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Nonpharmacologic Management of BPSD*

Nonpharmacologic Management of BPSD*. *Behavioral and Psychological Symptoms of Dementia. Christine Chang, MD Brookdale Dept of Geriatrics and Palliative Medicine October 2015. Objectives. Participants will be able to: Define BPSD Evaluate BPSD

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Nonpharmacologic Management of BPSD*

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  1. NonpharmacologicManagement of BPSD* *Behavioral and Psychological Symptoms of Dementia Christine Chang, MD Brookdale Dept of Geriatrics and Palliative Medicine October 2015

  2. Objectives Participants will be able to: • Define BPSD • Evaluate BPSD • Discuss the Guidelines for Management of BPSD Nonpharmacologic Interventions

  3. What Is BPSD?

  4. What Is BPSD? Behavioral and Psychological Symptoms of Dementia

  5. What Is BPSD? Non-cognitivemanifestations of dementia Behavioral Symptoms Psychological Symptoms

  6. What Is BPSD? Behavioral Symptoms “Agitation” Related to resistiveness to care Physical vs Verbal Aggressive vs Nonaggressive

  7. What Is BPSD? Psychological Symptoms Mood Symptoms Psychotic Symptoms Sleep Disturbances

  8. Why Is BPSD Important? • Lifetime risk is nearly 100% • Associated with increased morbidity and nursing home placement • Potentially treatable

  9. Case 1: Part 1

  10. 1. How would you approach this case?

  11. Evaluation of BPSD • Obtaina History- clear description of the behavior from the patient & others • Temporal onset, course • Associated circumstances • Relationship to key environmental factors • In context of the patient’s medical, family and social history

  12. Evaluation of BPSD • Careful Physical & Neurologic Exam Assess Mental Status Pay attention to: • Appearance and Behavior • Speech • Mood • Thoughts and Perceptions • Cognitive Function • Attention

  13. Evaluation of BPSD • Lab Studies • CBC, metabolic panel and drug levels in all cases of new onset BPSD • Brain imaging, EKG, CXR, and urinalysis based on the history and exam

  14. Evaluation of BPSD R/O Delirium • Acute Conditions such as acute infection like pneumonia and UTI, angina, electrolyte imbalance, endocrine abnormality, pain and constipation • Medication Toxicity or adverse effects of medications due to new or existing medications

  15. Evaluation of BPSD R/O Environmental Causes 1. Make sure basic physical needs are met 2. Environmental Precipitant • Disruptions in routine • Over Stimulation • Under Stimulation

  16. Evaluation of BPSD After medical, environmental, and care giving causes are excluded, it can be concluded that the primary cause is progression of the dementia

  17. Case 1: Part 1 continued

  18. 2. What is the most appropriate treatment?

  19. Case 1: Part 2

  20. 3. What is the most appropriate approach?

  21. Guidelines for Management of BPSD 2007 American Psychiatric Association practice guideline for the treatment of pts with Alzheimer's disease and other dementias. Second edition1 2012 Nonpharmacologic mgt of BPSD by Gitlin LN, Kales HC, Lyketsos CG2 2013 Management of the BPSD (the National Resource Center for Academic Detailing) with support AHRQ3 1 Am J Psychiatry. 2007; 164 (Suppl 12): 5-56 2 JAMA. 2012 Nov 21; 308 (19): 2020-9 3NaRCAD with support from a grant from the Agency for Healthcare Research and Quality December 28, 2013

  22. Guidelines for Management of BPSD Nonpharmacologic Interventions First • 40% of BPSD symptoms spontaneously resolve; “they come and go” • Placebo response can be quite substantial • No FDA approved medications for psychosis in AD

  23. Guidelines for Management of BPSD 4 Effective Nonpharmacologic Interventions • CG Interventions • Unmet Needs Interventions • Behavioral Interventions • Psychosocial Interventions Worldviews evidence based nursing. 2015;12 (2):108-15 JAMA. 2012; 308 (19):2020-2029 Ont Health Technol Assess Ser. 2008 Arch Intern Med. 2006;166:2182-2188 Am J Psychiatry 2005; 162:1996–2021

  24. Guidelines for Management of BPSD 4 Effective Nonpharmacologic Interventions • CG Interventions CG education about • Disease, prognosis, realistic expectations • Techniques to minimize development of BPSD • Maintain a structured daily routine • Environmental modifications • Communication Techniques • Encourage independence in ADLs • Patient –Centered Care JAGS 2010; 58:1465–1474: ACT-Advancing Caregiver Training JAMA.2010; 304 (9):983-991: COPE: Care of Persons with Dementia in their Environments Gerontologist 2003; 43:908–15: Savvy Caregiver, STAR-C, REACH II

