…feeding the pigeons by lakesideQatar international Geriatric conference

workshop –behavioral issues in dementia

DR Hanadi Al Hamad and Team

No Conflict of Interest

Learning Objective

Understand What are Behavioral and Psychological Symptoms of Dementia ( BPSD )

Understand Evidence Base on Evaluation and Management of BPSD

Understand Emphasis of Person-Centered Care in Management of BPSD

………..we will learn all this –through a real-life case scenario

Person Centered Care

NOV 4 1906“The first symptom the 51 year old women showed

was the idea that she was jealous of her husband,soon she developed a rapid loss of memory ,she was

disoriented in her house ,carried things from oneplace to another and hid them, sometimes she

thought somebody was trying to kill her and started to

cry loudly”

- AugusteD

Alois Alzheimer

What is BPSD

Person Centered Care

IPA Consensus Group –Define BPSD as symptom of disturbed perception, thought content ,mood or behaviour that frequently occur in patients with Dementia

Behavioural Symptom-Usually identified on the basis of observation of the patient Physical aggression, Screaming, Restlessness, Agitation, Wandering ,Culturally inapp behaviour ,hoarding, cursing, shadowing

Psychological symptoms –Usually assessed on basis of interview with patient and relatives –these symptoms include anxiety, depression ,hallucinations and Delusions

BPSD-The Significance

Person Centered Care

With Aging of the world population-Absolute increase in elderly with AD and other forms of Dementia

Dementia is associated with Progressive cognitive disability ,high prevalence of BPSD –Agitation ,Psychosis ,Depression

BPSD is an integral part of the Disease process and presents with severe problems to Patients,family,carers and society at large

Worsening Cognition and progression to more severe stages of Dementia

Individual suffering and Care Giver Burden

Increased Risk of Falls –Fractures –ED Admission

Institutionalisation

Higher Cost of Care

BPSD Symptom ClusterJost&Grossberg 1996

Person Centered Care

BPSD –How Prevalent it is ?

Nearly Universal Frequently Co-occur with higher Prevalence Rates in patients with Severe Dementia ) -( Lyketsos et al 2000,2002)

Cache County Study 97 % of subjects with Dementia had One BPSD when Followed over 5 Years -( Stienberg et al 2008)

Person Centered Care

( Recent Metanalysis Zhao et al 2016 )

Theories of Behavioral disorders in Dementia

Four theoretical frameworks proposed

1. Biological theory-symptoms stems from the neurological changes in the brain

2. Behavioural theory:behavior controlled by antecedents and consequences

3. Theory of reduced stress threshold in dementia4.Unmet needs model: Person unable to express their needs and as a result there is a failure to detect and address the needs

Jiska Cohen-Mansfield, PhD non pharmacological treatment of dementia Current Treatment Options in Neurology (2013) 15:765–785

Assessment of BPSD – Essential Elements

Type ,Frequency ,Severity ,Pattern ,Context and Timing ( NPI /BEHAVE –AD )

Risk of Harm to Self or Others

Presence of Delirium ( In particular New Onset BPSD )

Precipitating Factor ( Constipation /UTI /Medication /Medical Illness )

Modifiable Factors

Person Centered Care

(Modifiable Factors)

(PCC)

(PCC Person Centered care )

BPSD –DICE APPROACH

DESCRIBE INVESTIGATE CREATE EVALUATE

( Multidisclinary National Expert Panel Kales Et al )

Person Centered Care

Real Life Case Scenario

You are called in by the Senior manager of a secure Long Term care Setting for a Crisis assessment Call is with Reference to a New Resident 70 Yr Old Mr S who has been there since 3 days. When you walk in ; You have Senior Manager with her 2 Deputies 5 Nurses who straight come over to you ,with set of papers

“ We will call the Ambulance and can you take him to your Locked Psychiatric Ward Now ““This is all his Dementia”

I have been a Manager in this Long Term setting for 10 Years and working for over 20 Years .I have never come across anything like this ever in my Working Career “ in the last 72 Hours .We have filled in 70 Incident Forms. Before you Initiate any further Question ,Desk Phone of the manager Rings ,It’s the Call from Physician services attending the Long Term Care .Adding –” Wherever in the Country you get the Bed –Move him now “

