Dementia Care 2013

1. Dementia Care 2013 Tim Gieseke MD, CMD Assoc. Clinical Prof. UCSF Multi-facility Medical Director gieseke@sonic.net

2. Objectives • Dementia Syndromes • Stressors & Delirium Syndrome • Mental Health Co-morbidities • Pharmacologic Management • Environmental Management • Resources

3. DSM –IV Dementia Diagnosis • An acquired impairment in areas of intellectual function: • Memory + at least 1 of 4 other cognitive domains • Language (Aphasia) • Movement (Apraxia) • Object/Situation Recognition (Agnosia) • Executive Function (Initiative, Med Management, Problem solving) • Interferes with either Occupational or Social functioning, or Interpersonal relationships. • Represents a Decline • Progresses slowly over years with onset usually after 60 y/o

4. Importance • Many NH residents have cognitive impairment (25-74%), but commonly not recognized in early stages • Over 75% of NH residents meet MDS-based criteria for dementia. • Dependency is common • 73% dependent for toileting, transfers, & continence • 21% for feeding • Behavior and Psychological problems are common and may be difficult to manage • Low stress tolerance with high risk for delirium • Poor prognosis particularly after acute stressor like Pneumonia or Hip fx • 4-5 times > 6 mo mortality compared to non-demented

5. Common Screening tests • BIMS part of MDS 3.0 • http://dhmh.dfmc.org/longTermCare/documents/BIMS_Form_Instructions.pdf • Mini Mental Status Exam • http://www.health.gov.bc.ca/pharmacare/adti/clinician/pdf/ADTI%20SMMSE-GDS%20Reference%20Card.pdf • Mini Cog • http://www.alz.org/documents_custom/minicog.pdf • SLUMS cognitive Assessment • http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf

6. If cognitive impairment detected, must find a reliable historian. • When did it begin? • What is the time course of the cognitive decline? • What was the pre-hospital function? • ADLs –Bristol ADL Scale http://www.health.fgov.be/internet2Prd/groups/public/%40public/%40dg1/%40acutecare/documents/ie2divers/19073273_nl.pdf • IADLS: http://www.abramsoncenter.org/pri/documents/iadl.pdf • Are any medicines or medical conditions contributing to cognitive impairment? • Any current exacerbating factors? • Hearing Aids, Eyeglasses, Death of spouse, dog, etc.

7. If Rapid Decline in Cognition, Consider Delirium • CAM = Confusion Assessment Method • Below information apparent from interview of family and patient • 1. Acute onset and fluctuating course • And • 2. Inattention • And EITHER • 3. Disorganized thinking • OR • 4. Altered level of consciousness • http://consultgerirn.org/uploads/File/trythis/try_this_13.pdf

8. Dementia and Delirium • Dementia is the strongest risk factor for the development of delirium • 25-75% of patients with delirium have co-morbid dementia • 5-fold > risk • Medications that Challenge Cognition • Benzodiazepines • Tricyclic Antidepressants (Amitryptyline) • Anti-cholinergic meds: (Benedryl, Meclizine) • Narcotics • Withdrawal states (SSRIs, Alcohol, Benzos) • Digoxin toxicity

9. Evaluation of the Acutely Confused Patient? • Use INTERACT 3.0 Algorithm to support your SBAR • Acute Mental Status Change Algorithm • http://interact2.net/docs/INTERACT%20Version%203.0%20Tools/Decision%20Support%20Tools/Care%20Paths/INTERACT%20Care_Path_%20Acute_MENTAL_STATUS_CHANGE%20Dec%2029%202012%20revised.pdf • Change in Behavior Algoithm • http://interact2.net/docs/INTERACT%20Version%203.0%20Tools/Decision%20Support%20Tools/Care%20Paths/Care_Path_CHANGE_IN_BEHAVIOR%20Dec%2029%202012%20revised.pdf

10. Depression is Common in Dementia • Screen with PHQ-9 and OV for non-verbal patients on MDS 3.0 • Is there a history (or family hx) of prior depression? • Is there a history of substance abuse disorder? • If depression is present, cognition may improve with effective treatment of depression. • Apathy is common in both depression and dementia, but folk with depression usually: • Complain of memory loss, but memory tests well. • Poor concentration • Gives up easily on testing • Orientation is generally intact • Aphasia and apraxia are absent

11. Dementia Syndromes ~ Prevalence • Alzhiemers (DAT) 50-60% • Lewy Body (DLB) 10-15% • Vascular (VaD) 10-15% • Mixed (DAT + VaD) 10-15% • Parkinsons (PDD) 5% • Fronto-Temporal (FTD = Picks dz) 5% • Reversible: 5% • Depression; B-12; Meds; etc. • Others: SupranuclearPalsey; Jacob Creutzfeld, and many others

12. Alzheimer's Clinical Picture • Age is greatest risk factor • 1% at 60 y/o and doubles q 5 years • Insidious onset with slow decline over many years • Life expectancy ~ 10 years from diagnosis • Initial cognitive loss in memory and executive function • loss of initiative (apathy) is common • Language loss and agnosias with confusion occur later • Predisposes to behavioral problems, sleep disturbance, and poor hygiene • Apraxias and loss of music appreciation occur late in the disease.

