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Rational Treatment of Agitation and Behavioral Symptoms in Patients with Dementia December 2, 2011 Indiana Osteopathic Association 30 th Annual Winter.

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Presentation on theme: "Rational Treatment of Agitation and Behavioral Symptoms in Patients with Dementia December 2, 2011 Indiana Osteopathic Association 30 th Annual Winter."— Presentation transcript:

1 Rational Treatment of Agitation and Behavioral Symptoms in Patients with Dementia December 2, 2011 Indiana Osteopathic Association 30 th Annual Winter Update John J. Wernert, M.D., MHA Geriatric Psychiatrist Medical Director, Medical Management Wishard Hospital

2 “The singular benefit of old age is to see life whole and know it’s natural course” Philosopher Arthur Schopenhauer

3 Faculty Disclosure John J. Wernert, M.D, MHA Consultant: Various ECF/LTC facilities Federally Qualified Health Centers Archdiocese of Indianapolis Speaker’s Bureau: Sunovion Ownership Interest: PDA, LLC

4 Goals and Objectives Understand the demographic shifts in America and the challenges of treating neurodegenerative disorders Gain Knowledge of the Differential Diagnosis of Dementia in Elderly patients Discuss the unique challenges of treating agitation and behavioral issues in dementia Discuss various pharmacological and behavioral interventions

5 Key Points Neurodegenerative disorders are increasing rapidly, and will present the greatest health challenge for an already overburdened American health system Psychosis and agitation are common symptoms in elderly patients, especially in patients with dementia Physical conditions, physical discomfort, and medication side effects need to be ruled out as causative factors Treatment involves caregiver education and support, patient-centered behavioral interventions, milieu adaptations, and pharmacotherapy It is important to consider drug and nondrug interventions that will provide the most effective and tolerable relief of patient symptoms and decrease caregiver burden.

6 The Perfect Storm = The Perfect Storm = The Aging American Population and the Inevitable Tsunami of Health Care needs that will overwhelm our Society

7 Healthcare Expenditures in America 17.2% GDP in 2009 Current projections 19.5% by 2017 $2.5 trillion spent on all of healthcare $8087 per person $557 billion on physician care and other clinical services

8 Healthcare Coverage in America 52 million uninsured (18% of population) Fastest growing segment of uninsured are those making over $60,000/yr 83 million (27.8%) covered by government programs 166 million (55%) private or employer- based insurance Less than 9% buy their own insurance

9 What about 2016? CMS projects $4 trillion spent on HC $2.2 trillion paid by Gov’t payors 20% of US GNP $800 billion attributed to physician care $1.3 trillion on hospital care $497 billion on prescription drugs

10 The Cost of Brain Disorders U.S. Society = $430 Billion annually 18 % of the average American income is devoted to treating Brain diseases 50% cost is Dementias Psychiatric Illnesses = $160 Billion Direct and indirect costs of Alzheimer ’ s and other dementias in 2010 will amount to more than $172 billion. By 2015, Medicare is projecting to spend $189 billion in DIRECT COST on beneficiaries with Alzheimer ’ s and other dementias.

11 Demographics of American Elderly “Old” old - Born before 1925 Elderly - 1925 – 1946 Baby Boomers - 1946 - 1964

12 “Old” old Americans Period of Austerity – usually raised on farm, healthy living Resourceful Learned to be resilient and do without Good Genes Stress made them stronger (natural selection) Avoid Healthcare – tough it out Predominant Attitudes: Perseverance Conservative Survivors 900 years old!

13 Nonagenarians 90 yo have tripled since 1980 1.9 million according to 2010 census 1900 = less than 100,000 Projected to increase to 8.7 million by 2050 3:1 female to male 37.3% live alone 37.1% live with family 23 % live in nursing homes Median income $14,700 – ½ from SS Reported in Indianapolis Star 11/18/11

14 The American Elders (the Greatest Generation) Lived through the “tough times” Good Genes Disposable income Less healthy living Honorable Commitments Wealth-Builders and Savers Attitudes: Patriotic Family oriented Selfless

15 Baby Boomer Demographics 77,702,865 Americans born 1946-1964 28% single ( 16% divorced, 2.9 % widowed, 9.1% never married)

16 Baby Boomers Raised in times of largess (more is better) Exposed to fewer social stressors Technology blossoms Wealth Spenders EgoCenticism Love healthcare Attitudes: “me” generation Liberal Quality of Life and Retirement are important goals.

