Essentially, CMS has made off-label use of antipsychotic medications in dementia residents a national priority
A, B & C is correct
Behavioral Disturbances of Dementia
Behavioral Disturbances of DEMENTIA: Interventions to Reduce the Use of Psychotropic Medications MICHELE THOMAS ANDREW HECK Pharmacy Services Manager Clinical Director Virginia Department of Piedmont Geriatric Hospital, Behavioral Health, Virginia Department of Developmental Services Behavioral Health, Developmental Services(c) 2013 by the authors, on behalf of the Virginia Geriatric Mental Health Partnership & made possible through a grant from the Virginia Center on Agings Geriatric Training EducationInitiative and supported by the Riverside Center for Excellence in Aging and Lifelong Health, the Virginia Geriatric Mental Health Partnership, and the VCUs Department of Gerontology.
ABBREVIATION DETAIL ADE Adverse Drug Effects ADL Activities of Daily Living ALF Assisted Living Facility BPSD Behavioral and Psychological Symptoms of Dementia CMS Centers for Medicare & Medicaid Services GDR Gradual Dose Reduction LTC Long Term Care LTCF Long Term Care Facility Sx Symptoms ABBREVIATIONS
By the end of thepresentation,participants will: Learn about appropriate use of antipsychotic medications in individuals diagnosed with problematicBe able to more clearly behaviors in dementiadescribe Behavioral andPsychological Symptoms ofDementia, (problematic Become familiar withbehaviors, [BPSD or BPSD nonpharmacological strategies forSx’s]) and possible triggers; preventing and/or reducing problematic behaviors;Objectives
The patient is an 84 year old white female newly admitted to a LTC setting exhibiting the following signs and symptoms: • two to three year history of increasing forgetfulness • Increased wandering and elopement attempts • distractibility • repetitive requests calling out for her husband • intrusiveness • resistance to personal care • language deficits.Ms. Take (MT) Over the next few weeks at the LTCF, MT declined. She: • no longer recognized her husband • exhibited repetitive behaviors • verbalized suspicious statements about husband’s whereabouts • exhibited increased restlessness, and Patient Intake & • began experiencing persistent nighttime History wakefulness. Case of Ms. Take (MT)
Common BPSD/Behaviors in DementiaAggression/Agitation Apathy Delusions Anxiety Psychomotor Disturbance Up to 46% 72% 9-63% 48% 80% Sleep/Wake Hallucinations Physical Aggresion Irritability/Lability Depression/Dysphoria Distburbance 4-41% 31-42% 42% 42% 38% Disinhibition Sundowning Hypersexuality Obsessive/Compulsive 36% 18% 3% 2% Jeste D, et al. Neuropsychopharmacology. 2008;33:957 Spalletta G, et al. Am J Geriatr Psychiatry. 2010;18:1026
Early(~0-3yrs) Mild-Mod(~3-5yrs) Severe(~6yrs) Mood Cognition Behavior / Function 100 Agitation 80 Diurnal rhythm Depression% patients 60 Irritability Wandering Aggression Social withdrawal 40 Anxiety Mood Paranoia change Hallucinations 20 Socially unacceptable behavior Suicidal ideation Accusatory Delusions behavior Sexually inappropriate behavior -40 -30 -20 10 0 10 20 30 months before dementia diagnosis / months after dementia diagnosis Estimated Timeline of BPSD in Dementia Jost BC, Grossberg GT. J Am Geriatr Soc. 1996;44:1078-1081 Brodaty et al. 2003. J. Clin Psychiatry 64:36. http://www.ucc.ie/en/
POLLAppropriate Antipsychotic Treatment targets include thefollowing:(Check all that apply) A. Distressing hallucinations B. Physically aggressive behavior C. Delusional jealousy D. Anger over accepting assistance with ADL’sPOLL: CMS ―Approved‖ Indications for LTC Facilities
BPSD Clusters & Antipsychotic Medications PSYCHOMOTOR AGITATION • Pacing *AGGRESSION • Restlessness • Physically aggressive • Repetitive actions • Verbally aggressive • Dressing/undressing • Aggressive resistance MANIA • Sleep disturbance to care • Euphoria • Pressured Speech • Irritable *PSYCHOSIS • Hallucinations • Delusions APATHY • Misidentifications • Withdrawn DEPRESSION • Suspiciousness • Lacks interest • Sad • Amotivation • Tearful • Hopeless • Low self esteem • Anxiety • GuiltBugden. Antipsychotics and Dementia: Part of the Solution or Part of the Problem, Dementia Care Conf. 2012
Apathy Calling out e.g., screaming Most Hiding/hoarding common Nocturnal restlessness BPSD Repetitive activities e.g., pulling on locked doors, etc. NOT Wanderingamenable to Unsociability medication/ Poor self‐careantipsychotic Uncooperativeness without aggressive behavior medication Verbal expressions or behaviors that do not represent a danger Nervousness / fidgeting / Mild anxiety Impaired memory Bugden. Antipsychotics and Dementia: Part of the Solution or Part of the Problem, Dementia Care Conf. 2012