13. Lewy Body Dementia • Presents typically with: • Early Parkinson shuffle, tremor, imbalance < 1 year duration • Vivid frightening visual & auditory hallucinations with potential for sudden and unexpected physical aggression • Paranoid delusions supported by hallucinations • Fluctuating levels of consciousness and impairment • Some days seem normal • Not much memory loss early on • Very sensitive to side effects of antipsychotics. • Aricept (Donepezil) or other Acetylcholine Esterase Inhibitors (ACEIs) may dramatically reduce hallucinations and paranoia • Antidepressants may help

14. Vascular Dementia • CVAs may result in sudden development of dementia in close proximity to the CVA. • Presents with more defined onset and cognition tends to decline with each new CVA. • CVAs may be “Silent” only seen on CT or MRI scans • Age is a strong risk factor, so DAT and VaD commonly occur together as a Mixed Dementia • Other risk factors to manage: • Atrial Fibrillation – consider anticoagulation • HBP • Diabetes • Lipid Disorders • Cigarettes

15. Parkinson’s Dementia • Dementia generally occurs > 7 years after diagnosis of PD when commonly see • Significant mobility impairment, dystonia, dysphagias, and dysautonomias • Once dementia develops PD meds may increase nocturnal hallucinations and impulsiveness (> fall risk) • Dementia manifestations are similar to Lewy Body with significant delusions • Aricept (Donepezil) may be tried. • Sometimes tapering off the PD meds helps the distressing hallucinations, delusions and impulsiveness, but PD motor symptoms may worsen off meds.

16. Fronto-Temporal Dementia • Progressive Atrophy of above lobes, but not memory centers, so memory tends to be preserved • Fail to recognize functional impairments • Receptive & Expressive Aphasia • Social disinhibition with repetitive behaviors • Pseudobulbar affect • Occurs at younger age then other dementias • 35-70 y/o at onset • Familial occurrence in 20-40% of cases • Shorter survival from dx ~ 8.7 years • Anti-depressants occasionally helpful, but not ACEIslike Aricept (Donepezol)

17. Is there a Mental Health History or Brain Injury? • Substance Abuse Disorder • Alcohol • Opiods or Benzos • Borderline Personality • http://en.wikipedia.org/wiki/Borderline_personality_disorder • Brain injury? • Trauma, anoxic, Multiple Sclerosis, or hypoglycemic • Encephalopathy • Hepatic, HIV, Herpes Encephalitis • http://www.nlm.nih.gov/medlineplus/encephalitis.html

18. Pre-dementia Mental Disorders? • Anxiety Disorder • Generalized, PTSD, Panic Attacks, OCD, Phobias • http://www.webmd.com/anxiety-panic/guide/mental-health-anxiety-disorders • Bipolar Disorder • Antidepressants if used without mood stabilizer may promote rapid cycling to mania • http://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml • Autistic Spectrum Disorder • http://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-pervasive-developmental-disorders/index.shtml • Schizophrenia • http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml

19. Pharmacologic Management • Meds appropriate for identified co-morbid mental health problems • Antidepressants in Dementia • Sertraline (Zoloft) SSRI of choice – well tolerated and few drug interactions • Citalopram (Celexa) may prolong QT interval at higher doses and has many drug interactions that worsen the QT interval. • Mirtazepine (Remeron) consider if need hypnotic & appetite enhancer. • Venlefaxine (Effexor) or Duloxetine (Cymbalta) if neuropathic pain & depression • Memory Enhancers (in DAT, most don’t benefit) • ACEIs like Donepezil (Aricept), but falls & anorexia risk • NMDA Antagonists like Memantine (Namenda) • Not both: no increased efficacy in recent studies

