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Session #2: Dementia & Behavioral Disturbances
Session #3: Psychopharmacology in the Nursing Home
Session #4: Principles of Non-pharmacologic Management & the Formulation of Behavioral Care Plans
Session #5: The Implementation of Behavioral Strategies & the Management of Pharmacologic Interventions
Session #6: Addressing Barriers to Change: the Perspective of Psychiatry, Nursing, and Medical Directors
Chat Monitor: Britt Kuertz, RDN [email protected]
615-936-1499
Moderator: Emily Hollingsworth, MSW [email protected]
615-936-2718
How many people are in the room with you to view this webinar?
(Please answer in the chat pane, and be sure to include your full facility name)
Paul Newhouse, MD Director, Vanderbilt Center
for Cognitive Medicine,
Jim Turner Chair in Cognitive Disorders
Department of Psychiatry,
Vanderbilt University
Become familiar with common dementing disorders and their clinical symptoms.
Describe common behavioral problems in dementia
Understand the context in which behavioral disturbances occur in dementia patients
Auguste Deter
November, 1902
Her condition steadily deteriorates despite treatment with memory loss, speech difficulty, confusion, suspicion, agitation, wandering and screaming to becoming bedridden, incontinent, and unaware of her surroundings.
She dies and her brain is sent for
autopsy by… Dr Alois Alzheimer
Recently, her tissue was reexamined and found to show a rare familial Alzheimer’s Disease gene mutation (PS1).
Clinical Picture of Behavioral Problems in Dementia
A 51 year old , A.D. is admitted to the long-
term care facility for being unmanageable
at home..
Her husband reports that she has loss of
memory, delusions, and temporary
vegetative states. She will drag sheets
across the house, and scream for hours
in the middle of the night.
On examination, she has a cluster of
symptoms that include reduced
comprehension and memory, as well as
language disturbance, disorientation,
unpredictable behavior, paranoia,
auditory hallucinations, and severe
social impairment.
Alzheimer’s disease (AD) refers to the neurodegenerative brain disorder regardless of clinical status
AD can be conceptualized as
having two major stages
Preclinical (presymptomatic)
Symptomatic
Prodromal (MCI)
Dementia of the Alzheimer type
Dr Alois Alzheimer
More Recent Cases of Alzheimer’s Disease
Thursday, March 19, 15
16
A global impairment of higher cortical functions including memory, capacity to
solve problems of daily living, performance of learned perceptuomotor skills, correct use of social skills and control of emotional reactions.
Multiple Cognitive Deficits:
Memory dysfunction: especially new learning, a prominent early symptom
At least one additional cognitive deficit
aphasia, apraxia, agnosia, or executive dysfunction
Cognitive Disturbances must be sufficiently severe to cause impairment
of occupational or social functioning
Must represent a decline from a previous level of functioning
Symptom
Trouble remembering new information 46%
Difficulty with complicated tasks 27%
Trouble responding to problems 14%
Frequently getting lost or trouble staying oriented 18%
Trouble expressing thoughts, ideas, or following conversations
21%
Change in personality or behavior 25%
CHS Alzheimer’s Disease Caregiver Project: Wave 6, 2000
Co
gn
itiv
e f
un
ctio
n
•Forgetfulness
•Repetitive questions
•Daily function impaired
•Progression of cognitive deficits
•Short-term memory loss
•Word-finding difficulties
•Agitation
•Altered sleep patterns
•Total dependence: dressing, feeding, bathing
MCI
MMSE 24–30 Mild AD
MMSE 20–23
Moderate
AD
MMSE 10–19
Severe AD
MMSE 0–9
•Mild subjective/objective memory loss
•Normal function
10 y 0 y
Time (y)
Time?
MILD STAGE
Forgetfulness, difficulty learning new information
Difficulty planning meals, managing finances, taking medications on schedule
Symptoms sometimes mistaken for depression
Ability to perform activities of daily living (ADL) usually maintained
Sources: Galasko D. Eur J Neurol. 1998;5(suppl 4):S9-S17. Cefalu C, Grossberg GT. Diagnosis and Management of Dementia. Leawood, Kan: American Academy of Family Physicians; 2001.
MODERATE STAGE
Short- and Long- term memory impairment
Difficulty performing tasks (e.g., following written notes, using the shower or toilet)
Agitation, behavioral symptoms appear (e.g., restlessness, wandering, delusions, hallucinations)
Deficits in intellect and reasoning (e.g., poor judgment, forgets manners)
Sources: Galasko D. Eur J Neurol. 1998;5(suppl 4):S9-S17. National Institute on Aging Alzheimer’s Disease Education and Referral Center. Available at: http://www.alzheimers.org/unraveling/unraveling.pdf. Accessed April 6, 2005.
SEVERE STAGE May lose language function and
mumble or speech may be unintelligible
Behavioral symptoms common (e.g., refuses to eat, cries out inappropriately)
Failure to recognize family or faces
Difficulty with all essential ADL (e.g., eating, toileting, walking)
Source: Gwyther LP. Caring for People With Alzheimer’s Disease: A Manual for Facility Staff. 2nd ed.
