Download Managing “The Why & When”

Treatment Modalities for the
Management of Distressed
Behaviors in Elderly
Nursing Home Residents
Jeanne Jackson-Siegal, MD
James E. Lett II, MD, CMD
January 9, 2004
1
Definitions
 “Behavior” refers to an individual’s observable
actions.
 “Cognition” refers to any personal activities related
to organizing memory, sensation, and thinking
 “Mental status” refers to an individual’s overall
level of alertness, activation, and responsiveness
to the outside world.
AMDA Dementia CPG 1998
2
Incidence of Behaviors
 Apathy (72%)
 Agitation (60%)
 Anxiety (45%)
 Irritability (42%)
 Motor restlessness (38%)
 Disinhibition (36%)
 Sleep disturbance (24%)
 Depression (23%)
 Delusions (22%)
 Hallucinations (10%)
3
Distressed Behaviors in Nursing Homes
 Increases stress between patients and caregivers1
 Create intensive and costly levels of treatment1
 Increase morbidity and mortality 1
 Lead to public health problems that contribute to the
enormous cost of treating dementia1
 Increase risk of overmedication and restraints
1. Finkel SI et al. Int Psychogeriatr. 1996;8:497-500
4
“Agitation”
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Excessive motor or verbal activity that is 1
1. One of the following
 Disruptive OR
 Unsafe OR
 Distressing to the patient
2. Interferes with care and
3. Is not because of need
Generally, is a poor descriptor of behavior
Appears similar despite great variety of causes
Need to make diagnosis, not focus only on symptoms
When severe, may be the target for urgent intervention
1. Cohen-Mansfield et al, 1996; Tariot et al, 1994
Cohen- Mansfield Agitation Inventory. www.medafile.com/zyweb/CMAI.htm
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Agitation and Aggression in Dementia
Physical
Hitting
Pacing
Kicking
Biting
Pushing
Spitting
Scratching
Verbal
Threats
Accusations
Name-calling
Obscenities
Complaining
Attention-seeking
Screaming
Cohen-Mansfield et al, 1996; Tariot et al, 1994
6
Behavior Diagnosis: Pitfalls
 Many etiologies can present with the same
behaviors (Example of fever)
 Co-existence of multiple risk factors present
in any one resident: disease, medications,
changed environment, etc.
 The key is to have a process to evaluate the
resident for the behavior
7
General Approach to Behaviors
 Clearly characterize target symptoms
 Standard medical evaluation to identify
possible medical disorder
 Differential diagnosis of behavior cause
 The A,B,C’s of Behavior Intervention
– Antecedent, Behavior, Consequences
 Document, Document, Document
 Non-pharmacologic intervention
8
Good Target Symptoms
 Anxiety
 Insomnia
 Delusions (stressful)
 Hallucinations (stressful)
 Dysphoria/Depression
 Compulsive behaviors
 Agitation/Aggressiveness
 Motor restlessness
 Pain
9
Poor Target Symptoms
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Exit-seeking
Pacing & Wandering
Perseverant vocalizations
Hoarding/Stealing
Inappropriate sexual touching
Non-stressful delusions
Disrobing
10
Medical Evaluation
 Medical/Psychiatric History
 Medication: excess, withdrawal, ADR
 Physical evaluation: urinary retention,
fecal impaction (constipation), pain,
dental problems
 Mental Status Exam
 Lab studies/oximetry
 Imaging Studies
11
Medical Illness
 Illnesses: GERD, angina, OA, etc.
 Medication side effects
 Chronic pain
 Constipation
 Hearing or vision impairment
 Sleep deprivation
 Dental problems
12
Differential for Behavior
Causes
 Dementing disorders
 Frontal Lobe impairment
 Delirium
 Medications
 Toxic personality syndrome
 Pain
13
Differential for Behaviors (cont.)
 Primary psychiatric illness
- Affective disorder (Depression)
- Anxiety disorder
- Psychotic disorder
- Personality disorder
 Environment/Stressors
14
Definition: Dementia
A syndrome (a collection of signs &
symptoms) of progressive decline in multiple
areas of cognitive function which eventually
produces significant deficits in self-care and
social and occupational performance.