20. Pharmacologic Management • Meds for Palliative Care • Pain • GI symptoms: Constipation, Diarrhea, Nausea, • SOB/OSA: CPAP, O2 • Skin: Pruritis • Sleep: Trazodone?, Tylenol • Benzodiazepams • Predispose to delirium & increase risk of falls, sundowning, & malnutrition • Chemical Restraint issue • Use lowest dose for shortest period of time with clearly defined goal • Prazocin • 1 small study showed some efficacy for agitation • Antipsychotics • May reduce delirium associated agitation • May reduce dementia associated paranoia, delusions, and hallucinations • Evidence best for Aripiprazole (Abilify), Olanzepine (Zyprexia), and Risperidone (Risperdal) • Evidence for Quetiapine (Seroquel) is equivocal

21. Antipsychotics are Risky and have “Black Box Warning” • Antipsychotics increase the risk of dying within months of use by 1.6-1.7 times. • For atypical antipsychotics after 12 weeks of use in 100 demented patients with psychosis: • 9-25 will have some objective benefit • 1 will die • Most controlled studies don’t show efficacy beyond 3-4 months in patients with dementia. • Risperidal may have long term benefits (NEJM Nov 2012) • For typical first generation antipsychotics, the risk of death is probably higher (e.g. Haloperidol) • OIG has found that these meds are commonly used in nursing homes without an appropriate indication, at excessive dose, and longer then is necessary. • Other risks include: Cognitive decline accelerated, falls, CVA, Diabetes, High Lipids, Wt gain, Pneumonia, and reduced ADLs.

22. Antipsychotic Use Requires: • Documented informed consent by the attending physician or referring physician prior to administration, except in a serious emergency and then only for the shortest of times. • An NP is not allowed to do this. • Because use of more then 1 antipsychotic has very little evidence for added efficacy or safety, this practice should be rare, apart from geropsychiatrist order. • Clearly identified acceptable indication and measureable target behaviors • Delirium, Hallucinations, Delusions, Paranoid ideation that are distressful to the patient. • Documented evidence of efficacy over time and with efficacy achieved at the lowest possible dose.

23. Approved Indication of CDPH Survey Tool (July 2012) • Schizophrenia & Schizoaffective Disorder • Delusional Disorder • Mood Disorders (Bipolar, Depression with psychotic features) • Distressing Psychosis and Atypical Psychosis’ • Brief Psychotic Disorder • Medical Illness with Psychotic symptoms (Delirium, Steroid Psychosis, etc.) • Tourette’s Disorder or Huntington disease • Hiccups or nausea associated with Ca or Chemotherapy.

24. Surveyor Tool Expects: • Those receiving antipsychotics have a documented comprehensive evaluation and care plan indicating symptoms are not due to: • Medical Condition • Environmental stressors • Psychological stressors • Failure to identify and implement appropriate non-pharmacologic interventions • Dose of antipyschotic should not exceed recommended safe dose criteria of F329 unless clinical rationale justified and documented • Behavioral data made available to prescriber at least monthly along with adverse consequences data. • Reasons for dose escalation are clearly documented and medically necessary with informed consent.

25. Tool Expectations • Appropriate Indications • Chronic or Acute use • Dose Appropriate • Monitoring for Effectiveness • Monitoring for Adverse Consequences • GDR • Informed Consent • QAA

26. Preventing Problem Behaviors • Life long sleep & meal patterns • Exercise • Activities & social program • Life History • Birthplace and where has lived • Education, Career, & Awards • Social Connections and family • Affinity groups • Strengths & Weaknesses • Historic “Hot Buttons”

27. Managing Problem Behaviors in Dementia • ABCDEs of Neurobehavioral Care • Antecedents • Behaviors • Consequences • Documentation • Emotional – recognize the fears, anger and distress of patient, family, and staff. These emotions may impede critical thinking. • Systematic – adjust the overall system on the basis of what you find from these incidents

28. Antecedents • Goal is to view all behavior as an attempt at communicating something important • Our job is to decode the potential meaning of the behavior, its triggers, and factors that perpetuate it. • Consider: • What is the cause of the dementia? • What are the co-morbid illnesses? • Level of Stimulation (too much or too little?) • Hunger, Fatigue or Pain? • Lack of exercise or relevant activity • Related to ADL care? • Bad news? • Sick? • Triggering Staff Approaches • Cultural & gender issues • Tone of voice • Simple Direct Speech • Bathing without a battle • New caregiver or nurse?

