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Evaluation and Management of Behaviors in Persons with Cognitive Impairment

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The goal of this webinar is to enable healthcare clinicians to implement a comprehensive approach to non-pharmacologic and pharmacologic management of dementia-related behaviors for the benefit of patients and their caregivers.

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Evaluation and Management of Behaviors in Persons with Cognitive Impairment

  1. 1. Evaluation and Management of Behaviors in Persons with Cognitive Impairment Joseph W. Shega, MD
  2. 2. CE Provider Information VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through: VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved By: Florida Board of Nursing/Florida Board of Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling. VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists through: VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number: 139000207/RT CE Provider Number: 195000028/Approved By the Illinois Division of Profession Regulation for: Licensed Nursing Home Administrators and Illinois Respiratory Care Practitioner.
  3. 3. CE Provider Information (Cont.) VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2018 – 06/06/2021. Social workers completing this course receive 1.0 ethics continuing education credits. VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of Registered Nursing, Provider Number 10517, expiring 01/31/2021. Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois.
  4. 4. By the end of this presentation, you will be able to: • Differentiate among delirium, terminal restlessness, and dementia-related agitation and aggression • Identify and treat contributors to behaviors in dementia • Implement effective non-pharmacologic management approaches to behaviors in dementia • Incorporate pharmacologic treatment strategies to manage behaviors in dementia Objectives
  5. 5. • Current estimate: 5.1 million in US have dementia (ADAMS Study) – 3.2 million women – 1.8 million men • Projected for 2050: 14 million Americans with dementia • One in three women will develop dementia during her lifetime • Almost one-third of people over age 85 have dementia • Someone new develops dementia every 67 seconds in the US Background: Dementia Epidemiology
  6. 6. • One in three older adults who die each year have a diagnosis of dementia • Diagnosis of dementia cuts one’s life expectancy in half • Dementia is the fifth-leading cause of death in persons over 65 • >500,000 deaths a year in US are attributed to dementia Background: Dementia End of Life
  7. 7. Hospice Use by Primary Diagnosis 0 200,000 400,000 600,000 800,000 1,000,000 1,200,000 1,400,000 1,600,000 1,800,000 1992 1998 2005 2014 Other Kidney disease Stroke Chronic lower respiratory disesease Alzheimer disease Heart Disease Cancer
  8. 8. Symptoms of End-Stage Dementia 0 5 10 15 20 25 30 35 40 Dyspnea Pain Pressure ulcers Aspiration Agitation ResidentswithSymptoms(%) Distressing Symptoms Months before Death (no. of residents alive during interval) >9-12 (N=67) >6-9 (N=96) >3-6 (N=128) 0-3 (N=177)
  9. 9. • 61-year-old with Huntington’s Disease who presents to the hospice inpatient unit (IPU) with impulsivity and agitation - Has not slept in two days; is more confused, pacing, eating food out of garbage • Patient recently admitted to hospice with functional decline, falls, weight loss, dysphagia and worsening behaviors • Interventions to date: Haldol 5mg every six hours and every two hours as needed, mirtazapine 30mg at night, sertraline 50mg daily, lorazepam 1mg every six hours and one hour as needed, amantadine 200mg daily • Urinalysis and bloodwork were unremarkable. Patient was transferred to the IPU for further management of impulsivity and agitation Case 1:
  10. 10. • 86-year-old with cerebral atherosclerosis with recent functional decline - In the past two weeks: bedbound, fall, stage II sacrum, poor appetite, weight loss, and increased agitation/aggression • Daughter took patient out of ALF after patient hit and tried to bite several staff - Patient spends most of the day yelling, swearing, kicking; is very restless in bed • Comorbidities: hard of hearing, poor vision, arthritis, peripheral vascular disease, history of stroke, hypertension, depression, and heart failure • Bloodwork and urinalysis were unremarkable. Patient admitted to hospice and transferred to the IPU for management of vocalizations and agitation/aggression. • Medications: sertraline 100mg daily Case 2:
  11. 11. • Identify dementia etiology as symptoms and treatments vary • Differentiate delirium, terminal restlessness, and dementia-related behaviors • Evaluate and manage all contributors • Identify the target symptoms to be treated and characterize impact on patient/caregiver • Non-pharmacologic interventions – Person-centered – Caregiver – Environment • Pharmacologic treatment Guiding Principles