AMDA Dementia CPG 1998
15
Dementia
 Incidence of 1-2% at 65-70 years of age,
increasing to >30% after 85
 Up to 80% of NF residents have some
degree of dementia
 The resultant decline in functional capacity
is the chief cause of NF admission
16
Dementia Categories
 Alzheimer’s disease (65%)
 Lewy Body dementia (7%)
 AD w/vascular disease (10%)
 AD w/Lewy bodies (5%)
 Vascular dementia (5%)
 Other: Infectious, EtOH, etc. (8%)
17
Definition: Dementia of the
Alzheimer Type (DAT)
A degenerative neurologic disease that results in
impaired memory, thinking and behavior.
It is
characterized by a gradual onset of progressive
symptoms that include memory loss, personality
changes, and decline in ability to think and function.
DAT is by far the most common from of dementia in the
U.S., so it is generally used as the prototypical
dementia in most guide to diagnosis and treatment.
“All DAT is dementia, but not all dementia is DAT” 18
DAT
 60-80% of dementia that occurs in those >65
years old
 Slow, insidious decline in multiple cognitive skills
 Relatively well preserved motor function early in
disease course
 CT/MRI normal, or atrophy, perhaps with mild
white matter changes
 No biological markers - diagnosed at autopsy
 Etiology: genetics (APO e4) + ?
19
Dementia with Lewy Bodies (DLB)
 DLB more recently accounts for 15 - 20% of all dementia
 Hallmark feature: widespread Lewy bodies throughout
the neocortex with Lewy bodies and cell loss in the
subcortical nucleii with distinctive pattern of neuritic
degeneration on autopsy
 More males than females
 Age of onset: 50 – 83
 Insidious onset progressing to profound dementia
McKeith. I.G. Dementia with Lewy Bodies. British J of Psychiatry 2002, 180,144-147
Shiozaki et al:J Neurol Neurosurg
Psych: V67:1999
DLB Core Features
 Required: Cognitive Decline with decreased social
or occupational functioning
 A diagnosis of Probable DLB requires 2 of the
following (Possible DLB requires only one of the
following):
– Fluctuating cognition with pronounced variation in
attention and alertness 1
– Recurrent visual hallucinations that are typically well
formed and detailed
– Spontaneous motor features of parkinsonism
1.
2.
Quantification and Characterization of Fluctuating Cognition in Dementia with Lewy Bodies and Alzheimer's
Disease M.P. Walker, G.A. Ayre, E.K. Perry, K. Wesnes, I.G. McKeith, M. Tovee, J.A. Edwardson, C.G. Ballard
Dementia and Geriatric Cognitive Disorders 2000;11:327-335 (DOI: 10.1159/000017262
McKeith. I.G. Dementia with Lewy Bodies. British J of Psychiatry 2002, 180,144-147
21
Dementia with Lewy Bodies
 Treatment Issues
– Up to 80% of DLB patients have hypersensitivity
to neuroleptics. Prescribe antipsychotics only
when absolutely necessary and under strict
monitoring
– Provisional evidence suggests that patients may
respond more preferentially to AChI therapy
– Concomitant depression
 35% of DLB vs. 16% of AD
McKeith. I.G. Dementia with Lewy Bodies. British J of Psychiatry 2002, 180,144-147
22
Frontal Lobe Impairment: Sx
 Mood lability or inappropriate affect
 Poor impulse control
 Verbally rude, caustic, bigoted, etc.
 Episodically physically aggressive
 Perseverative
 Restless/grabbing/reacts strongly to stimuli
 Difficult to redirect
 Sexually inappropriate/aggressive
23
Frontal Lobe Impairment
 Not psychotic behavior, but poor impulse
control
 Seen in multiple types of disease processes
- SDAT
- Vascular dementia
- Multiple sclerosis
- EtOH disease
24
Frontal Lobe Impairment:
Non-Pharmacologic Management
 Maintain professional distance
– Exaggerated manners, professional attire
– Emphasize courtesy, avoid overly friendly
 Communicate concretely, no open ended comments
 Define the activity, give few and clear choices
 Shape the behavior, acknowledge improvements
 Medication when needed:
– Safety concerns
– Not responsive to nonpharmacologic interventions
25
Definition: Delirium
A state of acute confusion,
inattention, and altered level of
consciousness (LOC), usually
abrupt in onset (over several hours
to several days).