29. Behavior (avoid “Agitation” term) • A detailed report by those who observed the behavior • Exact setting, time of day, who was involved, etc. • Was there any warning or were there any triggering factors? • What was tried to diffuse the situation (distraction, redirection)? • Potential Specific Distressful Behaviors • Crying • Yelling / Calling out • Biting, Hitting, or Grabbing (Rubber duck intervention) • Fecal Play • Rejection of Care • Hoarding • Wandering / Pacing / Irritability

30. Consequences of the Behavior • Focus on Perspective of: • Patient • Family • Staff • Facility • Specific Consequencess: • Attention • Isolation • Abuse - reportable • Injury • Medication response • Behavior reinforcement (Borderline Personalities)

31. Documentation • By patient’s individual licensed nurse(s) • By IDT which meets on a weekly and prn basis and optimally includes activities director and possibly a facility clinical psychologist. • Task(s): • Define Triggers and decode the behavior • Defuse counter-productive emotional responses • Develop “Behavior Map” with measureable, well defined Monitors • Initiate at least 2 environmental interventions before resorting to medication, unless and absolute emergency • Decide when an intervention is ineffective, partially effective, or no longer necessary. • If antipsychotics are used, monitor for common potential side effects and have system to consider d/c med if s/e too great. • Adjust care plan including GDRs of meds • Regularly communicate with front line workers and the attending physician what is known and the current care plan • Adjust facilities neurobehavioral policies and procedures on the basis of what has been learned from individual cases

32. Common Reasons for Difficult Behaviors • Response to a Trigger • Fear/Boredom/Anxiety • Psychosis / Delirium • Discomfort • Personality / enjoys behavior • Sleep deficit • Exercise deficiency • New Medication with adverse effect • New Medical Problem • Change in caregivers • Apathy for perceived ADL care needs

33. Change in Perspective about Behaviors “Old” language “New” language Agitation Rummaging/Shopping Wandering Egress or Elopement Refusing Personal Care Repetitive Crying Out Energetic/Assertive Seeking Exploring Showing initiative Cautious Assertive

34. Strategies to Manage Behaviors • Start with Consistent Assignment • Sooth the anxiety – determine the cause (noise, constipation, dehydration, pain, or hungry) • Leave if they are escalating • Let the patient make a call to a family or friend – short list for day or night • Switch TV or radio to a calming show

35. Communication Techniques • Talk slow • Get their attention • Listen • Calm Tone • Yes or no questions • Orient to task • Use touch • Watch you language • Don’t argue • Repeat, rephrase, and repair • Smile and laugh • Reinforce positive moments • Affirmations • Use humor • Tell simple stories about life or events

36. Environmental Care • Optimal level of exercise and activity • Individualized Activity program • Music / recordings / Art • Comfortable seating • Appropriate lighting and color contrasts • Personalized care plan • Ambient temperature • Background Noise or voices

37. Alternative Medicine Approaches • Chamomile tea or milk • Magnesium 250-500 mg • Familiar or comfort foods • Essential oils – lavender, rose, rosemary – tiny amounts • Favorite cologne, aftershave, perfume • Colored lights – pink, blue, outside sunlight • Pets • Small children • Acupressure / shiatsu/ swaddling • Exercise • Foot bath, shoulder, massage, hydro therapy • Neutral temperature bath • Music

38. AHCA Recommends “1st Steps”(American Health Care Association) • Identify and review everyone on antipsychotics • Identify new admits with antipsychotics started in the hospital with goal of d/c or rapid taper if no longer medically necessary • DC prns • GDR for everyone q 3 months • Implement a process to ensure that all antipsychotics Rx initiated during the evening/night shift or on weekends are critically evaluated ASAP by Lead Clinical or Behavioral IDT

39. AHCA Recommends Track Quarterly • % new admissions w/o psychiatric diagnoses admitted to facility on antipsychotic drugs that have those drugs discontinued w/in 1st 30, 60, & 90 days of their admission • % new admissions w/o psychiatric diagnoses admitted w/o antipsychotic usage who are started on one or more of these drugs w/in 1st 90 days. • % of residents in your facility > 90 days on antipsychotics but lack a psychiatric diagnosis. • Track weekly the number of days since the last new antipsychotic was prescribed in your facility

40. Resources • Improving Antipsychotic Appropriateness in Dementia patients • https://www.healthcare.uiowa.edu/igec/iaadapt/ • Dementia Problem Behaviors app for android tablets and smart phones • Hand in Hand Training Videos from CMS for CNA training • http://www.cms-handinhandtoolkit.info/ • American Health Care Association’s Initiative to safely reduce antipyschotics. • http://www.ahcancal.org/quality_improvement/qualityinitiative/Pages/Antipsychotics.aspx

41. Resources • Partnership to Improve Dementia Care in Nursing Homes in conjunction with Advancing Excellence • .http://www.nhqualitycampaign.org/star_index.aspx?controls=dementiaCare • CDPH L&C SNF Antipsychotic Use Survey Tool • http://www.caltcm.org/assets/documents/forms/cdph_lc_antipsychotic_survey_tool_07_11_12.pdf