  12. 12. Most Common Etiologies of Dementia Dementia Diagnosis Relative Frequency Pathophysiology Alzheimer’s disease 35-55% amyloid plaques and neurofibrillary tangles Mixed: Vascular and Alzheimer’s disease 25-35% Combination of Alzheimer’s disease and vascular disease Lewy Body Dementia 0-30% alpha-synuclein protein Vascular Dementia 10-20% cortical infarcts, subcortical infarcts and leukoaraiosis Frontotemporal Dementia <5% Tau protein
  13. 13. • Depression is more common in vascular dementia • Hallucinations are seen more often in Lewy body dementia – Special consideration ACEI and antipsychotics • Frontotemporal dementia often exhibits executive control loss – Disinhibition – Wandering – Social inappropriateness – Apathy • Behaviors increase in frequency with all conditions as disease progresses Dementia Etiology Considerations
  14. 14. • Identify dementia etiology as symptoms and treatments vary • Differentiate delirium, terminal restlessness, and dementia-related behaviors • Evaluate and manage all contributors • Identify the target symptoms to be treated and characterize impact on patient/caregiver • Non-pharmacologic interventions – Person-centered – Caregiver – Environment • Pharmacologic treatment Guiding Principles
  15. 15. Definition of Delirium AND plus either Acute Onset and Fluctuating Course Inattention Disorganized Thinking Altered Level of Consciousness (LOC) DELIRIUM
  16. 16. Terminal Restlessness 16 THE USUAL ROAD THE DIFFICULT ROAD
  17. 17. Thought and Perceptual Disturbances • Delusions • Paranoia • Hallucination Mood Disturbances • Anxiety • Depression • Irritability Dementia Behaviors Activity Disturbance • Agitation • Aggression • Wandering • Purposeless hyperactivity • Apathy • Impulsivity • Socially inappropriate behavior • Sleep problems • Repetitive behavior
  18. 18. • Identify dementia etiology as symptoms and treatments vary • Differentiate delirium, terminal restlessness, and dementia-related behaviors • Evaluate and manage all contributors • Identify the target symptoms to be treated and characterize impact on patient/caregiver • Non-pharmacologic interventions – Person-centered – Caregiver – Environment • Pharmacologic treatment Guiding Principles
  19. 19. Contributors to Behaviors Contributor Causes Approach Physical symptom Pain, SOB Opioid Psychological symptom Depression, anxiety SSRI, SNRI CBT Medical illness Delirium, infection, constipation Treat condition Unmet need Hunger, thirst, cold Attend to need Sensory impairment Poor vision/hearing Adaptive Environment Under-/over-stimulation Modify Pharmacologic Dig, caffeine, benzo Discontinue Dementia AD, Mixed, LBD AChEI
  20. 20. • Identify dementia etiology as symptoms and treatments vary • Differentiate delirium, terminal restlessness, and dementia-related behaviors • Evaluate and manage all contributors • Identify the target symptoms to be treated and characterize impact on patient/caregiver • Non-pharmacologic interventions – Person-centered – Caregiver – Environment • Pharmacologic treatment Guiding Principles
  21. 21. • Patient – Increased morbidity and mortality – Increased likelihood of hospitalization and longer length of stay – Early placement in a nursing home • Caregiver – Stress and strain – Depression and anxiety – Reduced income from employment – Lower quality of life • Behaviors and their management contribute to one-third of total dementia- related costs Behaviors in Dementia and Health- Related Outcomes
  22. 22. • Identify dementia etiology as symptoms and treatments vary • Differentiate delirium, terminal restlessness, and dementia-related behaviors • Evaluate and manage all contributors • Identify the target symptoms to be treated and characterize impact on patient/caregiver • Non-pharmacologic interventions – Person-centered – Caregiver – Environment • Pharmacologic treatment Guiding Principles
  23. 23. • Person with Dementia – Unmet need; behavior as an underlying need – Agitation etiology, remaining abilities, level of cognitive functioning, and past/present interests • Caregiver – Learning and behavioral (ABC) – Behavior Consequence Reinforces behavior • Environment – Environmental vulnerability and reduced stress thresholds: a mismatch between the setting and the patient’s ability to deal with it Dementia Behavior Models
  24. 24. • Reminiscence therapy (discussion of past experiences) • Validation therapy (working through unresolved conflicts) • Simulated presence therapy (use of audiotaped recordings of family members’ voices) • Aromatherapy (use of fragrant plant oils) • Snoezelen® (placing the person with dementia in a soothing and stimulating multi-sensory environment known as a “Snoezelen room”) • Cognitive training and rehabilitation • Acupuncture • Light therapy Non- Pharmacologic Persons with Dementia: Inconclusive Evidence
  25. 25. • Physical activity positively impacts depression and sleep • Hand massage • Personalizing the bathing experience Non- Pharmacologic Persons with Dementia: Evidence Exists in Two or More Randomized Clinical Trials (RCTs)