• No FDA-approved medications to treat dementia-related behavioral disturbances• Medications utilized today, prescribed off-label: • Typical & atypical antipsychotics • Benzodiazepines • Anticonvulsants • Cholinesterase inhibitors • NMDA receptor antagonist • Selective serotonin reuptake inhibitors (SSRIs)BPSD and Psychotropics Lawrence RM et al, Psychiatric Bulletin. 2002;26:230
• 2005: FDA issued warning: 1.6 – 1.7 fold increase in mortality in response to analysis of 17 placebo-controlled studies.• 2010: Nearly 1/3 of elderly patients with dementia residing in nursing homes are on atypical antipsychotics for BPSD even though.. Most episodes of BPSD appear as single episode (~86%) and the average duration of each episode lasts between ~9 to 19 months BLACK BOX WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS and SUICIDALITY … *Antipsychotic drugs have increased risk of death…* Jablow V. Trial. 2008;44:12 Recupero PR et al. J Psychiatric Pract. 2007;13:143
• HHS Initiative: National Partnership to Improve Dementia Care • CMS’s initial goal to reduce unnecessary antipsychotic medication use in all care settings.• Goal: Using person- centered and Unnecessary By improving individualized medication use dementia care interventions for will decrease. behavioral health in nursing homes Antipsychotics are the initial focus of the partnership, however attention to other potentially harmful medications is also part of this initiative. §483.25(l) Unnecessary Drugs Each resident’s drug regimen must be free from unnecessary drugs (F329)
National prevalence Initiative: Reduce the rate of antipsychotic national rate by 15% medication use in long-stay residents 23.9%This number includes all residents . 2012 GOALin NH’s EXCEPT personsdiagnosed with Schizophrenia, 2013 GOALs?Tourette’s Syndrome orHuntington’s disease Reevaluate. based on 2012 4th quarter findingsFirst Year Goals
• Effective interventions follow thorough assessments aimed at the problem’s specific cause • Management of BPSD must be comprehensive and systematic • Successful BPSD management blends reactive and proactive strategies to experience to feel safe pleasure Treatment of BPSD should begin with nonpharmacological approaches keeping in to experience minimal mind five care goals for the patient with stress with adequate to feel comfortable dementia: positive stimulation to experience a sense of control BPSD: Need for Alternative Approaches in Treatment Buhr GT, White HK. Difficult behaviors in long-term care patients with dementia. J Am Med Dir Assoc. 2006;7(3):181.Ryden MB, Feldt KS. Goal-directed care: caring for aggressive nursing home residents with dementia. J Gerontol Nurs. 1992;18(11):35-42.
Is it: Why is • only problematic for the resident? this • endangering/irritating/ upsetting to other behavior a residents/family members/visitors/staff? • interfering with care? problem? • Focus resources towards behaviors that are dangerous or cause marked distress to the resident or othersFirst Question in Identifying & Describing BPSD Behaviors
PRIORITY RISK AREAS ROAMING? IMMINENT PHYSICAL RISK (fire, falls, frailty?) SUICIDE? K INSHIP RELATIONSHIP ABUSE/NEGLECT? SELF NEGLECT, SUBSTANCE ABUSE, SAFE DRIVING?Risk Assessment: Taking Inventory
Static Presence of delusions Depression Impaired Low serotonin levels communication Psychosis; esp. Frontotemporal command hallucinations dementia and thought disorganization Certain forms of Irritability traumatic brain damage DynamicBPSD Example: Aggression Risk Factors Heck, A. Aggressive behavior in the elderly: prevention and management. Cross Country Education Seminar, 2006.
• Will want to know the following about the BPSD: • Type • Frequency • Intensity • Duration• Functional analysis of behavior: • an examination of what a behavior’s purpose (i.e., function) serves for the individual• Answers the ―what, where, when and how‖ questions• Basic functional analyses can be performed by anyone clinically familiar with the residentClarifying the BPSD
Behavior Behavior Behavior Description Prediction Functions did the behavior(s) What functions did the what specific behavior(s) behavior(s) appear to primarily occur during occurred? serve for the person? specific time periods? What were the were there periods when consequences that were if >1 behavior, did any the behavior(s) typically provided when ever occur together? consistently did not occur? the behavior(s) occurred? when behavior(s) were occurring, were there setting events or stimuli which were consistently related to their occurrence?With answers to these questions, along with any baseline data gathered, clinicians maybegin to draw conclusions about the cause(s) and treatment of the problematic behavior Clarifying the BPSD (cont.)