  25. Nonpharmacologic Strategies:To Minimize Development of BPSD Person-Centered Showers and Towel Baths • Create environment based on patient comfort and preference • Cover with towels to maintain warmth and modesty • Use warm water or no-rinse soap • Use gentle massage to cleanse • Modify shower spray www.bathingwithoutabattle.unc.edu

  26. Guidelines for Management of BPSD 4 Effective Nonpharmacologic Interventions • Unmet Needs Interventions Cohen-Mansfield J et al RCT of UNMET NEEDS protocol-TREA (TX Routes for Exploring Agitation). Clin Psychiatry. 2012

  27. Guidelines for Management of BPSD 4 Effective Nonpharmacologic Interventions • Behavioral Interventions • 3 R’s(Repeat, Reassure, Redirect) • Positive reinforcement for desirable behaviors by praising, encouraging or reassuring • Distraction technique-redirection • Be a Sleuth: Do the “ABC’s”-Avoid triggers

  28. Guidelines for Management of BPSD 4 Effective Nonpharmacologic Interventions • Psychosocial Interventions • Preferred Calming Music • Aromatherapy-lavender • Thermal bath • Bright Light and Pet Therapy • Snoezelen-Multisensory: light, sound, aroma, massage • Exercise and Structured activity therapies ***PHYSICAL RESTRAINTS SHOULD BE AVOIDED Aging & Mental Health. 2009, 512–520

  29. Evidence for Guidelines Ont Health Technol Assess Ser. 2008

  30. Evidence for Guidelines Ont Health Technol Assess Ser. 2008

  31. Evidence for Guidelines • Effectiveness of 4 interventions: nonpharmacologic behavior management intervention, haloperidol (1.8mg), trazodone (200mg), and placebo1. • Training programs for family CG (Savvy Caregiver, STAR-C, REACH II)2,3 • ACT-Advancing Caregiver Training4 and Prospective 2-group randomized trial COPE: Care of Persons with Dementia in their Environments (community-living dyads) 5 Found no significant differences in outcomes, but fewer adverse events (e.g., bradykinesia and parkinsonian gait) 1 Neurology. 2000 Nov 14;55(9):1271-8 2 Gerontologist 2003; 43:908–15 3 Ageing Res Rev. 2012 Jul 20 4 JAGS 58:1465–1474, 2010 5 JAMA. 2010; 304(9):983-991

  32. Evidence for Guidelines ACT-Advancing Caregiver Training • DESIGN: Two-group randomized trial • PARTICIPANTS: 272 CGs and people with dementia at home • INTERVENTION (ACT-Advancing Caregiver Training): • <11 home and telephone contacts over 16 wks by professionals • Identified potential triggers of BPSD • Communication factors • Environmental factors • Undiagnosed medical conditions (by blood and urine samples) • Trained caregivers in strategies to modify triggers and reduce their upset • 3 telephone contacts reinforced strategy use btw 16 and 24 weeks JAGS 58: 1465–1474, 2010

  33. Evidence for Guidelines ACT-Advancing Caregiver Training • RESULTS at 16/24 wks : • 67.5% (cf with 45.8% (P=0.002) of intervention CGs reported improvement in targeted problem behavior • Reduced upset with problem behavior (P=0.03) • Enhanced confidence managing (P=0.01) the behavior • Less upset with all problem behaviors (P=0.001) • Less negative communication (P=0.02), • Less burden (P=0.05) + Better well-being (P=0.001) c/w CGs had depressive sxs (53.0% cf 67.8%, P=.02). • Intervention CGs perceived more study benefits (P=0.05), including ability to keep family members home, than controls. JAGS 58: 1465–1474, 2010

  34. Evidence for Guidelines Care of Persons with Dementia in their Environments Design • Prospective 2-group randomized trial COPE: Care of Persons with Dementia in their Environments (community-living dyads) recruited from March 2006 -June 2008 in Pennsylvania. Interventions • Up to 12 home or telephone contacts over 4 months by health professionals • Assessed patient capabilities and deficits • Trained families in home safety, simplifying tasks, and stress reduction • Obtained blood and urine samples • Control group CGs- 3 telephone calls and educational materials JAMA. 2010; 304(9):983-991