Washington, DC and Chicago, Ill: American Health Care Association and the Alzheimer’s Association; 2001.
Act
ivit
ies
of
Da
ily
Liv
ing
Progressive Loss of Function MMSE Score
Keep Appointments
Use the Telephone
Obtain Meal/Snack
Travel Alone
Use Home Appliances
Find Belongings
Select Clothes
Dress
Groom
25 20 15 10 5 0
0 2 4 6 8 10 Years
Maintain Hobby
Dispose of Litter
Clear Table
Walk
Eat
Mild Moderate Severe
Adapted from Galasko D, et al. Eur J Neurol. 1998;5(suppl 4):S9-S17.
Safety (driving, compliance, cooking, etc.)
Family stress and misunderstanding (blame, denial)
Early education of caregivers of how to handle patient (choices, getting started)
Advance planning while patient is competent (will, proxy, power of attorney, advance directives)
Specific treatments: May slow underlying disease process, (disease-modifying
treatments now under study) Standard treatment may delay nursing home placement longer if
started earlier May slow conversion from Mild Cognitive Impairment to AD
Patient initially diagnosed with AD
Patient’s first diagnosis other than AD
Yes 28%
No 72%
21%
7%
9%
14%
14%
35%
Normal aging
Depression No diagnosis
Dementia (not AD) Stroke
Other Source: Consumer Health Sciences, LLC. Alzheimer’s Caregiver Project. 1999.
Clinical features of FTD include
decline in personal hygiene and grooming,
mental rigidity and inflexibility, distractibility and impersistence,
hyperorality and dietary changes,
perseverative and stereotyped behavior, and utilization behavior
Common cause of early onset dementia 1:1 with AD 45-64 years More common than AD below
60 years
Lack of concern for loved one’s illness Cruelty to children, animals, elderly Lack of concern when others are sad Rude comments to others Lose respect for intrapersonal space “Disgusting” behaviors Diminished response to pain
Presence of dementia, gait/balance disorder, prominent hallucinations and delusions, sensitivity to traditional antipsychotics, and fluctuations in alertness
Neuropsychological tests do not reliably differentiate DLB from AD
Brain shows cortical Lewy bodies (alpha synuclein)
Fluctuating cognition with pronounced variations in attention and alertness Occurs in 80-90% of DLB, only 20% of AD
Recurrent visual hallucinations that are typically well
formed and detailed ▪ can involve scenes and bizarre situations
▪ can start with misinterpretations and are usually short
▪ often occur at night
Spontaneous motor features of parkinsonism: slow
gait, increased muscle tone, tremor
1. Preserve cognition and reduce decline
2. Maintain quality of life
3. Maximize function and maintain dignity
4. Treat mood and behavior problems
5. Refer, educate, and counsel
Source: Cefalu C, Grossberg GT. Diagnosis and Management of Dementia. Leawood, Kan: American Academy of Family Physicians; 2001.
Management Goals
Cholinesterase inhibitors are the mainstay of therapy
3 oral drugs currently on the market
Though some patients experience immediate improvement, most prominent effect is cognitive stabilization
Functional improvement may follow cognitive enhancement or stabilization
Positive effects of these agents appear to be sustained but fade over long periods
(Secondary Prevention)
Feldman et al. Poster presented at the 8th International Montreal/Springfield Symposium on Advances in Alzheimer Therapy, 2004
. Neuropsychiatric Inventory total
score (NPI) (n ~ 96) Holmes et al, 2004
.Randomization to donepezil
continuation or placebo
Significant differences were observed for the domains of depression, anxiety, and apathy (P.0166).
Adapted with permission from Feldman et al. Neurology. 2001;57:613-620. Gauthier et al. Int Psychogeriatr. 2002;14:389-404.
0
Endpoint
4
12
18
8
24
P=.0303
P=.0083 P=.0005
Clinical improvement
Clinical decline
-8
-6
-4
-2
0
2
4
Study week
To
tal N
PI c
ha
ng
e f
rom
ba
seli
ne
Aricept (n=144)
Placebo (n=146)
Most common reason for institutional placement
Agitation is the most common reason for
psychiatric consultation
In study by Cummings, only 12% of patients did
not have a behavioral problem.
Most common reason for caregiver distress
Jots, B. C. and Grossberg, G. T. (1996) The evolution of psychiatric symptoms in Alzheimer’s disease: a natural history study. J. Am. Geriatr. Soc. 44, 1078–1081
Apathy: Decreased motivation, indifference
Disrupted Mood: Depression, mania-like.