Health and medical conditions E nvironment Approach Resident factors• An ordered strategy for examining common sources of a behavior problemThe HEAR method
B12/Folic Acid Deficiencydangerous causes of BPSD Sxs Infection (UTI/Pneumonia) Hunger/Thirst Most common and potentially Nocturia MEDICAL Hypercalcemia Pain Hypothyroidism Constipation Digoxin Anticholinergic agents Benzodiazepines MEDICATIONS/DRUG INDUCED DELIRIUM Opioids Antihistamines Health and Medical Conditions: BPSD Common Causes and Trigger Factors Bugden. Antipsychotics and Dementia: Part of the Solution or Part of the Problem, Dementia Care Conf. 2012
POLLDelirium is a state of acute cognitive impairment caused bya medical problem. Three primary cardinal features ofdelirium are: A. Acute/onset is days to weeks B. Transient in severity often fluctuating throughout the day for short periods of time C. Reversible state of confusion D. Most often irreversible state of confusionPOLL: Delirium
• The likelihood of developing delirium increases with age• Three primary features to look for: 1. ACUTE 2. TRANSIENT (lasts only for a short time) and 3. REVERSIBLE state of confusion.• Delirium diagnosis is often missed in up to 70% of cases • This is especially concerning, since up to 60 % of elderly individuals experience a delirium prior to or during a hospitalization Delirium is Always an Acute Medical Emergency Delirium http://www.nlm.nih.gov/medlineplus/ency/article/000740.htm
DRUGS, DRUGS, DRUGS! EYES, EARS –POOR HEARING AND VISION = RISK FACTORS L OW O STATES (MI, CHF, COPD, acute respiratory distress syndrome) 2 I NFECTION, IMMOBILZATION RETENTION (URINE/STOOL), RESTRAINTS ICTAL—SEIZURES CAN CAUSE DELIRIUM UNDERHYDRATION, UNDERNUTRITION METABOLIC ABNORMALITIES(s)UBDURAL, SLEEP DEPRIVATION Common Causes of Delirium
84 year old white female newly admitted to LTC setting exhibiting signs & symptoms of: • wandering • elopement attempts • distractibility at mealtime • repetitive requests for husband • intrusiveness • resistance to personal care, and MT • language deficits. MT’s Husband MT’s current medications Adherence• Staff talked with MT’s • Docusate 100mg bid • Prior to admission, Mr. Take husband. He noted she constipation. reported that his wife’s dose appeared more worried, • Oxybutynin 10mg XL daily of oxybutynin had been apprehensive, fearful and incontinence. increased from 5mg to 10mg she no longer recognized him but, he also stated that his during their daily visits wife rarely took her medications, let alone on a regular basis... Case Update: Ms. Take
• MT became more and more challenging exhibiting increasing exit seeking behaviors; daytime restlessness and pacing increased to where it became extremely difficult for staff to redirect her • She had periods of feeling exhausted, appearingMs. Take overly sedated or subdued; this resulted in frequent daytime napping. • MT also began exhibiting increased distractibility and began refusing to eat. As a result, MT had an eight pound weight loss. MT: 30 Day Update
Orthopedic issues / arthritis: feet (e.g., poorly fitting shoes), Is there shoulder, back, knee, Dehydration/ etc Nutritional Constipation, urinary issues? retention / incontinence?Musculoskeletal: Joint pain? HPE, Vital Signs, Is there Infection/ Is there Pain? Labs Illness? Eyes: Corneal abrasion? as warranted Sensory deficits? Is the resident Skin: Bed sores/ skin experiencing lesions? ADEs? Evaluation: Are there any Physical Causes or Medication Adverse Effects (ADE)?