26
Delirium: Symptoms
 Fluctuations in alertness & mental
functioning manifested by inattention
 Anxiety
 Hallucinations
 Disorientation
 Tremors
 Delusions
 Incoherence
27
Common Delirium Triggers
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Acute illness
Heart or lung disease
Infections
Poor nutrition
Endocrine disorders
MEDICATIONS
Alcohol use
28
Delirium
 A syndrome, not a final diagnosis
 Fluctuating level of alertness
 Difficult to assess with dementia
 Must identify etiology to treat
appropriately
 If psychotic, time-limit use of
antipsychotics
29
Delirium
 10% of all hospitalized patients
 22-38% of hospitalized patients >65
 60% of hip fracture cases
 Up to 75% of hospitalized patients from SNF’s
 Associated with a 35% increase in hospital
mortality
 Physicians correctly diagnose delirium in less than
20% of cases
30
Distinguishing Delirium from Dementia
Delirium
Dementia
•Acute onset, usually
occurring over days or less
•Gradual onset that cannot
be dated
•Global disorder of attention • Attention fairly normal
& cognition
initially
•Level Of Consciousness:
Hypoactive, hyper-active or
both
•Generally lasts days to
weeks
•Usually reversible
•Prominent physiologic
changes
•Level Of Consciousness:
normal until final stages
•Chronically progressive
over months or years
•Irreversible
•Minimal physiologic
changes
31
Depression: Diagnosis
 Depressed mood for at least 2 weeks
Plus
 At least four of the following:
- Insomnia or hypersomnia
- Significant weight loss or malnutrition
- Fatigue or loss of energy
- Decreased ability to concentrate
- Psychomotor agitation or retardation
- Excessive guilt or feelings of worthlessness
- Thoughts of death, suicidal ideation, or a planned or
attempted suicidal act
- Loss of interest or pleasure in nearly all activities
32
Depression: Diagnosis
 Geriatric Depression Scale (GDS)
 Cornell Scale for Depression in Dementia
 Center for Epidemiologic Studies of
Depression (especially for African-American
and Native Americans)
 No direct biologic marker
33
Depression: Elder vs Younger
• Elders exhibit different symptoms
• Multiple somatic complaints
• Fatigue
• Insomnia
• Functional loss
• Irritability
• Younger: tearfulness, sadness and suicidal
indications
34
Depression
 The most common geriatric psychological disorder
 Up to 1/3 of NF residents
 Estimated that PCP’s fail to diagnose depression
up to half the time & fail to provide adequate
treatment for half of those so diagnosed (Kroenke,
AIM. 1997)
 Closely associated with functional decline &
triggering quality indicators
35
Depression
 Often co-morbid with dementia
 Common post-stroke – up to 30%
 Beware “ageism” as a barrier to diagnosis/tx
 Look for underlying medical/medication
causes
36
Depression
 May be mimicked/caused by ADR
- Carbidopa/levodopa
- Beta-blockers
- Clonidine
- Benzodiazepines
- Barbituates
- Anticonvulsants
- H2 blockers
37
Depression… or Dementia… (or Both?)
Depression
Dementia
 Clear, recent onset
 Gradual onset
 Shorter duration
 Progression over years
 Often previous psychiatric
history
 May not have psychiatric
history
 Memory complaints
 Minimizes disabilities
 Fluctuating performance
 Tries hard to perform
 Recent and remote memory
equally bad
 Memory loss greater for
recent events
 Depressed mood precedes
memory complaints
 Memory loss precedes
depression
38
Anxiety: Definition
 Awareness of the physiologic reactions of the
“fight or flight” responses
 May be triggered by internal or external factors
 May be triggered by issues considered
“irrelevant” to others but are real to the sufferer
 Anxiety symptoms are far more common than
anxiety disorder
39
Anxiety Disorders
 Think Differential Diagnosis:
– Psychosis/Depression/Delirium/Pain/GAD
 Modify environmental triggers if possible
 Medications:
- Caffeine
- Bronchodilators
- Pseudoephedrine
 Medical illness
- Hyperthyroidism
- Cardiac arrhythmias (Atrial fibrillation, PVC’s, etc)
40
Psychosis
 Definition
– Impaired connection to reality
– Auditory or visual hallucinations or delusions
 Psychosis is a symptom, not a final diagnosis
 Differential Diagnosis includes all types of
Dementia, Delirium, Drugs (both intoxication and
withdrawal), Schizophrenia, Bipolar Mania and
Psychotic Depression
 The diagnosis indicates duration of treatment
41
Personality Disorders
 Easy to over-diagnose when elder
patients decompensate due to
dementia, depression, pain, etc.