17 Caring for the Elderly is expensive In 2009, the average private room in a nursing home cost $219 daily. Assisted living costs averaged $3,131 monthly. Home health aides averaged $21 per hour. Adult day care services averaged $67 daily.

18 Long Term Care Insurance About 60 percent of individuals over age 65 will require at least some type of long-term care services during their lifetime. About 40% of those receiving long-term care today are between 18 and 64. Premiums have risen dramatically in recent years even for existing policy holders. Coverage costs can be expensive, especially when consumers wait until retirement age to purchase LTC coverage. Don’t count on the Government ! Obama Administration announces HHS Will Not Implement CLASS Long-Term Care Insurance Plan – Oct 2011

19 The Crisis of the Aging Human Brain – Genes, Stress and Lifestyle

20 Alzheimer’s Statistics An estimated 5.3 million Americans of all ages have Alzheimer’s disease (2010). 5.1 million people aged 65 and older (13%) and 200,000 individuals under age 65 who have younger- onset Alzheimer’s. The Alzheimer’s Association estimates that there are 500,000 Americans younger than 65 with Alzheimer’s and other dementias. Of these, approximately 40 percent are estimated to have Alzheimer’s. By 2030, all baby boomers will be at least 65 years old. That year, the number of people aged 65 and older with Alzheimer's is expected to reach 7.7 million.

21 Who cares for Dementia Patients? 70% are cared for in the community Almost 11 million Americans provide unpaid care for a person with Alzheimer ’ s disease or another dementia. In 2009, they provided 12.5 billion hours of unpaid care, a contribution to the nation valued at almost $144 billion. Caring for a person with Alzheimer ’ s or another dementia is very difficult and expensive. Family and other unpaid caregivers experience high levels of emotional stress and depression as a result. Caregiving also has a negative impact on their health, employment, income and financial security.

22 Physicians Perspective – c ommunity-based care of Dementia patients Recurring themes insufficient time difficulty in accessing and communicating with specialists low reimbursement poor connections with community social service agencies, and lack of interdisciplinary teams. J Gen Intern Med. 2007 Nov;22(11):1487-92. Epub 2007 Sep 7.Practice constraints, behavioral problems, and dementia care: primary care physicians' perspectives. J Gen Intern Med. Hinton L, Franz CE, Reddy G, Flores Y, Kravitz RL, Barker JC Hinton LFranz CEReddy GFlores YKravitz RLBarker JC

23 Challenges: Physicians often feel challenged in caring for dementia patients, particularly those who are more behaviorally complex Because of time and reimbursement constraints as well as other perceived barriers. Lack of effective educational interventions (for families and physicians) Caregivers breaking down Constraints may lead to delayed detection of behavior problems, "reactive" as opposed to proactive management of dementia, and increased reliance on pharmacological rather than psychosocial approaches.

24 What is agitation? Irritability, frustration, excessive anger “Blow ups” out of proportion to the cause Constant demands for attention and reassurance Repeated questions or telephone calls Stubborn refusal to do things or go places followed by explosive behavior Constant pacing, searching, rummaging Yelling, screaming, cursing, threats Hitting, biting, kicking

25 Agitated Behaviors Agitated behavior is common during Alzheimer's disease (AD) progression, with symptoms that may include delusions, hallucinations, and aggression. Behavioral changes can greatly increase caregiver distress. Primary reason for institutionalization. Treatment that delays or decreases these symptoms may ease caregiver burden and postpone institutionalization of the patient.

26 Honing in on the problem Before initiating treatment, the physician must rule out any potential contributing factors, such as medical disorders, physical discomfort, medication effects, and preexisting psychiatric illness. Target behaviors must then be identified in order to initiate appropriate treatment (pharmacologic and/or environmental) that is aimed at those behaviors.

