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Treatment Modalities for the Management of Distressed Behaviors in Elderly Nursing Home Residents Jeanne Jackson-Siegal, MD James E. Lett II, MD, CMD January 9, 2004. Definitions. “Behavior” refers to an individual’s observable actions.

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  1. Treatment Modalities for the Management of Distressed Behaviors in Elderly Nursing Home ResidentsJeanne Jackson-Siegal, MDJames E. Lett II, MD, CMDJanuary 9, 2004

  2. Definitions • “Behavior” refers to an individual’s observable actions. • “Cognition” refers to any personal activities related to organizing memory, sensation, and thinking • “Mental status” refers to an individual’s overall level of alertness, activation, and responsiveness to the outside world. AMDA Dementia CPG 1998

  3. Incidence of Behaviors • Apathy (72%) • Agitation (60%) • Anxiety (45%) • Irritability (42%) • Motor restlessness (38%) • Disinhibition (36%) • Sleep disturbance (24%) • Depression (23%) • Delusions (22%) • Hallucinations (10%)

  4. Distressed Behaviors in Nursing Homes • Increases stress between patients and caregivers1 • Create intensive and costly levels of treatment1 • Increase morbidity and mortality 1 • Lead to public health problems that contribute to the enormous cost of treating dementia1 • Increase risk of overmedication and restraints • 1. Finkel SI et al. Int Psychogeriatr. 1996;8:497-500

  5. “Agitation” • Excessive motor or verbal activity that is 1 • One of the following • Disruptive OR • Unsafe OR • Distressing to the patient • Interferes with care and • Is not because of need • Generally, is a poor descriptor of behavior • Appears similar despite great variety of causes • Need to make diagnosis, not focus only on symptoms • When severe, may be the target for urgent intervention 1. Cohen-Mansfield et al, 1996; Tariot et al, 1994 Cohen- Mansfield Agitation Inventory. www.medafile.com/zyweb/CMAI.htm

  6. Agitation and Aggression in Dementia PhysicalVerbal Hitting Threats Pacing Accusations Kicking Name-calling Biting Obscenities Pushing Complaining Spitting Attention-seeking Scratching Screaming • Cohen-Mansfield et al, 1996; Tariot et al, 1994

  7. Behavior Diagnosis: Pitfalls • Many etiologies can present with the same behaviors (Example of fever) • Co-existence of multiple risk factors present in any one resident: disease, medications, changed environment, etc. • The key is to have a process to evaluate the resident for the behavior

  8. General Approach toBehaviors • Clearly characterize target symptoms • Standard medical evaluation to identify possible medical disorder • Differential diagnosis of behavior cause • The A,B,C’s of Behavior Intervention • Antecedent, Behavior, Consequences • Document, Document, Document • Non-pharmacologic intervention

  9. Good Target Symptoms • Anxiety • Insomnia • Delusions (stressful) • Hallucinations (stressful) • Dysphoria/Depression • Compulsive behaviors • Agitation/Aggressiveness • Motor restlessness • Pain

  10. Poor Target Symptoms • Exit-seeking • Pacing & Wandering • Perseverant vocalizations • Hoarding/Stealing • Inappropriate sexual touching • Non-stressful delusions • Disrobing

  11. Medical Evaluation • Medical/Psychiatric History • Medication: excess, withdrawal, ADR • Physical evaluation: urinary retention, fecal impaction (constipation), pain, dental problems • Mental Status Exam • Lab studies/oximetry • Imaging Studies

  12. Medical Illness • Illnesses: GERD, angina, OA, etc. • Medication side effects • Chronic pain • Constipation • Hearing or vision impairment • Sleep deprivation • Dental problems

  13. Differential for Behavior Causes • Dementing disorders • Frontal Lobe impairment • Delirium • Medications • Toxic personality syndrome • Pain

  14. Differential for Behaviors (cont.) • Primary psychiatric illness - Affective disorder (Depression) - Anxiety disorder - Psychotic disorder - Personality disorder • Environment/Stressors

  15. Definition: Dementia A syndrome (a collection of signs & symptoms) of progressive decline in multiple areas of cognitive function which eventually produces significant deficits in self-care and social and occupational performance. AMDA Dementia CPG 1998

  16. Dementia • Incidence of 1-2% at 65-70 years of age, increasing to >30% after 85 • Up to 80% of NF residents have some degree of dementia • The resultant decline in functional capacity is the chief cause of NF admission

  17. Dementia Categories • Alzheimer’s disease (65%) • Lewy Body dementia (7%) • AD w/vascular disease (10%) • AD w/Lewy bodies (5%) • Vascular dementia (5%) • Other: Infectious, EtOH, etc. (8%)

  18. Definition: Dementia of the Alzheimer Type (DAT) A degenerative neurologic disease that results in impaired memory, thinking and behavior. It is characterized by a gradual onset of progressive symptoms that include memory loss, personality changes, and decline in ability to think and function. DAT is by far the most common from of dementia in the U.S., so it is generally used as the prototypical dementia in most guide to diagnosis and treatment. “All DAT is dementia, but not all dementia is DAT”

  19. DAT • 60-80% of dementia that occurs in those >65 years old • Slow, insidious decline in multiple cognitive skills • Relatively well preserved motor function early in disease course • CT/MRI normal, or atrophy, perhaps with mild white matter changes • No biological markers - diagnosed at autopsy • Etiology: genetics (APO e4) + ?