Person Centered Care

They start Reading up the Incidents –one after the Other

Kicking staff

Punching Staff

Banging Doors

Throwing Chairs

We nearly Got Him “ This morning Tried Throwing Chair through Glass Window “

………..List Goes on

Real Life Case Scenario

First Step -Collect Information

70 Yr old Mr S Has been under Care of Memory Services .Evaluated and has an Established

Diagnosis of Alzheimer's Dementia Moderate Severity .On Rivastigmine 9.5 MG/24 Hours

Transdermal He was Living alone ,supported by periodic .Visit from his daughters living close by

.5 Weeks back Found on the Floor in Local Bus stop Appeared Confused .Evaluated at Acute

Medical Unit .Following the 10 Days Inpatient Evaluation MDT Team Decided way forward –Move

to Long Term Care

Real Life Case Scenario

Week Back he Was Discharged from the Medical Unit

To another Long Term Care Setting in the Community

Two Days into that care setting –He Went Missing

After 3 Hours , Police Search was Found 4 Miles away from the Unit ,Walking through Cold

Winter Day , Not knowing where he was and not able to Express where he was Going .Following

that Incident –He was Moved to this Secure Long Term Care Setting and you have since been

Called in with Concerns as Informed

Real Life Case Scenario

You Request the Nurses if you Can See Him

Moderate Built ,Smartly dressed Elderly Gentleman .Sitting in the Foyer area of the Care setting .Turning the Pages of the Days Newspaper

Assessment

Alert No Evidence of agitation or Restlessness Able to Exchange Pleasantries Word Finding Difficulty +Cognitive Limitations Evident No Clear Evidence of Depression No Objective Evidence of Psychosis Limited Insight

Real Life Case Scenario

This is not how he is –See these Incident Forms

“We are not Keeping Him “

“5 of my Staff are off Work “

“We cant take it any More”

“Can you Take him now”

Real Life Case Scenario

Your First Step should be ( Select the Best Option )

1) Inj Haloperidol 10 mg Intramuscular Stat –Close review

2) Inj Lorazepam 4 MG IM Stat –Close Review

3) He is on Promazine 50 MG Upto BID PRN ,make it 100 MG BIDClose Review

4) Risperidone 0.5 MG BID Close Review

5) None of the Above

So What should be Your First Step ??

Mr. S has established diagnosis of dementia over 4 years now falls in bus stop ,wandering out .Going missing .seventy incidents with marked aggression spells .Staff are distraught ,no longer can he stay there now.

Arrange Transfer to Locked Psychiatry Ward

a) Yes

If Yes –Why ?

b) No

If No –Why ?

D I C E Describe Investigate Create Evaluate

Kales et al 2015

How Would You Go About the DICE Steps ?

Should You Go Through Incident Forms ?

If you decide Going Through the Incident Forms–Areas you would Look out For ????

D I C E

D I -Type /Freq /Severity /Context /Timing /Triggers

“ There is a Pattern to It “

Before we further look into our patients care aspects and how we move forward Quick Review of Current Evidence Base on Management of BPSD

Management of BPSD –Evidence Base Non-Pharmacological Management

Non-Pharmacological Interventions are Universally recommended as 1st Line Mgt For BPSD

( Kales et al 2015 )

q Individualized Strategies –For Identified Modifiable Factors

q Additional Strategies

- Providing Education for Caregivers

- Enhancing Effective Communication Caregivers and PwD

- Creating Meaningful activity for person with Dementia

- Simplifying tasks and establishing structured routine

- Enhancing Safety and Enhancing Env

q Person Centered Care

q Communication skills training

q Adapted Dementia Care Mapping

Standardized Non-Pharmacological Interventions

Management of BPSD –Evidence Base Non-Pharmacological Management

Person Centered Care

( Reduce agitation upto 6 Months –Review of 33 RCT ; Livingstone et al 2014)

Group activity and music therapy decreased agitation in the short term ,but did not demonstrate

sustained long term benefits.

