Dementia/ Delirium an Overview

1. Dementia/ Delirium an Overview October 2011

2. Introduction to Harvest Healthcare • Experience. Education. Excellence. • Harvest is a leading full-service behavioral health provider, specializing in the delivery of progressive and innovative consultative behavioral health services for patients and residents residing in skilled nursing, rehabilitation, and assisted living facilities. Our multidisciplinary team of highly skilled professionals work together to offer a broad menu of services including but not limited to 24-hour prescriber on-call services and hospitalization support, comprehensive cognitive assessments, documentation review, OBRA compliance support and customized educational programs designed for the individual needs of your facility.

3. Objectives • This presentation was developed for the continuing education of health care providers • At the conclusion of this presentation the audience will have a basic understanding of dementia and delirium, symptoms and management. • Mental health care professionals should be consulted for the treatment of patients with dementia or delirium.

4. Dementia (taken from Latin, originally meaning "madness", from de- "without" + ment, the root of mens "mind") • Is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging. • It may be static, the result of a unique global brain injury, or progressive, resulting in long-term decline due to damage or disease in the body. • Although dementia is far more common in the geriatric population, it may occur in any stage of adulthood.

5. Dementia • Is a non-specific illness syndrome (set of signs and symptoms) in which affected areas of cognition may be memory, attention, language, and problem solving. • It is normally required to be present for at least 6 months to be diagnosed; cognitive dysfunction that has been seen only over shorter times, in particular less than weeks, must be termed delirium. • In all types of general cognitive dysfunction, higher mental functions are affected first in the process.

6. Diagnosis of Dementia • The earlier the better as there are medications that slow the process of cognitive loss. • Diagnosis is made through the review of medical history, review of medical record, medical evaluation and cognitive testing with multiple measures. • MMSE is no longer the standard for detection as it is unreliable.

7. Orientation concerns • Especially in the later stages of the condition, affected persons may be: • disoriented in time (not knowing what day of the week, day of the month, or even what year it is), • in place (not knowing where they are), • and in person (not knowing who they are or others around them).

8. Behavioral and psychological symptoms of dementia (BPSD) • Dementia is a condition in which individuals progressively lose cognitive function and, as a result, often develop difficult behaviors that cause stress for both patients and their caregivers. These behaviors, are collectively known as behavioral and psychological symptoms of dementia (BPSD). • BPSD include screaming, wandering, resisting care, hitting, and psychological symptoms such as depression, psychosis, and sexual disinhibition.

9. BPSD • BPSD is prevalent in nursing homes where 67-78 percent of patients have dementia and, of them, 76 percent exhibit BPSD. • In fact, it is common for patients to be institutionalized because of BPSD, so clinicians must become proficient in assessing and managing these symptoms.

10. Medications • Acetylcholinesterase inhibitors: Tacrine (Cognex), donepezil (Aricept), galantamine (Razadyne), and rivastigmine (Exelon) are approved by the United States Food and Drug Administration (FDA) for treatment of dementia induced by Alzheimer's disease. They may be useful for other similar diseases causing dementia such as Parkinson's or vascular dementia. • N-methyl-D-aspartate Blockers. Memantine (Namenda) is a drug representative of this class. It can be used in combination with acetylcholinesterase inhibitors.

11. Off-Label Medications • Antidepressant drugs: Depression is frequently associated with dementia and generally worsens the degree of cognitive and behavioral impairment. Antidepressants effectively treat the cognitive and behavioral symptoms of depression in patients with Alzheimer's disease, but evidence for their use in other forms of dementia is weak.

12. Anxiolytic drugs: Many patients with dementia experience anxiety symptoms. • Although benzodiazepines like diazepam (Valium) have been used for treating anxiety in other situations, they are often avoided because they may increase agitation in persons with dementia and are likely to worsen cognitive problems or are too sedating. Buspirone (Buspar) is often initially tried for mild-to-moderate anxiety. There is little evidence for the effectiveness of benzodiazepines in dementia, whereas there is evidence for the effectiveness of antipsychotics (at low doses).

13. Antipsychotic drugs: Both typical antipsychotics (such as Haloperidol) and atypical antipsychotics such as (risperidone) increase the risk of death in dementia-associated psychosis. • This means that any use of antipsychotic medication for dementia-associated psychosis is off-label and should only be considered after discussing the risks and benefits of treatment with these drugs, and after other treatment modalities have failed. • In the UK around 144,000 dementia sufferers are unnecessarily prescribed antipsychotic drugs, around 2000 patients die as a result of taking the drugs each year.