  20. Dementia with Lewy Bodies(DLB) • DLB more recently accounts for 15 - 20% of all dementia • Hallmark feature: widespread Lewy bodies throughout the neocortex with Lewy bodies and cell loss in the subcortical nucleii with distinctive pattern of neuritic degeneration on autopsy • More males than females • Age of onset: 50 – 83 • Insidious onset progressing to profound dementia McKeith. I.G. Dementia with Lewy Bodies. British J of Psychiatry 2002, 180,144-147 Shiozaki et al:J Neurol Neurosurg Psych: V67:1999

  21. DLB Core Features • Required: Cognitive Decline with decreased social or occupational functioning • A diagnosis of Probable DLB requires 2 of the following (Possible DLB requires only one of the following): • Fluctuating cognition with pronounced variation in attention and alertness 1 • Recurrent visual hallucinations that are typically well formed and detailed  • Spontaneous motor features of parkinsonism • Quantification and Characterization of Fluctuating Cognition in Dementia with Lewy Bodies and Alzheimer's Disease M.P. Walker, G.A. Ayre, E.K. Perry, K. Wesnes, I.G. McKeith, M. Tovee, J.A. Edwardson, C.G. Ballard Dementia and Geriatric Cognitive Disorders 2000;11:327-335 (DOI: 10.1159/000017262 • McKeith. I.G. Dementia with Lewy Bodies. British J of Psychiatry 2002, 180,144-147

  22. Dementia with Lewy Bodies • Treatment Issues • Up to 80% of DLB patients have hypersensitivity to neuroleptics. Prescribe antipsychotics only when absolutely necessary and under strict monitoring • Provisional evidence suggests that patients may respond more preferentially to AChI therapy • Concomitant depression • 35% of DLB vs. 16% of AD McKeith. I.G. Dementia with Lewy Bodies. British J of Psychiatry 2002, 180,144-147

  23. Frontal Lobe Impairment: Sx • Mood lability or inappropriate affect • Poor impulse control • Verbally rude, caustic, bigoted, etc. • Episodically physically aggressive • Perseverative • Restless/grabbing/reacts strongly to stimuli • Difficult to redirect • Sexually inappropriate/aggressive

  24. Frontal Lobe Impairment • Not psychotic behavior, but poor impulse control • Seen in multiple types of disease processes - SDAT - Vascular dementia - Multiple sclerosis - EtOH disease

  25. Frontal Lobe Impairment: Non-Pharmacologic Management • Maintain professional distance • Exaggerated manners, professional attire • Emphasize courtesy, avoid overly friendly • Communicate concretely, no open ended comments • Define the activity, give few and clear choices • Shape the behavior, acknowledge improvements • Medication when needed: • Safety concerns • Not responsive to nonpharmacologic interventions

  26. Definition: Delirium A state of acute confusion, inattention, and altered level of consciousness (LOC), usually abrupt in onset (over several hours to several days).

  27. Delirium: Symptoms • Fluctuations in alertness & mental functioning manifested by inattention • Anxiety • Hallucinations • Disorientation • Tremors • Delusions • Incoherence

  28. Common Delirium Triggers • Acute illness • Heart or lung disease • Infections • Poor nutrition • Endocrine disorders • MEDICATIONS • Alcohol use

  29. Delirium • A syndrome, not a final diagnosis • Fluctuating level of alertness • Difficult to assess with dementia • Must identify etiology to treat appropriately • If psychotic, time-limit use of antipsychotics

  30. Delirium • 10% of all hospitalized patients • 22-38% of hospitalized patients >65 • 60% of hip fracture cases • Up to 75% of hospitalized patients from SNF’s • Associated with a 35% increase in hospital mortality • Physicians correctly diagnose delirium in less than 20% of cases

  31. Distinguishing Delirium fromDementia • Delirium • Acute onset, usually occurring over days or less • Global disorder of attention & cognition • Level Of Consciousness: Hypoactive, hyper-active or both • Generally lasts days to weeks • Usually reversible • Prominent physiologic changes • Dementia • Gradual onset that cannot be dated • Attention fairly normal initially • Level Of Consciousness: normal until final stages • Chronically progressive over months or years • Irreversible • Minimal physiologic changes

