Presentation on theme: "Approaches to behavioral and psychological symptoms of Dementia"— Presentation transcript:
1 Approaches to behavioral and psychological symptoms of Dementia Marie-France Rivard, MD, FRCPCDivision of Geriatric PsychiatryUniversity of Ottawa
2 ObjectivesDescribe the causes of common psychological and behavioral symptoms in dementia (BPSD)Introduce the purpose of the PIECES programIdentify appropriate interventionsAdvise on the role of pharmacotherapy
3 Disclosure slideOver last 28 years, received honoraria for Continuing education activities from most pharmaceutical companies and some grants for research.Over last 7 years, no direct funding for research or Continuing Education: honoraria by organizing committees who may have, in turn, received un-restricted grants.Currently Chair, Seniors Advisory Co to MHCC, mostly volunteer work.
4 Prevalence of BPSD90% of patients affected by dementia will experience Behavioral and Psychological Symptoms of Dementia (BPSD) that are severe enough to be labeled as a problem during the course of their illness.Agitation (75%) Wandering (60%) Depression (50%) Psychosis (30%) Screaming and violence (20%) are most common
5 Impact of BPSD50 – 90% of caregivers considered physical aggression as the most serious problem they encountered and a factor leading to institutionalization. (Rabins et al. 1982)Front-line staff working in LTC report that physical assault contributes to significant work related stress (Wimo et al. 1997)Agitation, depression, anxiety, paranoid ideation cause significant suffering.
6 BPSD Symptom Clusters Aggression Agitation Apathy Mania Psychosis Physical aggressionVerbal AggressionAggressive resistanceto carePacingRepetitive actionsDressing/undressingRestless/anxiousApathyWithdrawnLacks interestAmotivationEuphoriaPressured speechIrritableHallucinationsDelusionsMisidentificationSuspiciousSadTearfulHopelessGuiltyAnxiousIrritable/screamingSuicidalManiaPsychosisDepressionAdapted from McShane R. Int Psychogeriatr 2000;12(suppl 1): 147
7 Causes of BPSD What is P.I.E.C.E.S. Person-centered assessment and care planning approach, using the care team to develop hypotheses and test the implementation of possible solutions.An acronym that conveys the individuality and importance of the various factors that contribute to BPSD in dementia.These factors are: Physical, Intellectual, Emotional, Capabilities, Environment and Social
8 P.I.E.C.E.S. Taught in Ontario since 1998 to LTC registered staff From expanded to include administrators of LTC, unregistered staff, acute care hospitals, CCAC case managers: PIECES program for physicians:Soon available for distributionTo be tested with family health teams and utilized by Peer Presenters and Preceptors of Ontario’s Alzheimer strategy
9 Why use the P.I.E.C.E.S. approach? Identification of target behaviors which present risk or urgencyFlags possible deliriumFramework for synthesis of non-pharmacologic approachesNutrition, comfort, hydration, sleep, etc…Environment, personhood, social, stimulationGuide the pharmacologic approach
10 PIECES Template The Three Question Template 1. What has changed? 2. What are the RISKS and possible causes (using the PIECES framework)?3. What is/are the action (s)?
11 P - Physical Drugs Disease Delirium – 30% mortality if undetected Anticholinergics, benzos,Include OTC, alcoholDiseaseAtypical presentations, hypoxia, pain, infectionsDelirium – 30% mortality if undetectedHypoactive and hyperactiveBasicsHydration, bowels, bladder, fatigue, sleep
12 Delirium I – infectious W - withdrawal A – acute metabolic, dehydration, renal, bowelsT –toxins, drugsC – CNS pathologyH – hypoxia,D - deficienciesE - endocrineA – acute vascularT - traumaH – heavy metals
13 Delirium work up and intervention History and physicalBowel/bladder/pain/mobilityCaregivers re what has changedReview medications including prnsInvestigations to identify and correct underlying causes:Vitals, O2 sat, glucose, chest X-rayCBC, Na, K, Creatinine, Albumin, Drug levels, Ca, Mg, TSH, B12, Folate, Urine, etc….CT head if warranted
14 Intellectual/cognitive changes Memory loss, Amnesia:Annoying repetitive questioning.Accusing others of not telling them about upcoming events.Being “uncooperative” with previous requests.AgnosiaAccusing family member of being an imposter when cannot quite recognize face…Failing to recognize one’s image in the mirror.Utilizing objects inappropriately.