14. Agitation • One of the greatest impacts on quality of life for patients with dementia is the presence of agitation behavior in the middle stages of the disease process. • More than half of patients with dementia exhibit some type of "agitation" behavior over the course of a year, in addition to depression or psychosis. • Experts suggest that the best way to manage agitation is through environmental and atmosphere changes rather than medications. Medications are a last resort.

15. Agitation • Behavior management experts define "agitation behavior" as "inappropriate verbal or motor activity.” • Non-aggressive Verbal Behavior: Incoherent babbling, screaming or repetitive questions is frustrating to the caregiver and family members, especially as a sign that the person with dementia is "losing it."

16. Agitation • Non-aggressive Physical Behavior: Pacing, wandering, repetitive body motions, hoarding or shadowing represent ways for the person with dementia to communicate boredom, fear, confusion, search for safety or inability to verbalize a request for help or a feeling of pain.

17. Agitation • Aggressive Verbal Behavior: Cursing and abusive language can be shocking when the person with dementia was previously upright and proper. • Aggressive Physical Behavior: Clearly, physically aggressive behavior such as hitting, scratching or kicking can be dangerous or life-threatening to the caregiver and care recipient.

18. Agitation • Men are twice as likely to exhibit aggressive behavior, especially in the middle to late stages of the disease, or if they have major depression. • The degradation of different parts of the brain causes aberrant behavior. Other conditions, such as pain, can also lead to it.

19. Agitation • Some caregivers cope by ignoring agitation behaviors. This is one of the worst things to do since it ultimately makes things worse for both the caregiver and the person with dementia. • The stress placed on the caregiver at home by these agitation behaviors often forces premature placement in a nursing facility, health problems for the caregiver and lessened quality of life for both.

20. Understanding Agitation Behavior • Experts say that all types of behavior are forms of communication. The patient is trying to tell you something even though the disease has robbed them of other ways (i.e., talking) of telling you. • They may be expressing depression or pain and the person does not know how to express it in words. • Some experts believe that agitation behavior is "the inability the deal with stress."

21. Sundowning • Refers to a state of confusion at the end of the day and into the night. The cause isn't known. But factors that may aggravate late-day confusion include: • * Fatigue • * Low lighting • * Increased shadows

22. Some tips for reducing sundowning: • Plan for activities and exposure to light during the day to encourage nighttime sleepiness. • Limit caffeine and sugar to morning hours. • Serve dinner early and offer a light snack before bedtime. • Keep a night light on to reduce agitation that occurs when surroundings are dark or unfamiliar. • In a strange or unfamiliar setting such as a hospital, bring familiar items such as photographs or a radio from home.

23. Sundowning • When sundowning occurs in a care facility, it may be related to the flurry of activity during staff shift changes. Staff arriving and leaving may cue some people with dementia to want to go home or to check on their children — or other behaviors that were appropriate in the late afternoon in their past. It may help to occupy their time during that period.

24. Is Behavior Event-Related? • Organization by the caregiver will help a great deal in beginning to combat these behaviors: • Modify the environment to reduce known stressors (e.g., shadowy lighting, mirrors, loud noises); • Note patterns of behavior and subtle (and not so subtle) clues that tension and anxiety are increasing (i.e., pacing, incoherent vocalization); • Dysfunctional behavior often increases at the end of the day as stress builds as the person becomes tired.

25. Certain stressors can trigger agitation behaviors. • As the caregiver, you have to use all of your senses to understand the environment and the behaviors. • Fatigue • Change of Environment, Routine or Caregiver • Affective Responses to Perception of Loss • Responses to Overwhelming or Misleading Stimuli. • Excessive Demand • Delirium

26. Fatigue: • If confusion and agitation increase late in the day, suspect that fatigue may be a factor. • Encourage rest or have quiet periods for up to two times a day.

27. Change of Environment, Routine or Caregiver: • Sameness and routine help to minimize stress in the patient with Alzheimer’s Disease.

28. Affective Responses to Perception of Loss: • This means that persons with dementia still have memories and perceptions of activities that they used to enjoy. They miss being able to drive a car, cook or care for children. • Safe activities should be substituted to deal with grief and loss. • Depression should be treated.

