Vanderbilt & atom Alliance Webinar Series Vanderbilt University - - PowerPoint PPT Presentation

Vanderbilt & atom Alliance Webinar Series

 Vanderbilt University Medical

Center

 Vanderbilt University Center

for Quality Aging

 atom Alliance

 Session #2: Dementia & Behavioral Disturbances  Session #3: Psychopharmacology in the Nursing Home  Session #4: Principles of Non-pharmacologic

Management & the Formulation of Behavioral Care Plans

 Session #5: The Implementation of Behavioral Strategies

& the Management of Pharmacologic Interventions

 Session #6: Addressing Barriers to Change: the

Perspective of Psychiatry, Nursing, and Medical Directors

 Chat Monitor: Britt Kuertz, RDN

Brittany.t.kuertz@vanderbilt.edu 615-936-1499

 Moderator: Emily Hollingsworth, MSW

Emily.k.hollingsworth@vanderbilt.edu 615-936-2718

 How many people are in the room with you to

view this webinar? (Please answer in the chat pane, and be sure to include your full facility name)

Paul Newhouse, MD

 Paul Newhouse, MD

Director, Vanderbilt Center for Cognitive Medicine, Jim Turner Chair in Cognitive Disorders Department of Psychiatry, Vanderbilt University

• Become familiar with common dementing

disorders and their clinical symptoms.

• Describe common behavioral problems in

dementia

• Understand the context in which behavioral

disturbances occur in dementia patients

Auguste Deter November, 1902

• Her condition steadily deteriorates

despite treatment with memory loss, speech difficulty, confusion, suspicion, agitation, wandering and screaming to becoming bedridden, incontinent, and unaware of her surroundings.

• She dies and her brain is sent for

autopsy by…

• Dr Alois Alzheimer
• Recently, her tissue was reexamined

and found to show a rare familial Alzheimer’s Disease gene mutation (PS1).

Clinical Picture of Behavioral Problems in Dementia

A 51 year old , A.D. is admitted to the long- term care facility for being unmanageable at home..

• Her husband reports that she has loss of

memory, delusions, and temporary vegetative states. She will drag sheets across the house, and scream for hours in the middle of the night.

• On examination, she has a cluster of

symptoms that include reduced comprehension and memory, as well as language disturbance, disorientation, unpredictable behavior, paranoia, auditory hallucinations, and severe social impairment.

• Alzheimer’s disease (AD)

refers to the neurodegenerative brain disorder regardless of clinical status

• AD can be conceptualized as

having two major stages

• Preclinical

(presymptomatic)

• Symptomatic
• Prodromal (MCI)
• Dementia of the

Alzheimer type

Dr Alois Alzheimer

More Recent Cases of Alzheimer’s Disease

Thursday, March 19, 15

16

A global impairment of higher cortical functions including memory, capacity to solve problems of daily living, performance of learned perceptuomotor skills, correct use of social skills and control of emotional reactions.

• Multiple Cognitive Deficits:
• Memory dysfunction: especially new learning, a prominent early

symptom

• At least one additional cognitive deficit
• aphasia, apraxia, agnosia, or executive dysfunction
• Cognitive Disturbances must be sufficiently severe to cause impairment
• f occupational or social functioning
• Must represent a decline from a previous level of functioning

Symptom Trouble remembering new information 46% Difficulty with complicated tasks 27% Trouble responding to problems 14% Frequently getting lost or trouble staying oriented 18% Trouble expressing thoughts, ideas, or following conversations 21% Change in personality or behavior 25%

CHS Alzheimer’s Disease Caregiver Project: Wave 6, 2000

Cognitive function

• Forgetfulness
• Repetitive

questions

• Daily function

impaired

• Progression of

cognitive deficits

• Short-term memory

loss

• Word-finding

difficulties

• Agitation
• Altered sleep patterns
• Total dependence:

dressing, feeding, bathing

MCI MMSE 24–30 Mild AD MMSE 20–23 Moderate AD MMSE 10–19 Severe AD MMSE 0–9

• Mild

subjective/

• bjective

memory loss

• Normal

function

10 y 0 y

Time (y)

Time?