27 Prevalence of Symptoms of Psychosis and Neuropsychiatric Inventory Item Dementia (n = 329) No Dementia (n = 673) Apathy27.43.1 Depression23.77.0 Agitation/aggression23.72.8 Irritability20.44.5 Delusions18.52.4 Anxiety17.05.6 Aberrant motor behavior14.30.4 Hallucinations13.70.6 Disinhibition 9.10.9 Elation 0.90.3 Adapted from Lyketsos CG, et al. Am J Psychiatry 2000; 157: 708.

28 Differential Diagnosis of Behavioral Problems Dementing disorders Delirium Medical illness Iatrogenic Psychosocial triggers Physical discomfort Primary psychiatric illness Adapted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). 4th Ed. Washington, DC, American Psychiatric Association, 1994.

29 Delirium “an acute disorder of attention and cognition” (de lira “off the path”) Can persist for days to weeks Other terms used include organic brain syndrome, metabolic encephelopathy, toxic psychosis, acute mental status change, exogenous psychosis, sundowning

30 Delirium in the elderly Delirium is common in older inpatients, associated with poor outcomes, and commonly missed or misdiagnosed Underlying dementia is risk factor 25% delirious are demented 40% demented in hospital are delirious Prevention is the best approach Management involves treating underlying causes, minimizing medications, supportive care, and avoidance of restraints when possible ICU delirium poses particular challenges and risks for elderly patients (CCU)

31 Delirium versus Dementia Delirium Rapid onset Primary defect in attention Fluctuates during the course of a day Visual hallucinations common Respond rapidly to neuroleptics Dementia Insidious onset Primary defect in short term memory Attention often normal Does not fluctuate during day Visual hallucinations less common Response to meds inconsistent

32 Various types of Dementia DAT vs SDAT Vascular Lewy Body Dementia Parkinson’s Pick’s Demylinating diseases (MS) Infectious/Metabolic (HIV, cancer)

33 Senile Dementia of the Alzheimer’s type (SDAT) Is this what Alzheimer Described? Early onset of Memory Deficits Absence of Neurologic Deficits No CVA or injury on CT Makes up 70 % of Dementia Pt’s >5 million elderly Americans currently Dx Already 6 th leading cause of death

34 Vascular Dementias Onset: Abrupt More common in males Progress: Stepwise History: TIA, strokes Clinical examination: Evidence of atherosclerosis Neurologic deficits + CT/MRI findings

35 Dementia With Lewy Bodies Fluctuating course, rapidly progressive Hallucinations are detailed and prominent Psychosis, delusional or paranoid ideation Mild extrapyramidal signs Cortical deficits: 4 As (amnesia, anomia, agnosia, apraxia) Subcortical deficits: attention, verbal fluency Neuroleptics may aggravate symptoms

36 Parkinson's Disease and Dementia About 25% of patients with Parkinson's disease will develop serious dementia Impaired executive functions Psychomotor retardation, depression Hallucinations, delusions Speech disturbances Low educational or socioeconomic status Dopamine precursors may trigger confusional states or delirium Neuroleptics may worsen condition

37 Development of Agitation More prevalent in later stages “Prisoner of the Present” Misinterpretations Medical co-morbidities worsen Pain Frontal lobe involvement Disinhibited behaviors Sexualized behaviors “Once mean, always mean” Sundowning = majority requests for Rx

38 Psychosis and Agitation: Management Reassure, distract patient; provide structure Identify and adjust environmental triggers Assemble an interdisciplinary treatment team Educate patient, family, and staff about treatment plan, including goals of pharmacotherapy Monitor and evaluate pharmacologic interventions Ensure support for the caregiver to prevent burnout

39 Treating Psychotic Symptoms Delusions or hallucinations appear in 30% to 50% of patients with AD, and up to 70% demonstrate agitated or aggressive behaviors. In findings published in 2006 in the New England Journal of Medicine, atypical antipsychotics showed "modest efficacy" in decreasing behavioral symptoms in the CATIE-AD patients after 12 weeks compared with placebo. However, they also showed more treatment-related adverse events.published in 2006