Aromatherapy and light therapy were ineffective in controlled trails ( Brodaty and arasaratnam

2012).

Overall nonpharmacological intervention with the greatest evidence of benefit are those based on

family care giver interventions

These interventions include :

q Skill training for caregivers

q Education for caregivers

q Planning activity with care giver for care recipient

q Environment redesign

q Enhanced support for caregivers

Management of BPSD -Evidence Base –Pharmacological

Pharmacological MGT is recommended where Behaviour intervention have failed and risk benefit analysis favors .No medication has approval for use from US FDA for treatment of BPSD in US –all treatment is off label .

Risperidone is licensed in Britain for short term treatment of persistent aggression in patients with mod –severe ALZ –where aggression -;

unresponsive to nonpharmacological approach and where there is risk of harm to self or others

Also approved in Canada.

Off label prescribing is accompanied by an increased risk of liability .Evidence base use is justified where and risk and benefit has been carefully weighed and appropriate consent has been obtained.

Pharmacological MGT BPSD ; Antipsychotics

Among Pharmacological agents ,atypical antipsychotics have the best evidence of Efficacy ( Modest ) Unfortunately they are also linked with evidence of serious harm in form of increased risk of Mortality.

Efficacy of Typical antipsychotics in treatment of agitation and Psychosis is small at best ( Sink et al )

Efficacy of atypical antipsychotics for BPSD has been demonstrated in multiple Systematic Reviews and a Meta Analysis.

Person Centered Care

Efficacy of Atypical Antipsychotics in Management of BPSD

Antipsychotics use in BPSD –Practical Considerations

Reus et al APA Practice guidelines 2016

Pharmacological MGT BPSD –antipsychotics ; mortality and other serious risks

2003 ; FDA prescribing information for risperidone with warning for increased cerebrovascular adverse events including stroke in elderly with dementia.

2005 ; black box warning for entire class of atypical antipsychotics with a reported 1.6-1.7 fold increase in mortality in placebo controlled trails with olanzapine ,aripiprazole ,risperidone and quetiapine. cause of death heart related ( heart failure ,sudden death ) or infection ( pneumonia ).

2008 ; black box warning applied to typical antipsychotics ( shah and aftab 2016).

Person Centered Care

Pharmacological MGT ; BPSD ; Other Molecules

Cholinesterase Inhibitors and Memantine

Evidence for ACHEIs for agitation and Psychosis is Limited Systematic Review for that 11 Out of

14 Studies demonstrated no efficacy compared with Placebo ( Rodda et al 2009) .Subsequent

Meta Analysis showed small benefit for BPSD SMD 0.12 –Unclear Clinical significance

.Memantine – a Randomized Trial no benefit Compared with Placebo.

Lack of Efficacy in subsequent Meta Analysis ( Wang et al 2015 )

Pharmacological MGT ; BPSD ; Other Molecules

Anticonvulsants

Anticonvulsants have no Proven Efficacy for BPSD

Cochrane Review –Valproate is ineffective for Treatment of agitation in Dementia

( Lonergan and Luxenberg2009)

Valproate Mortality Risk similar to antipsychotics

Small Limited Evidence for use of Carbamazepine

(Gallagher and Herrmann 2014)

Antidepressant Studied ; Agitation and Psychosis in Dementia some benefit Citalopram and Sertraline

/Placebo

Dosage of Citalopram > 60 Yr Old not > 20 mg QTc ( Caution )( FDA 2011)

Benzodiazepines ; Current Recommendation avoid in Non-Emergency use –Cognitive Decline /Fall

/Hip Fracture )

(Defrancesco et al 2015)

Getting Back to Our Patient Mr S

D I C E

D I Type /Freq /Severity /Context /Timing /Triggers

“There is a Pattern to It”

Barring 5 incidents of reported agitation in the evening

Majority –morning hours approx. 9am -11am

Rest periods –no major concerns reported

Incident in previous care setting –missing from 9.30 am

Few evening incidents –context

How Would You Proceed Now ???