MILD STAGE

• Forgetfulness, difficulty learning

new information

• Difficulty planning meals,

managing finances, taking medications on schedule

• Symptoms sometimes mistaken

for depression

• Ability to perform activities of daily

living (ADL) usually maintained

Sources: Galasko D. Eur J Neurol. 1998;5(suppl 4):S9-S17. Cefalu C, Grossberg GT. Diagnosis and Management of Dementia. Leawood, Kan: American Academy of Family Physicians; 2001.

MODERATE STAGE

 Short- and Long- term memory

impairment

 Difficulty performing tasks (e.g.,

following written notes, using the shower or toilet)

 Agitation, behavioral symptoms appear

(e.g., restlessness, wandering, delusions, hallucinations)

 Deficits in intellect and reasoning (e.g.,

poor judgment, forgets manners)

Sources: Galasko D. Eur J Neurol. 1998;5(suppl 4):S9-S17. National Institute on Aging Alzheimer’s Disease Education and Referral Center. Available at: http://www.alzheimers.org/unraveling/unraveling.pdf. Accessed April 6, 2005.

SEVERE STAGE

 May lose language function and

mumble or speech may be unintelligible

 Behavioral symptoms common (e.g.,

refuses to eat, cries out inappropriately)

 Failure to recognize family

• r faces

 Difficulty with all essential ADL (e.g.,

eating, toileting, walking)

Source: Gwyther LP. Caring for People With Alzheimer’s Disease: A Manual for Facility Staff. 2nd ed. Washington, DC and Chicago, Ill: American Health Care Association and the Alzheimer’s Association; 2001.

Activities of Daily Living Progressive Loss of Function MMSE Score

Keep Appointments Use the Telephone Obtain Meal/Snack Travel Alone Use Home Appliances Find Belongings Select Clothes Dress Groom

25 20 15 10 5 2 4 6 8 10 Years

Maintain Hobby Dispose of Litter Clear Table Walk Eat

Mild Moderate Severe

Adapted from Galasko D, et al. Eur J Neurol. 1998;5(suppl 4):S9-S17.

 Safety (driving, compliance, cooking, etc.)  Family stress and misunderstanding (blame, denial)  Early education of caregivers of how to handle patient (choices, getting

started)

 Advance planning while patient is competent (will, proxy, power of

attorney, advance directives)

 Specific treatments:

• May slow underlying disease process, (disease-modifying

treatments now under study)

• Standard treatment may delay nursing home placement longer if

started earlier

• May slow conversion from Mild Cognitive Impairment to AD

Patient initially diagnosed with AD Patient’s first diagnosis other than AD

Yes 28% No 72% 21% 7% 9% 14% 14% 35% Normal aging Depression No diagnosis Dementia (not AD) Stroke Other Source: Consumer Health Sciences,

• LLC. Alzheimer’s Caregiver Project. 1999.

• Clinical features of FTD include
• decline in personal hygiene and

grooming,

• mental rigidity and inflexibility,

distractibility and impersistence,

• hyperorality and dietary changes,
• perseverative and stereotyped

behavior, and utilization behavior

• Common cause of early onset

dementia

• 1:1 with AD 45-64 years
• More common than AD below

60 years

• Lack of concern for loved one’s illness
• Cruelty to children, animals, elderly
• Lack of concern when others are sad
• Rude comments to others
• Lose respect for intrapersonal space
• “Disgusting” behaviors
• Diminished response to pain

• Presence of dementia, gait/balance disorder, prominent

hallucinations and delusions, sensitivity to traditional antipsychotics, and fluctuations in alertness

• Neuropsychological tests do not reliably differentiate DLB

from AD

• Brain shows cortical Lewy bodies (alpha synuclein)

• Fluctuating cognition with pronounced variations in

attention and alertness Occurs in 80-90% of DLB,

• nly 20% of AD
• Recurrent visual hallucinations that are typically well

formed and detailed

▪ can involve scenes and bizarre situations ▪ can start with misinterpretations and are usually short ▪ often occur at night

• Spontaneous motor features of parkinsonism: slow

gait, increased muscle tone, tremor

1.

