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Approaches to behavioral and psychological symptoms of Dementia Marie-France Rivard, MD, FRCPC Division of Geriatric Psychiatry University of Ottawa.

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Presentation on theme: "Approaches to behavioral and psychological symptoms of Dementia Marie-France Rivard, MD, FRCPC Division of Geriatric Psychiatry University of Ottawa."— Presentation transcript:

1 Approaches to behavioral and psychological symptoms of Dementia Marie-France Rivard, MD, FRCPC Division of Geriatric Psychiatry University of Ottawa

2 Objectives  Describe the causes of common psychological and behavioral symptoms in dementia (BPSD)  Introduce the purpose of the PIECES program  Identify appropriate interventions  Advise on the role of pharmacotherapy

3 Disclosure slide  Over 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 BPSD  90% 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 BPSD  50 – 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 Adapted from McShane R. Int Psychogeriatr 2000;12(suppl 1): 147 BPSD Symptom Clusters Pacing Repetitive actions Dressing/undressing Restless/anxious Hallucinations Delusions Misidentification Suspicious Agitation Physical aggression Verbal Aggression Aggressive resistance to care Sad Tearful Hopeless Guilty Anxious Irritable/screaming Suicidal Withdrawn Lacks interest Amotivation Psychosis Depression Apathy Aggression Euphoria Pressured speech Irritable Mania

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 distribution Soon available for distribution To be tested with family health teams and utilized by Peer Presenters and Preceptors of Ontario’s Alzheimer strategy To 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 urgency  Flags possible delirium  Framework for synthesis of non- pharmacologic approaches Nutrition, comfort, hydration, sleep, etc… Nutrition, comfort, hydration, sleep, etc… Environment, personhood, social, stimulation Environment, personhood, social, stimulation  Guide 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 Anticholinergics, benzos, Anticholinergics, benzos, Include OTC, alcohol Include OTC, alcohol  Disease Atypical presentations, hypoxia, pain, infections Atypical presentations, hypoxia, pain, infections  Delirium – 30% mortality if undetected Hypoactive and hyperactive Hypoactive and hyperactive  Basics Hydration, bowels, bladder, fatigue, sleep Hydration, bowels, bladder, fatigue, sleep

12 Delirium  I – infectious  W - withdrawal  A – acute metabolic, dehydration, renal, bowels  T –toxins, drugs  C – CNS pathology  H – hypoxia,  D - deficiencies  E - endocrine  A – acute vascular  T - trauma  H – heavy metals

13 Delirium work up and intervention  History and physical Bowel/bladder/pain/mobility Bowel/bladder/pain/mobility Caregivers re what has changed Caregivers re what has changed  Review medications including prns  Investigations to identify and correct underlying causes: Vitals, O2 sat, glucose, chest X-ray Vitals, O2 sat, glucose, chest X-ray CBC, Na, K, Creatinine, Albumin, Drug levels, Ca, Mg, TSH, B12, Folate, Urine, etc…. CBC, Na, K, Creatinine, Albumin, Drug levels, Ca, Mg, TSH, B12, Folate, Urine, etc…. CT head if warranted CT head if warranted

14 Intellectual/cognitive changes  Memory loss, Amnesia: Annoying repetitive questioning. Annoying repetitive questioning. Accusing others of not telling them about upcoming events. Accusing others of not telling them about upcoming events. Being “uncooperative” with previous requests. Being “uncooperative” with previous requests.  Agnosia Accusing family member of being an imposter when cannot quite recognize face… Accusing family member of being an imposter when cannot quite recognize face… Failing to recognize one’s image in the mirror. Failing to recognize one’s image in the mirror. Utilizing objects inappropriately. Utilizing objects inappropriately.

15 Intellectual/cognitive changes  Apraxia Dressing inappropriately—upset with assistance provided/required Dressing inappropriately—upset with assistance provided/required Needing assistance to eat Needing assistance to eat  Aphasia Frustration/anxiety Frustration/anxiety Inappropriate requests/comments Inappropriate requests/comments Reacting concretely to abstract concept Reacting concretely to abstract concept

16 Intellectual/cognitive changes  Anosognosia Not recognizing that one is no longer knows about or how to do some things, being unaware of deficits and need for help Not recognizing that one is no longer knows about or how to do some things, being unaware of deficits and need for help  Impaired executive functions: poor planning/initiation poor planning/initiation unable to appreciate consequences of things said or done before saying/doing them, impulsive behavior unable to appreciate consequences of things said or done before saying/doing them, impulsive behavior  Return 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. Resisting a bath or toileting, running over others.  Apathy and “perseveration” May be confused with depression or “ill-will”. May be confused with depression or “ill-will”.  Return of primitive reflexes, perseverative behaviors Grabbing caregiver’s clothing or body part and being unable to let go. Grabbing caregiver’s clothing or body part and being unable to let go.