15 Intellectual/cognitive changes ApraxiaDressing inappropriately—upset with assistance provided/requiredNeeding assistance to eatAphasiaFrustration/anxietyInappropriate requests/commentsReacting concretely to abstract concept
16 Intellectual/cognitive changes AnosognosiaNot recognizing that one is no longer knows about or how to do some things, being unaware of deficits and need for helpImpaired executive functions:poor planning/initiationunable to appreciate consequences of things said or done before saying/doing them, impulsive behaviorReturn to a place back in time
17 Intellectual/cognitive changes Perceptual difficulties (distances, depth, time elapsed, gaps)Resisting a bath or toileting, running over others.Apathy and “perseveration”May be confused with depression or “ill-will”.Return of primitive reflexes, perseverative behaviorsGrabbing caregiver’s clothing or body part and being unable to let go.
18 E - Emotions Delusions/Hallucinations/agitation Dopamine and cholinergic mediatedDepression/irritability/anxietySerotonergic, adrenergic, cholinergic mediated.Adjustment DisorderReactivation of past psychiatric illness with stress of dementia, placementEmotional Memory, past trauma, losses
19 C - Capabilities Balance of Physical Demands and Capabilities Capacities too low to do a task?Resistive behaviours, FrustrationCatastrophic reactionsWithdrawalAble to do more but assumed incapableBoredom, “attention-seeking” behaviorsBe sensitive to changes in functionAcute change – rule out reversible componentGradual change – Adapt care to progression of dementia
21 S - Social Life story, life accomplishments Social network ‘All about me’, personhoodSocial networkRelationships of familyLifelong coping strategiesInteractions with caregivers who may not know you as a personInteraction with other residents, roommates, others with dementia…
22 P.I.E.C.E.S. tools Daily Observation Sheet (DOS), A-B-C charting Shows frequency, severity, patterns of behaviours, can be individualizedCohen Mansfield Agitation Inventory (CMAI)Identifies behaviours and severity over 7 day periodConfusion Assessment Method (CAM)Delirium screenMMSE, MOCA, ClockSig: E Caps, Cornell Depression Scale
23 DOS Behavior Map Time MON TUE WED THU FRI SAT SUN 6am 7am 8am 9am 10a 1pm2pm3pm4pm
24 Other Common Tools Scale Assessment CMAI NPI-NH BEHAVE-AD The Cohen-Mansfield Agitation Inventory29 agitated behaviors rated by caregiver on 7 point frequency scaleNPI-NHNeuro-psychiatric Inventory-Nursing Home Version12 items rated by caregiver on a 4 point frequency and a 3 point severity scaleBEHAVE-ADThe Behavioral Pathology in Alzheimer’s Disease Rating Scale25 symptoms rated by caregiver on a 4 point severity scale
25 Caregiver Scales Useful for patients in the community Self report can be used in office setting or home visitAllow caregivers to identify behaviours they may not be comfortable talking about in front of their loved oneie - Kingston Behavioural Assessment
26 Pharmacological treatment Clear indication, potential benefitsExpected time to responseRisks associated with and without RxAppropriate dose rangeMonitoring for side effects and responseWhen to consider dose reduction, discontinuation.