40 Pharmacotherapy Antipsychotics Typicals Atypicals Mood Stabilizers (AED’s) Depakote Anxiolytics Sedatives Hypnotics Antidepressants

41 Risks of “chemical restraints” ISBOH Guidelines Accreditation agencies frown on perceived “overuse” of medications Family resistance Side effects May worsen target symptoms

42 Atypicals: Have become the standard “go to” class May actually worsen cognitive decline Increased risk of stroke and CVA events (black box warning) Metabolic Syndrome also a risk for elderly patients

43 Atypical Antipsychotics Risperidone Olanzapine Quetiapine Ziprasidone Aripiprazole Clozapine All have black box warning – CVA risk in elderly

44 Anticonvulsants May have efficacy for explosive, paroxysmal nonpsychotic agitation Most effective in frontal lobe impairment Sodium valproate Carbamazepine – less commonly used Newer agents unproven

45 Valproic Acid (Depakote) Great choice for disinhibited behaviors Calming without being excessively sedating Easier to use; Depakote ER Depakote EC bid Depakene syrup Depakote sprinkles Starting dosage: 50 mg / kg Blood levels helpful - can titrate to serum level of 80 – 120 Generics available

46 Anxiolytics Benzodiazepines Ativan - # 1 fall risk Long acting better (Clonazepam) Vistaril – anticholinergic delirium Buspar – minimal benefit Antidepressants SSRI’s TCA’s

47 Sedative/Hypnotics Can be helpful for sleep regulation Low dose Trazodone 25 – 50 mg q 8 pm Give at 5 pm if sundowning an issue Remeron 7.5 mg = increase sedation / appetite Vistaril + Benadryl – avoid Melatonin 3 -6 mg may be helpful Minimize use of Ambien, Lunesta and BZ hypnotics

48 Medications used too often? “Much of medication use is due to the lack of interest, willingness, funding, or ability to provide psychosocial or environmental interventions to patients with agitation, aggression, and psychosis who have dementia.” “Despite the widespread awareness of adverse consequences, we can only infer that atypical antipsychotics continue to be prescribed for dementia treatment because there is a lack of alternatives and there is a perceived clinical benefit by care providers.” Am J Psychiatry. 2011;168:831-839, 767-769. Abstract EditorialAbstractEditorial

49 Behavioral Interventions Identify and reduce antecedents Has little effect on overall functioning Can reduce problem behaviors such as wandering, inappropriate voiding and exit seeking Work towards strict daily routines

50 Emotion-oriented interventions Reminiscence therapy Memory corner Memory book Sensory integration Snoezelen room Simulated Presence therapy Validation therapy

51 Cognition-oriented Cognitive retraining Reality orientation In later stages, may result in more frustration Has very limited utility in decreasing agitation

52 Stimulation-oriented Primarily helps patients daily routine Exercise Recreational activities Art therapy Music – age appropriate Pet therapy

53 Important Change: Limit Antipsychotics For patients who have neuropsychiatric symptoms, such as agitation, delusion, hallucinations, and aggression, there is stronger evidence that nondrug treatment should be tried first and that real efforts should be made to limit the use of antipsychotics in all settings — at home and in the long-term-care setting. "That is the most important way the guidelines will change practice." “Real efforts need to be made to make sure that when antipsychotics are prescribed, they are both necessary and effective; when they are not effective, they should be discontinued." 2007 second addition APA Treatment Guidelines Updated Guidelines for Treating Patients With Dementia Supplement to American Journal of Psychiatry

54 If you must use atypicals: Be prepared to do Gradual Dose Reductions (GDR’s) – even if patient is doing well Start low Write for automatic stop dates Don’t assume the patient is better solely because of medication Continue to trial behavioral interventions

55 Summary Patients with dementia commonly become restless and agitated Environmental triggers, medical disorders, and medication side effects need to be ruled out as contributing factors Treatment approach must include appropriate nondrug interventions, as well as thoughtfully chosen medications Primary caregiver requires attention, support, and respite Unfortunately, medications have become the mainstay of treatment. Use short term

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