  35. Evidence for Guidelines Care of Persons with Dementia in their Environments Results At 4 months, COPE patients had • Less functional dependence (adjusted mean difference, 0.24; 95% CI, 0.03-0.44; P=.02; Cohen d=0.21) • Less dependence in instrumental activities of daily living (adjusted mean difference,0.32; 95% CI, 0.09-0.55; P=.007; Cohen d=0.43), measured by a 15-item scale modeled after the Functional Independence Measure; • Improved engagement (adjusted mean difference, 0.12; 95% CI, 0.07-0.22; P=.03; Cohen d=0.26), measured by a 5-item scale. • Improved in their wellbeing (adjusted mean difference in Perceived Change Index, 0.22; 95% CI, 0.08-0.36; P=.002; Cohen d=0.30) and confidence using activities (adjusted mean difference, 0.81; 95% CI, 0.30-1.32; P=.002; Cohen d=0.54), measured by a 5-item scale. By 4 months, 64 COPE dyads (62.7%) vs 48 control group dyads (44.9%) eliminated 1 or more caregiver-identified problems (21=6.72, P=.01). *No group differences were observed at 9 months for patients, though COPE caregivers perceived greater benefits. JAMA. 2010; 304(9):983-991

  36. Resources for Providers & Family • Alz.org • www.agingbraincare.org/ABC Care Protocols by Dr. Callahan at IU • Gitlin LN, Kales HC, Lyketsos CG. NPI mgt of BPSD. JAMA. 2012 • Books • International Psychogeriatric Assoc • Peter V. Rabins, Constantine G. Lyketsos and Cynthia D. Steele

  37. Resources for Providers & Family

  38. Resources for Providers & Family

  39. Resources for Providers & Family

  40. Resources for Providers & Family

  41. Resources for Providers & Family

  42. Resources for Providers & Family

  43. Resources for Providers & Family

  44. Case 2

  45. 4. What is your first intervention? • Prescribe zolpidem 5 mg • Recommend melatonin 1.5 mg • Prescribe triazolam 0.125 mg • Prescribe trazodone 25 mg • Prescribe mirtazapine 7.5 mg • Counsel about nonpharmacologic interventions to promote sleep

  46. 4. What is your first intervention? • Prescribe zolpidem 5 mg • Recommend melatonin 1.5 mg • Prescribe triazolam 0.125 mg • Prescribe trazodone 25 mg • Prescribe mirtazapine 7.5 mg • Counsel about nonpharmacologic interventions to promote sleep

  47. Matching Target Symptoms Sleep-wake Cycle Disturbance >1 Month Eval of insomnia Potential underlying causes • Complete Medication list with timing • Diuretic (nocturia) • Stimulants/sympathomimetic (nicotine, caffeine, bronchodilators) • Anticholinergics, sedating (sinemet, analgesics) • SSRI-dec REM • Sleep Diary • R/O depression + other psychiatric cond’ts • Physiologic changes with Age and AD:

  48. Physiologic changes with Age and AD: • Suprachiasmic Nucleus Damage (Sleep initiation/maintenance) • Circadian Rhythm Degeneration (inc sleep fragmentation, inc light sleep (stage ½), less restorative sleep (stage ¾), dec total sleep time 4 abnormal subtypes: • Aperiodic type • Free-running • Phase-delayed type • An ultradian rhythm type with an apparent cycle of about 3 to 4 hours; flattened amplitude type. Rest/activity cycles in AD patients have been characterized by marked day-to-day variability • Decreased Melatonin secretion • Decreased REM (loss of cholinergic neurons in nucleus basalis) • XS hypersomnulence with some apoE4 subtypes

  49. Matching Target Symptoms Sleep-wake Cycle Disturbance >1 Month Consider: Nonpharmacologic Interventions • The demented elder with insomnia.ClinGeriatr Med. 2008 • Sleep disorders in Alzheimer's disease and other dementias.Clin Cornerstone 2004 • No RCT of newer agents tested in this population • McCurry SM et al. Nighttime insomnia treatment and education for Alzheimer's disease: a RCT. JAGS. 2005

  50. Sleep-wake Cycle Disturbance >1 MonthNonpharmacologic Interventions • Follow Structured sleep and rising times that were not to deviate no more than 30 minutes from the selected times • Encouraged patients not to nap after 1 PM and limit naps to 30 minutes or less • Walk for 30 minutes, exercise daily • Reduce light/noise levels in their sleeping areas

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