27 Top Ten Behaviors not (usually) responsive to medication Aimless wanderingInappropriate urination /defecationInappropriate dressing /undressingAnnoying perseverative activitiesVocally repetitious behaviorHiding/hoardingPushing wheelchair bound co-patientEating in-ediblesInappropriate isolationTugging at/ removal of restraints
28 Top Ten Behaviors responsive (perhaps!) to medication Physical aggressionVerbal aggressionAnxious, restlessSadness, crying, anorexiaWithdrawn, apatheticSleep disturbanceWandering with agitation/aggressionVocally repetitious behaviorDelusions and hallucinationsSexually inappropriate behavior with agitation
29 Pharmacological treatment: When (indications) Behaviors that have not responded to non-pharmacological treatment.Persistent despite P.I.E.C.E.S. approachImminent and severe risk to self or othersE.g. delirium needing to be investigatedBehaviors that can respond to medication: listed previouslyTarget appropriate symptom cluster: depression, anxiety (acute or chronic), difficulty falling asleep, psychosis…
30 Pharmacological treatment: Choosing best drug Correct underlying cause, deficiency:Optimize treatment of dementia, CEIs, memantineTarget appropriate symptom cluster:Depression: AntidepressantAnxiety (longer term): antidepressantDifficulty falling asleep: TrazodonePsychosis: antipsychoticAggression: antipsychoticChoose least likely to worsen dementia and medical problemsE.g. Least anticholinergicChoose drugs without problematic interaction
31 Best choices: antidepressants SSRI for depression or anxietyCitalopram (Celexa) and Escitalopram (Cipralex)Sertraline (Zoloft)When noradrenergic properties may be wanted (pain, activation)Venlafaxine (Effexor XR) *not if unstable BPBupropion (not if unstable BP)When sedation may be needed urgentlyTrazodone *watch for hypotensionMirtazapine (some anticholinergic properties)When important to have a drug well toleratedMoclobemide (Manerix) * drug interactions
32 Best Choices - anxiety Cholinesterase inhibitor SSRIs particularly for anxiety of early dementia.SSRIsfirst line treatment for anxiety disorderswill take a few weeks to workcheck drug interactions.Consider trazodone (watch for hypotension)
33 Best choices: anti-psychotics For acute delirium– very short term (days)Haloperidol (0.5 mg that may be repeated)Loxapine (2.5 mg that may be repeated)For persistent psychosis/agitationRisperidone (Risperdal): start with mg daily and increase slowly as needed/tolerated over weeks to max. 2 mg per dayOlanzapine (Zyprexa): start with 2.5 mg daily and increase slowly as needed/tolerated over weeks, to max 10 mg dailyQuetiapine (Seroquel): start with 12.5 mg daily or BID and increase slowly over weeks to max 200 mg daily
35 Meds for BPSD Target symptoms Medication Starting Dose (mg/day) Average Target Dose (mg/day)Mood swingsEuphoriaImpulsivityMood stabilizers:valproic acidcarbamazepine25050-100AgitationApathyIrritabilityCholinesteraseInhibitors.MemantineAs directed5 mg daily10 mg BIDAnxiety (short term use in predictable situations)Anxiolytics:lorazepamoxazepam5-1010-30
36 Risks present when there is no pharmacological Rx Risks of injury (self and others), exhaustion, severe and prolonged suffering, increased risk of death with depression, etc.Need to present the risks of not treating with medications to pt or SDM when obtaining informed consent.
37 Risks associated with pharmacological Rx Risks of antidepressants:HyponatremiaIncreased agitation/insomnia/suicide in first few weeksGI upset and bleed if previous ulcersHeadachesRisks of anti-psychoticsIncrease risk of death (all antipsychotics), increased QT, cerebrovascular accidentEPS and tardive dyskinesiaWorsening of vascular risk factors (increased weight, lipids, diabetes)Risks of benzodiazepines:Falls, ataxia, worsening dementia, memory, disinhibition
38 Using minimal effective dose, only for the duration required Consider dose reduction for antipsychotic as soon as there is clear therapeutic response to prevent development of side effectsReview anti-psychotic medication for possible discontinuation Q 6 monthsMaintain full dose of antidepressant but review if still needed after 1-2 years? Only if no prior history of depression
39 Family physicians are at the core of the treatment team, working with: Patients and substitute decision makersOther caregivers (home care, LTC staff)Community resources (Alzheimer Society, First Link programs)Consultants such as PRCs, Outreach teams, Specialized geriatric medicine and mental health services
40 Questions and further readings Program for physicians should be available in the coming months: distribution strategies?CCSMH guidelines on LTC issues, depression, delirium and suicideNew Canadian Consensus guidelines on Dementia.