Psychosis: 50-70% of patients; paranoia, visual hallucinations
Agitation: Caused by anxiety or psychosis
Aggression: Loss of impulse control
Wandering: Searching, disorientation
APATHY
Most common behavioral change
Decreased motivation, indifference
Associated with frontal hypoperfusion
(medial frontal, supraorbital, anterior
frontal areas)
Not related to depression
Cummings 1998
PSYCHOTIC SYMPTOMS
Cross sectional studies: 20-50% Longitudinal studies: 50-70% Common Delusions: theft,
infidelity, pseudo-Capgras-type delusion (thinking spouse or family member is someone else), phantom boarder.
Hallucinations tend to be visual
rather than auditory Cummings 1998
Patients with dementia experience both hallucinations and delusions
Usually less complex than the delusions seen in schizophrenia or mood disorder
Common delusions in dementia:
Belief that one’s belongings have been stolen
Conviction that one is being persecuted
Belief that one’s spouse is unfaithful
MOOD CHANGES
Mood symptoms are frequent and
may be secondary to impairment of
mood regulatory systems in the
brain (e.g. emotional incontinence)
Major depressive disorder (MDD) is uncommon
MDD may precede diagnosis of Alzheimer’s disease or vascular dementia
Cummings 1998
AGITATION Excessive motor or verbal activity that is:
Disruptive OR
Unsafe OR
Distressing to the patient
Interferes with care and
Is not because of need
Appears similar despite great variety of causes
Cohen-Mansfield et al., 1996; Tariot et al., 1994
AGITATION ▪ Correlates with anxiety in mildly demented
patients
Correlates with psychosis in moderately
demented patients
Correlation to breakdown of mood and/or behavioral regulation in severely demented patients
Modified from Cummings 1998
SUNDOWNING
Agitation associated with late
afternoon or evening
Causes:
Fatigue
Circadian factors
Lack of sensory stimulation
Need for security, protection
Modified from Reichman et al
WANDERING
Disorientation
Restlessness
Searching
Sundowning
Fear
Medication-induced akathisia
Modified from Reichman et al
AGGRESSIVITY Can be in response to environment or spontaneous
Verbal and physical
Can occur without delusions or hallucinations
May be resistant to conventional pharmacotherapy
Which of the following is not a common behavioral symptom in Alzheimer's disease?
A. Apathy
B. Psychosis
C. Aggression
D. Shaking
E. Fear
F. Anxiety
Fear - disorientation,
abandonment,
confusion
Over-stimulation
Lowered frustration
tolerance
Loss of impulse control
Inability to recognize
family, caregivers
Disorientation to time
or place
Disrupted routine
Forgetting of appropriate behaviors
Modified from Reichman et al
Personal Pain Sensory Loss Infection Psychosis
Environmental
Transfers Personal Care/Bathing Family Visits Medications
Chronological Awakening Late Afternoon Meal Times Bedtime Middle of the Night
Modified from Reichman et al
Unmet physical needs?
Pain?
Infection/illness?
Thirsty? Hungry? Tired?
Sleep disturbance?
Medication side effects?
Sensory impairment?
Constipation?
Incontinence?
Unmet psychological needs?
Loneliness, boredom?
Apprehension, fear, worry?
Emotional discomfort?
Lack of enjoyable activities?
Lack of socialization?
Loss of intimacy?
Cause related to social environmental?
Too many people, too much noise?
Too little to do?
Expectations for performance
are too high?
Communication is unclear?
Caregiver approaches aren’t adjusted to level of ability?
Cause related to physical environment?
Physical surroundings are not
“understandable”?
TV, radio, PA systems confusing?
Pictures, photographs,
reflections misunderstood?
Lacks appropriate signage or
cues to way-find, be independent?
Lacks meaningful activities?
Lacks natural walking paths, daily exercise?
Cause related to other Psychiatric illness?
Depression?
Anxiety?
Delirium?
Psychosis?
Other mental illness?
Overlapping syndromes are common!!
Altered or fluctuating level of alertness
Sudden change in behavior suggests delirium
Acute or subacute onset
Look for infection, new medications, and any anticholinergic medications
Dementia patient is VERY susceptible to delirium
Abrupt changes in behavior in a previously stable patient with dementia may indicate:
A. Delirium
B. Infection
C. Metabolic disturbance
D. Drug interaction
E. All of the above
Dementia is a syndrome: Most common cause is Alzheimer’s Disease
Other dementias with behavioral disturbances include Fronto-temporal dementia, Lewy-Body dementia, vascular dementia
Behavioral disturbances are a core feature of dementia and can be expected in most patients
The context (environmental, personal, physical, psychological) will often determine whether and how behavioral disturbances are expressed
There will be a second presentation of Session #2 on Wednesday,
November 18th at 10AM CST (11AM EST)
Two options for attending Session #3:
• December 15th (Tuesday) 1pm CST • December 16th (Wednesday) 10am CST
Emily Hollingsworth [email protected]
Britt Kuertz [email protected] Project Website: www.VanderbiltAntipsychoticReduction.org Vanderbilt Center for Quality Aging 615-936-1499
www.vanderbiltcqa.org for other resources