29. Responses to Overwhelming or Misleading Stimuli: • Excessive, noise, commotion or people can trigger agitation behavior. Researchers have found that more than 23 people in a group (e.g., dining room or holiday party) can cause undue stress in a person with dementia. The television, mirror image, dolls or figurines may represent extra people in the environment. • Before medicating with anti-psychotic drugs, the health care team should consider these environmental factors.

30. Excessive Demand: • Caregivers and families must accept that the individual has lost (and continues to lose) mental functions. No amount of quizzing, reality orientation, "brain exercises," retraining or pushing them to try harder will improve their mental capabilities. Indeed, it can cause stress and a sense of futility. • The best a caregiver can do is provide positive support and understanding, encourage independence and assist the individual when they are unable to perform a task.

31. Delirium: • Illnesses such as infections, pain, constipation, trauma or drug interactions may cause dementia-like symptoms. • Preventive measures such as good oral care, nutrition, simplified medication regimens and adequate fluid intake play an important role in well-being.

32. Some Specific "Problem" Behaviors • Wandering: Caregivers should understand that individuals wanders for a reason. The exact reason may be hard to determine. Nevertheless, locking him/her in a room or restraining in a chair is inappropriate. Implement activities and adjust the environment to relieve agitation if possible. Minimize all safety risks.

33. Specific problem behaviors (BPSD) • Screaming: Consider medical causes for screaming that the person cannot verbalize such as pain, depression or hearing loss. • Gathering/Shopping: An individual with dementia who rearranges objects around the residence, hoards or appropriates other’s possessions can be a disruptive nuisance. Provide the individual with a "safe" place where s/he can store items (and you can retrieve them). You may provide the individual with a canvas "shopping bag."

34. BPSD • Pacing: An individual with dementia who paces incessantly can burn off too many calories. High-calorie finger foods may help the problem. You can try to reduce pacing by providing inviting places for the individual to sit and relax.

35. BPSD • Sexual Aggression: Try to determine whether the sexual gesture is indeed sexual in nature and not an expression of the need to go to the bathroom. • Refer to psychiatry to determine treatment options. Medications may not be useful in treating sexual symptoms. • Symptoms may indicate an atypical dementia such as Lewy Body Dementia or Pick’s Disease. These may require different types of psychiatric and behavioral interventions.

36. BPSD • Hallucinations/Illusions: After you have removed confusing stimuli (e.g., shadowy lighting, televisions, dolls), refer to psychiatry to assess for signs of an atypical dementia such as Lewy Body Dementia or Pick’s Disease. • These may require different types of psychiatric and behavioral interventions.

37. What can be done: • A simplified approach to managing agitation behaviors can be summed up as: "Modify the environment, modify the behavior and medicate as a last resort." • Recent research is starting to show that some relatively basic interventions can be used to ease agitation behaviors.

38. Music Therapy: • Some studies show that playing calming music or a favorite type of music can lead to a decrease in agitation. When used during meals, soothing music can increase food consumption; when used during bathing, relaxing or favorite music can make it easier to give a bath. Experiment with relaxing, soothing, classical, religious or period (e.g., 1920’s or Big Band) music.

39. Exercise and Movement: • Light exercise, such as chair exercises as directed by a physical therapist or activities coordinator each day can help to maintain function of limbs and decrease problem behaviors. Walking after dinner several times each week may help reduce aggression. • When small groups of 3-4 people go on walks, it may lead to beneficial social interactions such as singing and talking.

40. Activities: • Safe activities are a good way to get back in touch with their earlier life and find meaning throughout the disease process. • Activities can reflect either things the person enjoyed in the past or can reflect what they did for work.

41. Socialization: • Human interaction is essential for people with dementia. As mentioned, large groups and most strangers are definitely out. But you can introduce new individuals as a "new friend" or companion to spend time with the person who has dementia. • They can reminisce, converse, walk or perform activities together.

42. What can you do? • Help to identify dementia early by documenting memory loss and confusion. • Request a cognitive assessment from the Cognitive Assessment Program at Harvest. • Practice patience. • Be a detective and work toward finding the cause of agitation in an effort to resolve it.

43. Thought Provoking Questions: • Can you describe sundowning and name some potential causes? • Can you identify some potential causes of agitation? • Can you describe the difference between delirium and dementia?