**DELIRIUM** Delirium Assessment Labs: CBC, performed: PE electrolytes & U/A MT was Positive U/A >> Acute onset Sxs, VS: fluctuating in +orthostatic BUN relative course, and hypotension; to SCr >> +restlessness, Sp. Gravity>> +poor a change in 3+ leuks & cognition, attention WBCs in urine (increasing difficulty in focusing attention). Findings: ANTICHOLINERGIC TOXICITY "Compliance Toxicity”…due to increase in oxybutynin dose with resultant anticholinergic load/toxicity oxybutynin dose > oral intake > urinary retention >> bladder infection.MT: Evaluation/Findings
• Definition: • ANY ASPECTS OF AN INDIVIDUAL’S SURROUNDINGS THAT INFLUENCE BPSD• Both cognitively impaired and cognitively intact individuals can be very sensitive to even minor environmental irritants or changes• Irritant/change + behavioral dyscontrol = potentially harmful reaction!• Environmental changes are recommended in most circumstances • No adverse effects • Easy to implementHEAR: Environmental Factors
• Common examples: • Physical elements • Highly patterned wallpaper • Mirrors • Noise and activity level • Loud call bells/paging systems • Constant Television Programs (e.g., Soap Operas, CNN) • Space issues • Frequent room changes/redesign • Relocation (within or between facilities) • Lack of adequate physical spaceEnvironmental Factors cont.
Liberally attempt different environmental changes (being sensitive to the amount of change the residentsstrategies: can tolerate) General Try using soothing sounds (ocean waves, babbling brooks, even white noise) Scheduled walking or exercise programs have demonstrated effectiveness in preventing and addressing BPSD Exposure to bright light can also be effective (avoid in patients with a history of Bipolar Disorder) Environmental Factors cont.
Providing space to freely wander Brief gentle Individualized hand music massages Empirically supported interventions to prevent/ manage agitation Use of “gliding” Aromatherapy rockersEnvironmental Factors cont. Landreville P et al. Intl Psychogeriatrics 2006;18 Rayner A et al. Am Fam Physician 2006; 73 Camp C et al. In Lichtenberg D et al., Handbook of dementia 2003; NY: Wiley & Sons
• 69 year old male with Alzheimer’s disease • Has refused to leave room in past month; swings out at staff who try to get him to come out for meals, activities • Often observed to walk up to doorway, look at floor beyond threshold, and retreat into room • Staff discovered janitorial staff had recently changed toMr. a shinier wax for the hallway floors (looks slick?)Faller • Timing of change coincided with the emergence of Mr. Faller’s behaviors • Less shiny wax used, Mr. Faller was able to leave the room with minimal difficulty soon afterward Case Example: Mr. Faller
• Definition: • THE METHOD(S) BY WHICH INDIVIDUALS ARE ADDRESSED BY THEIR CAREGIVERS THAT CAN INFLUENCE BPSD• Can include physical, verbal, nonverbal, schedule/routine issues, etc. Common examples Stance and Physical touch Erratic or Violations of Caregiver Verbal positioning (esp. during unpredictablepersonal space attitude/reactions approaches issues ADLs) daily structure HEAR: Approach Factors
Emphasize lack of intentionality of resident behaviors Educate about signs and symptoms of dementia Staff training Teach communication skills (below) Train on proper physical approach to physical contact-based tasks (e.g., ADLs) Use short phrases that express one major idea at a time Use closed-ended rather than open-ended questionsPREVENTION/ Communication Focus on the emotion rather than the content of what is being saidMANAGEMENT (validation)STRATEGIES: Give directions one step at a time Use distraction rather than logic/reason to calm resident behavior (most often in later dementia stages) Keep predictable schedule (esp. mealtimes and sleep) Structure Use familiar staff whenever possible Approach Factors cont.
• Resident with 6-year diagnosis of Alzheimer’s disease • Memory unit in ALF: For the past three weeks, every morning Ms. Hurley has been observed to throw her toast from her tray across the room • Resident had not previously expressed a dislike for toast, and family said she used to like itMs. • After starting to observe Ms. Hurley from beginning of mealHurley forward, staff noticed that she struggled to apply the sealed butter and jelly packets (sequencing problems) • Staff started serving the toast with butter and jelly already spread on it, behavior ceased directly. • Example of catastrophic reaction Case Example: Ms. Hurley
• Definition: • THE NEEDS, WANTS, DESIRES, OR HABITS OF AN INDIVIDUAL THAT INFLUENCE BEHAVIORAL PROBLEMS• Can also be considered ―psychological‖ factors• These constitute a broad array of potential contributing causes for BPSD • Learned patterns of behavior • Lack of socialization and/or thinking • Boredom • History of trauma • Lack of autonomy/privacy/intimacy • Mood states • Distress/feeling abandoned • Emotional discomfort • Fear of danger • Misinterpretation paranoia HEAR: Resident Factors
PSYCHOTHERAPY (for some residents) • Individuals with early-state dementia may benefit from some forms of psychotherapy • Gather collateral information—family and others • “Has your loved one ever shown behavior like this before?” • “Is there anything about these circumstances that may be bringing up bad memories for your loved one?” • Pass along information and observations to therapistHEAR: Resident Factors (cont.)