Preserve cognition and reduce decline

2.

Maintain quality of life

3.

Maximize function and maintain dignity

4.

Treat mood and behavior problems

5.

Refer, educate, and counsel

Source: Cefalu C, Grossberg GT. Diagnosis and Management of Dementia. Leawood, Kan: American Academy of Family Physicians; 2001.

Management Goals

• Cholinesterase inhibitors are the mainstay
• f therapy
• 3 oral drugs currently on the market
• Though some patients experience immediate improvement,

most prominent effect is cognitive stabilization

• Functional improvement may follow cognitive enhancement or

stabilization

• Positive effects of these agents appear to be sustained but fade
• ver long periods

(Secondary Prevention)

Feldman et al. Poster presented at the 8th International Montreal/Springfield Symposium on Advances in Alzheimer Therapy, 2004

. Neuropsychiatric Inventory total

score (NPI) (n ~ 96)

Holmes et al, 2004

.Randomization to donepezil

continuation or placebo

Significant differences were observed for the domains of depression, anxiety, and apathy (P.0166).

Adapted with permission from Feldman et al. Neurology. 2001;57:613-620. Gauthier et al. Int Psychogeriatr. 2002;14:389-404.

Endpoint 4 12 18 8 24

P=.0303 P=.0083 P=.0005 Clinical improvement Clinical decline

• 8
• 6
• 4
• 2

2 4

Study week

Total NPI change from baseline Aricept (n=144) Placebo (n=146)

 Most common reason for institutional

placement

 Agitation is the most common reason for

psychiatric consultation

 In study by Cummings, only 12% of patients did

not have a behavioral problem.

 Most common reason for caregiver distress

Jots, B. C. and Grossberg, G. T. (1996) The evolution of psychiatric symptoms in Alzheimer’s disease: a natural history study. J.

• Am. Geriatr. Soc. 44, 1078–1081

 Apathy: Decreased motivation, indifference  Disrupted Mood: Depression, mania-like.  Psychosis: 50-70% of patients; paranoia, visual

hallucinations

 Agitation: Caused by anxiety or psychosis  Aggression: Loss of impulse control  Wandering: Searching, disorientation

APATHY

• Most common behavioral change
• Decreased motivation, indifference
• Associated with frontal hypoperfusion

(medial frontal, supraorbital, anterior frontal areas)

• Not related to depression

Cummings 1998

PSYCHOTIC SYMPTOMS

 Cross sectional studies: 20-50%

 Longitudinal studies: 50-70%  Common Delusions: theft,

infidelity, pseudo-Capgras-type delusion (thinking spouse or family member is someone else), phantom boarder.

 Hallucinations tend to be visual

rather than auditory

Cummings 1998

 Patients with dementia experience both hallucinations and

delusions

• Usually less complex than the delusions seen in

schizophrenia or mood disorder

 Common delusions in dementia:

• Belief that one’s belongings have been stolen
• Conviction that one is being persecuted
• Belief that one’s spouse is unfaithful

MOOD CHANGES

• Mood symptoms are frequent and

may be secondary to impairment of mood regulatory systems in the brain (e.g. emotional incontinence)

• Major depressive disorder (MDD) is

uncommon

• MDD may precede diagnosis of

Alzheimer’s disease or vascular dementia

Cummings 1998

AGITATION



Excessive motor or verbal activity that is:

• Disruptive OR
• Unsafe OR
• Distressing to the patient
• Interferes with care and
• Is not because of need



