Non-medication Management of Agitated Behavior in Dementia Patients

1. Non-medication Management of Agitated Behavior in Dementia Patients Josepha A. Cheong, MD University of Florida Departments of Psychiatry and Neurology Chief, Division of Geriatric Psychiatry

2. Current Prevalence of AD • AD is the fourth leading cause of death due to disease for people > 65 years of age in the United States1 • Approximately 4 million people in the United States have AD2 • AD is a progressive, neurodegenerative disease involving: • Loss of memory and other cognitive functions • Decline in ability to perform activities of daily living • Changes in personality and behavior • Increases in resource utilization • Eventual nursing home placement 1. Murphy SL. Natl Vital Stat Rep. 2000;48:1-106. 2. Evans DA. Milbank Q. 1990;68:267-289.

3. AD Is the Most Prevalent Type of Irreversible Dementia 100 80 60 Irreversible dementias (%) 40 20 0 AD VaD DLB FTD Other VaD, vascular dementia; DLB, dementia with Lewy bodies; FTD, frontotemporal dementia. , reflects difficulties diagnosing/reporting dementias; only estimations of prevalence can be made. Guttman R et al. Arch Fam Med. 1999;8:347-353. McKeith IG et al. Neurology. 1996;47:1113-1124. Cherrier MM et al. J Am Geriatr Soc. 1997;45:579-583.

4. Disease Progression in Alzheimer’s Disease 100% Cognitive ability Functional ability Behavioral problems Caregiver time Change in disease progression 0% 0 1 2 3 4 5 6 7 8 9 Years from diagnosis

5. What is Agitated Behavior? • Non-cognitive symptom of dementia (cognitive = memory loss, language difficulty) • 2 types of non-cognitive symptoms: • Psychiatric • Behavioral

6. Psychiatric Symptoms • Personality changes • Depression • Hallucinations • Paranoia • Misidentifications • Mania • Alzheimer’s Disease International Factsheet

7. Aggression Agitation Wandering Sexual disinhibition Incontinence Increased eating Screaming 20-30% >80% 25 - 50% 10% 50-60% 5-10% 5% Behavioral Disturbances Modified – Alzheimer’s Disease International Factsheet

8. Why Manage These Symptoms? • Caregiver stress and burden • Stress on the patient • Precipitant of nursing home placement • Very manageable with non-medication and medication treatment

9. Why Non-medication Management? • Less restrictive • Effective in early dementia • Fewer complications • Stresses the importance of family and non-medical caregivers

10. General Principle How would I deal with this problem behavior if this person were a 3-5 year old child?

11. Assessment • Rule out any environmental disturbance • change in home setting • change in the staff/family members • death of a pet • R/o any possible medical illness • urinary tract infection • dehydration

12. Assessment • R/o drug-drug interactions or drug intolerance • When does the behavior occur • constant regardless of stimuli • specific time of day • with caregiving activity

13. Assessment • Endocrine • Iatrogenic - consider non-prescription medications • Injury • Intoxication

14. Treatment • Behavioral Intervention • redirection • no-fail environment • adjusting the environment to meet the needs and the limitations of the patient • structure and consistency • avoid overstimulation

15. Specific Problems Wandering • >50% of AD pts wander • 86% are located w/in 5 miles of home • 37% are found w/in 1 mile of home • 14% are found > 5 miles from home 2002 – Meredith Rowe – UF College of Nursing, Institute of Aging

16. Wandering • Planned activities to counteract boredom • Reassurances • Redirection • Red STOP sign • Disguise the door

17. Wandering Safety • Appropriate identification • Bright vest

18. Wandering Alzheimer’s Association Safe Return • Education • National photo/info database • 24 hour toll-free emergency crisis line • 1-888-572-8566 • 1-800-272-3900 • www.alz.org

19. Baker Act - 52/32 • 52 - involuntary evaluation • 32 - involuntary committment

20. Referral Shands at UF Inpatient Geriatric Psychiatry Unit Intake Coordinator 352-265-5411

21. GO GATORS!