18 E - Emotions  Delusions/Hallucinations/agitation Dopamine and cholinergic mediated Dopamine and cholinergic mediated  Depression/irritability/anxiety Serotonergic, adrenergic, cholinergic mediated. Serotonergic, adrenergic, cholinergic mediated.  Adjustment Disorder  Reactivation of past psychiatric illness with stress of dementia, placement  Emotional Memory, past trauma, losses

19 C - Capabilities  Balance of Physical Demands and Capabilities  Capacities too low to do a task? Resistive behaviours, Frustration Resistive behaviours, Frustration Catastrophic reactions Catastrophic reactions Withdrawal Withdrawal  Able to do more but assumed incapable Boredom, “attention-seeking” behaviors Boredom, “attention-seeking” behaviors  Be sensitive to changes in function Acute change – rule out reversible component Acute change – rule out reversible component Gradual change – Adapt care to progression of dementia Gradual change – Adapt care to progression of dementia

20 E - Environment  Environmental structure design, lighting (glare), physical space, temperature design, lighting (glare), physical space, temperature  Ambience Sounds, smells, colour, noise Sounds, smells, colour, noise  Familiarity  Noise – excessive, distressing, confusing, unfamiliar  Over/under stimulation  Changing environment Relocation, routines, caregivers Relocation, routines, caregivers

21 S - Social  Life story, life accomplishments ‘All about me’, personhood ‘All about me’, personhood  Social network  Relationships of family  Lifelong coping strategies  Interactions with caregivers who may not know you as a person  Interaction 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 individualized Shows frequency, severity, patterns of behaviours, can be individualized  Cohen Mansfield Agitation Inventory (CMAI) Identifies behaviours and severity over 7 day period Identifies behaviours and severity over 7 day period  Confusion Assessment Method (CAM) Delirium screen Delirium screen  MMSE, MOCA, Clock  Sig: E Caps, Cornell Depression Scale

23 DOS Behavior Map TimeMONTUEWEDTHUFRISATSUN 6am 7am 8am 9am 10a 11a 12p 1pm 2pm 3pm 4pm

24 Other Common Tools ScaleAssessment CMAI The Cohen-Mansfield Agitation Inventory 29 agitated behaviors rated by caregiver on 7 point frequency scale NPI-NH Neuro-psychiatric Inventory- Nursing Home Version 12 items rated by caregiver on a 4 point frequency and a 3 point severity scale BEHAVE-AD The Behavioral Pathology in Alzheimer’s Disease Rating Scale 25 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 visit  Allow caregivers to identify behaviours they may not be comfortable talking about in front of their loved one  ie - Kingston Behavioural Assessment

26 Pharmacological treatment  Clear indication, potential benefits  Expected time to response  Risks associated with and without Rx  Appropriate dose range  Monitoring for side effects and response  When to consider dose reduction, discontinuation.

27 Top Ten Behaviors not (usually) responsive to medication  Hiding/hoarding  Pushing wheelchair bound co-patient  Eating in-edibles  Inappropriate isolation  Tugging at/ removal of restraints  Aimless wandering  Inappropriate urination /defecation  Inappropriate dressing /undressing  Annoying perseverative activities  Vocally repetitious behavior