 Consider empiric treatment with
antidepressant
 Look for LIFELONG history of the
personality disorder
42
Toxic Personality Syndrome
 Not a disease, but a personality type
 This personality type is often hypercritical, angry,
and accusatory in spite of every effort to give them
comfort and optimal care. (Take care not to judge
the care in a facility based solely on the behaviors
or statements of this personality)
 Does not require (or respond to) any treatment
43
The ABC’s of Behavior Intervention
 “A” = The Antecedent Events
 “B” = The Behavioral Event
 “C” = The Consequences
Slattery et al, Annals of Long Term Care 1999; 7[10]:385-391
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The Antecedent Event
(Behavior events are rarely unprovoked)
 Triggers that occurred before or even caused
the behavioral event.
 Modifying triggers is best approach for
cognitively impaired, because memory loss
interferes with learning consequences.
45
Five Categories of Triggers
 Physical Triggers:: pain, impaired sight or hearing,
fecal impaction/constipation, needs changing or
repositioning, etc.
 Emotional Triggers: worried, afraid, distressed, etc.
 Environmental Triggers: too much or too little
lighting, noise, temperature, activity levels, etc.
 Task Triggers: difficulty when challenged by a
specific task like bathing, dressing or eating, etc.
 Communication Triggers: difficulty understanding
others or expressing self, etc.
46
Environment/Stressors
Areas to Consider
Examples
Stressors
Losses
Decreased control
Environment
Crowding
Level of stimulation
Premorbid personality
Identity
Activities
Caregiver issues
Burnout, need for respite
Education & expectations
Approach
Concrete with flexibility
Respect, redirection
47
The Behavioral Event
Defined as any behavioral episode
that is disruptive or adverse, or
that jeopardizes the safety of the
resident, other persons, or objects
in the environment.
48
Goals of Treating Behaviors in the
NH
 Reduce the risk of injury
 Reduce patient distress
 Minimize adverse drug events
 Maintain resident in most desirable
living setting
 Define for WHOM it is a problem
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Impact of Behavioral Symptoms
 25% required no intervention.
 0.8% resulted in injury to others.
 0.9% resulted in physical damage to the
environment.
 An average of 24 minutes of staff time
was required per intervention.
Souder E, Heithoff K, O’Sullivan PS , et al, Aging and Mental Health, 1999; 3:54-68
50
The Consequences
 Includes all actions or occurrences
encountered after the episode or as an
outcome of the event.
 A cognitively intact resident learns to repeat
behaviors that are “rewarded”, for example, if
they get attention from staff. Caregivers must
consistently reward desired behavior.
 Cognitively impaired residents don’t remember
the “rewards”, so it’s best to focus on
changing the antecedents or triggers.
51
Documentation Tips
 Document all diagnosis being actively treated in monthly
orders & progress notes
 Document behavior in progress notes
– Summarize target symptoms
– Attempted nonpharmacologic interventions
– PRN’s used
– onset, duration, frequency, associated factors
 Document medication efficacy re: target symptoms
 Look at behavior monitoring for accuracy and
completeness. Consider other ways to document
– GDS, Cornell, Behave AD, Cohen Mansfield
52
Documentation Shortfalls
 108 bed community nursing home.
 44 (41%) residents were on antidepressant therapy.
 14 residents were also on at least one antipsychotic
medication for management of agitation.
 Indication for use was documented in 42 cases
(95%).
 Outcome was documented in 25 cases (57%).
 Adverse drug reaction monitoring was documented
in 9 cases (20%).
Annals of Long Term Care 1999, 7[10]:364-368
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Non-pharmacologic Interventions:
Behavioral Strategies
 Behavioral Contracting
 Positive Reinforcers
 Written Communications
 One-on-One Intervention
 Redirection
 Distraction
 Traffic Controllers
 Signs/Symbols
 Wander Prevention Nets
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Urgent Action Issues
The immediacy and intensity of action
taken should reflect the severity
and safety of the situation.
There may not be time to explore
antecedents in an explosive situation
55
The Prescribing Cascade
 Important in behaviors as it is in other areas
of LTC issues
 The continuing use of medications to
address the adverse drug effects of prior
drugs
 On-call doctors and frequent staff changes
in facilities can inadvertently accelerate the
cascade
56