BEHAVIOR PLANNING • Some residents may benefit from more involved contingency management plans (AKA behavior plans) • Works across different levels of cognitive ability • Typically developed by a MH consultant, implemented by facility staff (with staff training) • Aimed at bringing about desirable behaviors while discouraging or eliminating harmful behaviorsHEAR: Resident Factors (cont.)
• 81 year old woman in psychiatric hospital • Cursing and swinging arms • Personality disorder and early dementia • Plan: could earn “treats” (coffee, strolls, etc.) every 2 hours if no cursing or striking outMrs. Sweet • Needed frequent reminders of treat opportunities • Problematic behavior dropped 66% in 2 months • After thinning reinforcement schedule, behavior stopped completely Case Example: Mrs. Sweet
Identification and attribution of behaviors • Prevalence of BPSD has been found to vary across cultures • Is behavior culturally normative? (e.g., loudly and constantly praying, high hostility in interpersonal interactions) • Is environment or approach having a disproportionate impact due to cultural factors? (e.g., physical touch during ADL care)Diagnosis • Were instruments geared toward individual’s [national or ethnic] culture? (e.g., normative data, language) • Was level of education accounted for? BPSD: Cultural Considerations for Clinicians Shah et al Int Psychogeriatr 2004; 16 Herbert P Can J Neurol Sci 2001; 28 Suppl 1
Communication difficulties “Taboo” topics Stigma attached to Cultural factors mental illness that may complicate the Bias and prejudice of clinicians diagnosis of dementia Institutional racism Unfamiliarity with sxs of dementia by relatives Sxs of dementia being viewed as a function of old ageCULTURAL CONSIDERATIONS: Diagnosis Shah, AS. CROSS-CULTURAL ISSUES AND COGNITIVE IMPAIRMENT http://www.rcpsych.ac.uk/pdf/Dementia%20%20Culture.pdf
When is an antipsychotic justified? Schizophrenia Schizoaffective disorder Delusional disorder Mood disorders (e.g. mania, bipolar disorder, depression with psychotic features, and treatment refractory major depression) Antipsychotic Schizophreniform disorder medication can beused for the followingconditions/diagnoses: Psychosis NOS Atypical psychosis Brief psychotic disorder Dementing illnesses with associated behavioral symptoms Medical illnesses or delirium with manic or psychotic Antipsychotic treatment goal[s]: to stabilize and or improve a resident’s outcome, quality of life and functional capacity
JUSTIFY BPSD Sxs must present a DANGER to the person or others“H” or, cause the patient to experience one of the following:After “E” - inconsolable or persistentHEALTH After “A” distress;and medical causes - a significant decline inhave been ruled out ENVIRON- After “R” function; MENTAL - substantial difficulty treatment strategies APPROACH have been tried/ FACTORS After receiving needed care implemented have been evaluated, RESIDENT (training, FACTORS communication & have been evaluated structure) SELECT 1. Individualize 2. Initiate monotherapy Start low, go slow 3. Titrate dose to effect, Rule of Thumb: 5-10% dose increases q 4-6 wks 4. If effective, continue few weeks – few months 5. STOP drug if INEFFECTIVE (appropriately tapering) Antipsychotic justification in BPSD Maixner, et al. J Clin Psychiatry. 1999;60(suppl 8):29. Jibson and Tandon. J Psychiatry Res. 1998;32:215.
GDR attempts can be omitted if they are ―clinically contraindicated.” For behavioral symptoms related to dementia, “clinically contraindicated” is defined when: Resident’s target symptom[s] return or worsen after most recent GDR attemptAND Physician has documented rationale for why additional GDR attempts would likely impair the resident’s function Gradual Dose Reduction : Antipsychotics Hardesty, JL. Presentation to VHCA, Under the Microscope: The Ever-Increasing Scrutiny of Antipsychotics in LTC, 2012
In clinical record: Clear documentation of treatment targets / symptoms Non-pharmacological interventions tried and/or in use Pharmacological intervention is prescribed: • Lowest effective dose is utilized • Time limited duration, (as warranted) Ongoing monitoring / reporting of efficacy and response • ADEs clearly being monitored for and supported in documentation • Tolerability & efficacy assessed every 3 to 7 days GDR attempts are documented • Reassess for tapering / discontinuation per CMS guidelines If the drug doesn’t help, stop it!
Explore, identify and address the following potential contributors: •Health/medical factors Clearly •Environmental factors documentConduct risk •Approach factors every step of analysis •Resident factors the way… Immediately Prescribe address medications imminent judiciously safety issues •Start low and go slow! Conclusions: Managing BPSD