28 Top Ten Behaviors responsive (perhaps!) to medication  Physical aggression  Verbal aggression  Anxious, restless  Sadness, crying, anorexia  Withdrawn, apathetic  Sleep disturbance  Wandering with agitation/aggression  Vocally repetitious behavior  Delusions and hallucinations  Sexually 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. approach Persistent despite P.I.E.C.E.S. approach  Imminent and severe risk to self or others E.g. delirium needing to be investigated E.g. delirium needing to be investigated  Behaviors that can respond to medication: listed previously  Target 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, memantine Optimize treatment of dementia, CEIs, memantine  Target appropriate symptom cluster: Depression: Antidepressant Depression: Antidepressant Anxiety (longer term): antidepressant Anxiety (longer term): antidepressant Difficulty falling asleep: Trazodone Difficulty falling asleep: Trazodone Psychosis: antipsychotic Psychosis: antipsychotic Aggression: antipsychotic Aggression: antipsychotic  Choose least likely to worsen dementia and medical problems E.g. Least anticholinergic E.g. Least anticholinergic  Choose drugs without problematic interaction

31 Best choices: antidepressants  SSRI for depression or anxiety Citalopram (Celexa) and Escitalopram (Cipralex) Citalopram (Celexa) and Escitalopram (Cipralex) Sertraline (Zoloft) Sertraline (Zoloft)  When noradrenergic properties may be wanted (pain, activation) Venlafaxine (Effexor XR) *not if unstable BP Venlafaxine (Effexor XR) *not if unstable BP Bupropion (not if unstable BP) Bupropion (not if unstable BP)  When sedation may be needed urgently Trazodone *watch for hypotension Trazodone *watch for hypotension Mirtazapine (some anticholinergic properties) Mirtazapine (some anticholinergic properties)  When important to have a drug well tolerated Moclobemide (Manerix) * drug interactions Moclobemide (Manerix) * drug interactions

32 Best Choices - anxiety  Cholinesterase inhibitor particularly for anxiety of early dementia. particularly for anxiety of early dementia.  SSRIs first line treatment for anxiety disorders first line treatment for anxiety disorders will take a few weeks to work will take a few weeks to work check drug interactions. check 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) Haloperidol (0.5 mg that may be repeated) Loxapine (2.5 mg that may be repeated) Loxapine (2.5 mg that may be repeated)  For persistent psychosis/agitation Risperidone (Risperdal): start with mg daily and increase slowly as needed/tolerated over weeks to max. 2 mg per day Risperidone (Risperdal): start with mg daily and increase slowly as needed/tolerated over weeks to max. 2 mg per day Olanzapine (Zyprexa): start with 2.5 mg daily and increase slowly as needed/tolerated over weeks, to max 10 mg daily Olanzapine (Zyprexa): start with 2.5 mg daily and increase slowly as needed/tolerated over weeks, to max 10 mg daily Quetiapine (Seroquel): start with 12.5 mg daily or BID and increase slowly over weeks to max 200 mg daily Quetiapine (Seroquel): start with 12.5 mg daily or BID and increase slowly over weeks to max 200 mg daily

34 Meds for BPSD Target Symptoms Medication Starting Dose (mg/day) Average Target Dose (mg/day) DelusionsHallucinationAggression“Agitation” Atypical Antipsychotics:  risperidone  olanzapine  quetiapine SadnessIrritabilityAnxietyInsomniaAntidepressants  citalopram  sertraline  venlafaxine  mirtazapine  trazodone

35 Meds for BPSD Target symptoms Medication Starting Dose (mg/day) Average Target Dose (mg/day)  Mood swings  Euphoria  Impulsivity Mood stabilizers:  valproic acid  carbamazepine  Agitation  Apathy  Irritability CholinesteraseInhibitors.Memantine As directed 5 mg daily As directed 10 mg BID  Anxiety (short term use in predictable situations) Anxiolytics:  lorazepam  oxazepam

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: Hyponatremia Hyponatremia Increased agitation/insomnia/suicide in first few weeks Increased agitation/insomnia/suicide in first few weeks GI upset and bleed if previous ulcers GI upset and bleed if previous ulcers Headaches Headaches  Risks of anti-psychotics Increase risk of death (all antipsychotics), increased QT, cerebrovascular accident Increase risk of death (all antipsychotics), increased QT, cerebrovascular accident EPS and tardive dyskinesia EPS and tardive dyskinesia Worsening of vascular risk factors (increased weight, lipids, diabetes) Worsening of vascular risk factors (increased weight, lipids, diabetes)  Risks of benzodiazepines: Falls, ataxia, worsening dementia, memory, disinhibition 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 effects  Review anti-psychotic medication for possible discontinuation Q 6 months  Maintain 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 makers  Other 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 suicide  New Canadian Consensus guidelines on Dementia.


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