Space issues • Frequent room changes/redesign • Relocation (within or between facilities) • Lack of adequate physical space Environmental Factors cont. fluctuating in course. MT: Evaluation/Findings • 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 • Common examples: • Physical elements • Highly patterned wallpaper • Mirrors • Noise and activity level • Loud call bells/paging systems • Constant Television Programs (e.. +poor attention U/A >> BUN relative to SCr >> Sp. Soap Operas. +restlessness. Findings: ANTICHOLINERGIC TOXICITY "Compliance Toxicity”…due to increase in oxybutynin dose with resultant anticholinergic load/toxicity oxybutynin dose > oral intake > urinary retention >> bladder infection.

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. Handbook of dementia 2003. Faller 11 ..4/18/2013 Liberally attempt different environmental changes (being sensitive to the amount of change the residents can tolerate) General strategies: Try using soothing sounds (ocean waves. babbling brooks. Mr. look at floor beyond threshold. Intl Psychogeriatrics 2006. Faller • Staff discovered janitorial staff had recently changed to a shinier wax for the hallway floors (looks slick?) • Timing of change coincided with the emergence of Mr.18 Rayner A et al. Am Fam Physician 2006. NY: Wiley & Sons • 69 year old male with Alzheimer’s disease • Has refused to leave room in past month. 73 Camp C et al. Faller’s behaviors • Less shiny wax used. activities • Often observed to walk up to doorway. 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. swings out at staff who try to get him to come out for meals. and retreat into room Mr. In Lichtenberg D et al. Landreville P et al. Faller was able to leave the room with minimal difficulty soon afterward Case Example: Mr.

g.. Hurley has been observed to throw her toast from her tray across the room • Resident had not previously expressed a dislike for toast. etc. Hurley from beginning of meal forward. every morning Ms. and family said she used to like it Ms. nonverbal.4/18/2013 • Definition: • THE METHOD(S) BY WHICH INDIVIDUALS ARE ADDRESSED BY THEIR CAREGIVERS THAT CAN INFLUENCE BPSD • Can include physical. Hurley • After starting to observe Ms. • Example of catastrophic reaction Case Example: Ms. 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. • Resident with 6-year diagnosis of Alzheimer’s disease • Memory unit in ALF: For the past three weeks. 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. Hurley 12 . behavior ceased directly. during ADLs) Erratic or unpredictable daily structure HEAR: Approach Factors 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. mealtimes and sleep) Use familiar staff whenever possible Structure Approach Factors cont. schedule/routine issues. verbal. Common examples Violations of personal space Caregiver attitude/reactions Stance and positioning issues Verbal approaches Physical touch (esp.

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 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.) 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. DESIRES. implemented by facility staff (with staff training) • Aimed at bringing about desirable behaviors while discouraging or eliminating harmful behaviors HEAR: Resident Factors (cont.) 13 . WANTS.4/18/2013 • Definition: • THE NEEDS.

normative data. language) • Was level of education accounted for? BPSD: Cultural Considerations for Clinicians Shah et al Int Psychogeriatr 2004.g.ac. etc. CROSS-CULTURAL ISSUES AND COGNITIVE IMPAIRMENT http://www.. physical touch during ADL care) Diagnosis • Were instruments geared toward individual’s [national or ethnic] culture? (e. behavior stopped completely Mrs. Sweet Identification and attribution of behaviors • Prevalence of BPSD has been found to vary across cultures • Is behavior culturally normative? (e.pdf 14 .4/18/2013 • 81 year old woman in psychiatric hospital • Cursing and swinging arms • Personality disorder and early dementia • Plan: could earn “treats” (coffee.rcpsych.g. Sweet Case Example: Mrs.uk/pdf/Dementia%20%20Culture. high hostility in interpersonal interactions) • Is environment or approach having a disproportionate impact due to cultural factors? (e.. 28 Suppl 1 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.) 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. AS. strolls. loudly and constantly praying.. 16 Herbert P Can J Neurol Sci 2001.g.

1999. “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. 1998. JL. Individualize 2.a significant decline in function. If effective. GDR attempts can be omitted if they are “clinically contraindicated.4/18/2013 When is an antipsychotic justified? Schizophrenia Schizoaffective disorder Delusional disorder Mood disorders (e. Under the Microscope: The Ever-Increasing Scrutiny of Antipsychotics in LTC. J Clin Psychiatry.” For behavioral symptoms related to dementia. depression with psychotic features. communication & structure) RESIDENT FACTORS have been evaluated SELECT 1. Jibson and Tandon. continue few weeks – few months 5. . mania. 2012 15 . 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 JUSTIFY “H” After “E” After BPSD Sxs must present a DANGER to the person or others or. J Psychiatry Res.60(suppl 8):29. STOP drug if INEFFECTIVE (appropriately tapering) Antipsychotic justification in BPSD Maixner.32:215.g. . 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 . (training. bipolar disorder. Rule of Thumb: 5-10% dose increases q 4-6 wks 4.substantial difficulty receiving needed care have been evaluated. et al. Initiate monotherapy Start low.inconsolable or persistent distress. Titrate dose to effect. Presentation to VHCA. go slow 3.

4/18/2013 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.. Psy.heck@dbhds.thomas@dbhds. (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. ABPP andrew.gov Contact 16 . BCPP michele.D. R.virginia.virginia..gov • Andrew Heck. stop it! Explore.D. Pharm. 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 • Michele Thomas..Ph.

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