  32. Depression: Diagnosis • Depressed mood for at least 2 weeks Plus • At least four of the following: - Insomnia or hypersomnia - Significant weight loss or malnutrition - Fatigue or loss of energy - Decreased ability to concentrate - Psychomotor agitation or retardation - Excessive guilt or feelings of worthlessness - Thoughts of death, suicidal ideation, or a planned or attempted suicidal act - Loss of interest or pleasure in nearly all activities

  33. Depression: Diagnosis • Geriatric Depression Scale (GDS) • Cornell Scale for Depression in Dementia • Center for Epidemiologic Studies of Depression (especially for African-American and Native Americans) • No direct biologic marker

  34. Depression: Elder vs Younger • Elders exhibit different symptoms • Multiple somatic complaints • Fatigue • Insomnia • Functional loss • Irritability • Younger: tearfulness, sadness and suicidal indications

  35. Depression • The most common geriatric psychological disorder • Up to 1/3 of NF residents • Estimated that PCP’s fail to diagnose depression up to half the time & fail to provide adequate treatment for half of those so diagnosed (Kroenke, AIM. 1997) • Closely associated with functional decline & triggering quality indicators

  36. Depression • Often co-morbid with dementia • Common post-stroke – up to 30% • Beware “ageism” as a barrier to diagnosis/tx • Look for underlying medical/medication causes

  37. Depression • May be mimicked/caused by ADR - Carbidopa/levodopa - Beta-blockers - Clonidine - Benzodiazepines - Barbituates - Anticonvulsants - H2 blockers

  38. Depression Clear, recent onset Shorter duration Often previous psychiatric history Memory complaints Fluctuating performance Recent and remote memory equally bad Depressed mood precedes memory complaints Dementia Gradual onset Progression over years May not have psychiatric history Minimizes disabilities Tries hard to perform Memory loss greater for recent events Memory loss precedes depression Depression… or Dementia… (or Both?)

  39. Anxiety: Definition • Awareness of the physiologic reactions of the “fight or flight” responses • May be triggered by internal or external factors • May be triggered by issues considered “irrelevant” to others but are real to the sufferer • Anxiety symptoms are far more common than anxiety disorder

  40. Anxiety Disorders • Think Differential Diagnosis: • Psychosis/Depression/Delirium/Pain/GAD • Modify environmental triggers if possible • Medications: - Caffeine - Bronchodilators - Pseudoephedrine • Medical illness - Hyperthyroidism - Cardiac arrhythmias (Atrial fibrillation, PVC’s, etc)

  41. Psychosis • Definition • Impaired connection to reality • Auditory or visual hallucinations or delusions • Psychosis is a symptom, not a final diagnosis • Differential Diagnosis includes all types of Dementia, Delirium, Drugs (both intoxication and withdrawal), Schizophrenia, Bipolar Mania and Psychotic Depression • The diagnosis indicates duration of treatment

  42. Personality Disorders • Easy to over-diagnose when elder patients decompensate due to dementia, depression, pain, etc. • Consider empiric treatment with antidepressant • Look for LIFELONG history of the personality disorder

  43. Toxic Personality Syndrome • Not a disease, but a personality type • This personality type is often hypercritical, angry, and accusatory in spite of every effort to give them comfort and optimal care. (Take care not to judge the care in a facility based solely on the behaviors or statements of this personality) • Does not require (or respond to) any treatment

  44. The ABC’s of Behavior Intervention • “A” = The Antecedent Events • “B” = The Behavioral Event • “C” = The Consequences Slattery et al, Annals of Long Term Care 1999; 7[10]:385-391

  45. The Antecedent Event(Behavior events are rarely unprovoked) A • Triggers that occurred before or even caused the behavioral event. • Modifying triggers is best approach for cognitively impaired, because memory loss interferes with learning consequences.

  46. Five Categories of Triggers • Physical Triggers::pain, impaired sight orhearing, fecal impaction/constipation, needs changing or repositioning, etc. • Emotional Triggers:worried, afraid, distressed, etc. • Environmental Triggers:too much or too littlelighting, noise, temperature, activity levels, etc. • Task Triggers:difficulty when challenged by a specific task like bathing, dressing or eating, etc. • Communication Triggers:difficulty understanding others or expressing self, etc.

  47. Environment/Stressors Areas to ConsiderExamples

  48. B The Behavioral Event Defined as any behavioral episode that is disruptive or adverse, or that jeopardizes the safety of the resident, other persons, or objects in the environment.

  49. Goals of Treating Behaviors in the NH • Reduce the risk of injury • Reduce patient distress • Minimize adverse drug events • Maintain resident in most desirable living setting • Define for WHOM it is a problem

  50. Impact of Behavioral Symptoms • 25% required no intervention. • 0.8% resulted in injury to others. • 0.9% resulted in physical damage to the environment. • An average of 24 minutes of staff time was required per intervention. Souder E, Heithoff K, O’Sullivan PS , et al, Aging and Mental Health, 1999; 3:54-68

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