Appears similar despite great variety of causes

Cohen-Mansfield et al., 1996; Tariot et al., 1994

AGITATION

▪ Correlates with anxiety in mildly demented patients

• Correlates with psychosis in moderately

demented patients

• Correlation to breakdown of mood and/or

behavioral regulation in severely demented patients

Modified from Cummings 1998

SUNDOWNING

Agitation associated with late afternoon or evening

 Causes:

• Fatigue
• Circadian factors
• Lack of sensory stimulation
• Need for security, protection

Modified from Reichman et al

WANDERING

 Disorientation  Restlessness  Searching  Sundowning  Fear  Medication-induced akathisia

Modified from Reichman et al

AGGRESSIVITY

 Can be in response to environment or spontaneous  Verbal and physical  Can occur without delusions or hallucinations  May be resistant to conventional pharmacotherapy

Which of the following is not a common behavioral symptom in Alzheimer's disease?

• A. Apathy

B.

Psychosis

C.

Aggression

• D. Shaking

E.

Fear

F.

Anxiety

 Fear - disorientation,

abandonment, confusion

 Over-stimulation  Lowered frustration

tolerance

 Loss of impulse control  Inability to recognize

family, caregivers

 Disorientation to time

• r place

 Disrupted routine  Forgetting of

appropriate behaviors

Modified from Reichman et al

 Personal

Pain Sensory Loss Infection Psychosis

 Environmental

Transfers Personal Care/Bathing Family Visits Medications

 Chronological

Awakening Late Afternoon Meal Times Bedtime Middle of the Night

Modified from Reichman et al

 Unmet physical needs?

• Pain?
• Infection/illness?
• Thirsty? Hungry? Tired?
• Sleep disturbance?
• Medication side effects?
• Sensory impairment?
• Constipation?
• Incontinence?

 Unmet psychological needs?

• Loneliness, boredom?
• Apprehension, fear, worry?
• Emotional discomfort?
• Lack of enjoyable activities?
• Lack of socialization?
• Loss of intimacy?

 Cause related to social

environmental?

• Too many people, too much noise?
• Too little to do?
• Expectations for performance

are too high?

• Communication is unclear?
• Caregiver approaches aren’t

adjusted to level of ability?

 Cause related to physical environment?

• Physical surroundings are not

“understandable”?

• TV, radio, PA systems confusing?
• Pictures, photographs,

reflections misunderstood?

• Lacks appropriate signage or

cues to way-find, be independent?

• Lacks meaningful activities?
• Lacks natural walking paths, daily exercise?

 Cause related to other Psychiatric illness?

• Depression?
• Anxiety?
• Delirium?
• Psychosis?
• Other mental illness?

Overlapping syndromes are common!!

 Altered or fluctuating level of alertness  Sudden change in behavior suggests delirium  Acute or subacute onset  Look for infection, new medications, and any

anticholinergic medications

 Dementia patient is VERY susceptible to

delirium

Abrupt changes in behavior in a previously stable patient with dementia may indicate:

• A. Delirium
• B. Infection
• C. Metabolic disturbance
• D. Drug interaction
• E. All of the above

Agitation should be assessed for causative factors

• A. TRUE
• B. FALSE

 Dementia is a syndrome: Most common cause is Alzheimer’s

Disease

 Other dementias with behavioral disturbances include Fronto-

temporal dementia, Lewy-Body dementia, vascular dementia

 Behavioral disturbances are a core feature of dementia and can

be expected in most patients

 The context (environmental, personal, physical, psychological)

will often determine whether and how behavioral disturbances are expressed

 Emily Hollingsworth

Emily.K.Hollingsworth@vanderbilt.edu

 Britt Kuertz

Brittany.T.Kuertz@vanderbilt.edu

 Project Website:

www.VanderbiltAntipsychoticReduction.org

 Vanderbilt Center for Quality Aging 615-936-1499

www.vanderbiltcqa.org for other resources