“Doc –Can you Confirm Transferto Locked Psychiatry Ward Now ”

Its Weekend Evening already 7 PM ,Care Staff are Distraught

We need Further Evaluation

Call your Ward Nurse In Charge , Ask Care Home Manager

Call Ambulance and Arrange Transfer –will evaluate Further in the Inpatient Unit

a) Agree

b) Disagree

“Why Mornings Predominantly”

PERSON CENTERED CARE PRINCIPLES

“ Try to Understand Person Behind Dementia “

NICE Dementia June 2018

Call Family ;

As You Start talking –Family Straight Interrupt and say

Doctor “ We have to Change This Long-term Unit –Yesterday Evening he Was

Unsteady “

They Pumped in Promazine –”Move to Another Care Unit ”

He is the Most Caring Person we Know

He Doesn’t Deserve this –Now they say Psychiatry Ward –No Way

“ Typical Day “ Likes –Dislikes “ Works “

Nicest person you could have ever met

He is very caring ,always helpful

Served in government services –retired 65

Mom passed away 2 years , his dementia has been there but he still managed with our support

Never wanted to leave home since mom passed away

Typical day “ Every morning carer would help with his breakfast and meds then dad goes alone for his outing “

“yes he loves going out –takes the number 72 “.Gets down by the lakes –feeding the pigeons

,then would go to my sisters by the corner evening sister family drop him back ,all was fine until this

fall by the bus stop we where worried of his safety going alone – hence agreed with plan for move

to care setting.

Call Transcript ;

Revisited –Incident Forms

Speak to staff --- Evident Triggers of Agitation and Aggression

“ Closed Doors “ “Staff moving him away from Door area “

Evening Incidents –Issues again when stopped from What he wanted to Do/Family visit and

Left

Made the Case – One to One Carer –Take Out Mornings !!!!!

D I C E

C E

Living in his own Home

One to One Carer Day Hours

“ By the Lakeside –Feeding Pigeons “

Going out to Parks

Evening onwards Daughter with him at his Home

Not on any Antipsychotics

Key Learning

Behavioral and Psychological Symptoms of Dementia ( BPSD ) such as agitation ,apathy ,Disinhibition ,Psychosis are nearly Universal at some point in course of dementia with Higher prevalence in later stages.

Evaluation of BPSD must Include a Comprehensive history ,Risk assessment ,Delirium assessment And Identification of Modifiable Factors ( This includes Precipitating Factors ).

Non-Pharmacological Intervention are Universally recommended as 1st Line in Management of BPSD With Family and Care Giver Intervention demonstrating greatest evidence of benefit

Person Centred care should be Integral in MGT Of BPSD

Among Pharmacological agents –atypical antipsychotics has the best evidence of Eficacy ,however useAssociated with Increased Mortality Risk

Citalopram may be useful for agitation in patients with Dementia

Person Centered Care

References ;Zhao et al –The Prevalence of Neuropsychiatric Symptom in Alz Disease –SR and MA

J Affective Disorder 190 ; 264-271

Kales et al Assessment and MGT of BPSD BMJ 350;2015

Lyketsos et al 2000-2002 Am J Psychiatry 2000

Livinstone et al Br J Psychiatry 2014

Brodarty and Arasaratnam 2012 MA of Non Pharmacological Intervention Am J Psychiatry 2012

Maher et al Efficacy and Comparative Effectiveness of atypical antipsychotic for off label use in adults a SR and MA JAMA 2011

Reus et al APA Practice guidelines 173 2016

Lonergan and Luxenburg Cochrane Dtabase SR 2009

Gallagher and Herrmann Drugs 2014

Practical Strategies in Geriatric Mental Health Lura Dunn Erin L APA Publishing 2019

Jost and Grossberg The Evolution of psychiatric symptoms In Alzheimers disease -a natural history study

JAm Ger Society 1996

Sietz DP Antidepressants for agitation and psychosis in Dementia Cochrane Data base Rev 2011

Shah and Aftab Should Physcians prescribe antipsychotics in Dementia ? Psychiatry Annals 2016

Thank You