  26. 26. • Problem-solving with a family caregiver – Identify precipitating and modifiable causes of symptoms – Deploy efforts to modify these causes with selected non-pharmacologic strategies • Program examples – REACH II and REACH VA: Coping approaches and tailored behavioral management – The Tailored Activity Program (TAP): Occupational Therapy – The Advancing Caregiver Training (ACT): Health Professionals • A meta-analysis of 23 randomized clinical trials, involving almost 3,300 community dwelling patients and their caregivers – Significantly reduced behavioral symptoms (effect size 0.34, 0.20 to 0.48) – Similar to antipsychotics for behavior; similar to cholinesterase inhibitors for memory Non Pharmacologic Caregivers: Most Robust Evidence
  27. 27. • Over-stimulation (e.g., excess noise, people or clutter in the home) • Under-stimulation (e.g., lack of anything of interest to look at) • Safety problems (e.g., access to household chemicals or sharp objects; easy ability to exit the home) • Lack of activity and structure (e.g., no regular exercise or activities that match interests and capabilities) • Lack of established routines (e.g., frequent changes in the time, location or sequence of daily activities) Non- Pharmacologic Environment: Paucity of RCTs, Positive Impact
  28. 28. Responses to Non- Pharmacologic Interventions Greater Response • Higher levels of cognitive function • Fewer difficulties with ADLs • Speech • Communication • Responsiveness Less Response • Staff barriers (refuse to participate) • Patient in pain
  29. 29. • Identify dementia etiology as symptoms and treatments vary • Differentiate delirium, terminal restlessness, and dementia-related agitation • Evaluate and manage all contributors to agitation • Identify the target symptoms to be treated and characterize impact on patient/caregiver • Non-pharmacologic interventions – Person-centered – Caregiver – Environment • Pharmacologic treatment Guiding Principles
  30. 30. Helpful • Agitation and aggression • Psychosis – Delusions – Hallucinations – Paranoia • Depression • Irritability Dementia Behaviors and Pharmacologic Treatment Not Helpful • Day/night reversal • Calling out • Repetitive behaviors • Wandering • Apathy • Resistance to care
  31. 31. Pharmacologic Treatment of Agitation Therapeutic Class Trial Side Effects Trazodone + RTC Sedation, Hypotension SSRI (citalopram) + RCT Nausea, diarrhea, QTc inc >20mg daily Dextromethorphan/qui nidine + RCT Falls, dizziness, diarrhea, UTIs Lorazepam + RCT Sedation, falls, ataxia, agitation Anti-psychotics + RCT Stroke, infection, sz, QTc inc, DM, death Carbamazepine Valproic acid - RCT - RCT Sedation, anemia, liver toxicity Liver toxicity, sedation NMDA antagonist - RCT/+obs Constipation, dizziness AChEI - /+RCT/+obs Nausea, dizziness, weight loss Cannabinoids - RCT Low does used, oral form
  32. 32. • Several small randomized controlled trials indicate benefit – Cochrane review inconclusive evidence • Dosing: 25-20 mg BID-TID and q 2hrs PRN, maximum dose 400mg daily • Adverse effects: – Orthostasis, syncope, hypotension, dizziness – Priapism – SIADH – Somnolence – QTc prolongation Trazadone
  33. 33. Citalopram for Agitation in Alzheimer’s Disease
  34. 34. • QTc prolongation, which is dose-dependent above 20mg • Starting dose 10mg up to 40mg daily • Consider twice-daily dosing – 10mg daily for two weeks – 10mg twice daily thereafter • Other SSRI side effects • Onset of action within a week in one study Citalopram Considerations
  35. 35. • Best-studied pharmacologic intervention for dementia-related agitation • Moderate efficacy across trials and agents – Typical antipsychotics – Atypical antipsychotics • Substantial side effects • Black box warning: cerebrovascular events and death Antipsychotics
  36. 36. Antipsychotics (Cont.) Antipsychotic Recommended Dose Formulations Frequency Characteristics Risperidone 0.5-2.0mg Tab, liquid, IM Twice daily Extrapyramidal symptoms Olanzapine 2.5-15mg tab Daily Weight gain, increased sugar Quetiapine 25-400mg tab Three times daily (unless ER) Sedating, least extrapyramidal Aripiprazole 5-30mg Tab, liquid, IM Daily Less QT Haloperidol 0.5-5mg Tab, liquid, IM, IV, sub q Twice to four times daily Chlorpromazine 10-200mg Tab, liquid, IV, rectal Twice to three times daily Very sedating
  37. 37. CATIE-AD
  38. 38. CATIE-AD (Cont.)
  39. 39. CATIE-AD (Cont.)
  40. 40. • Modest efficacy for treatment of behaviors in dementia – NNT 5 to 14 • Studies usually short duration: 6-12 weeks • Large placebo effect: 30% on average • No difference in efficacy between typical and atypical antipsychotics • Typical antipsychotics: greater side effects Antipsychotic Summary
  41. 41. • Binds to GABA receptor in CNS • Anxiolytic, sedative and hypnotic effects (anterograde memory) • Increased risk of adverse events – Falls – Cognitive impairment/confusion – Hip fracture – Sedation – Paradoxical agitation Anxiolytics
  42. 42. Agitation and Dementia: Lorazepam
  43. 43. Pharmacology Common Agents Benzodiazepine Half-life Dosage range diazepam 20-50 hours Over 100 OA 2-10mg 2-4 times a day lorazepam 12 hours 0.5-2mg 2-3 times a day alprazolam 16 hours (9-27 range) 0.25-3mg 2-4 times a day clonazepam 30-40 hours 0.25-5mg 2-3 times a day
  44. 44. Dextromethorphan- Quinidine For Dementia Agitation in Alzheimer’s Disease
  45. 45. • FDA-approved for the treatment of pseudobulbar affect • Modulates glutamate, serotonin and norepinephrine • Only one randomized controlled trial to date for agitation • Side effects include – Falls – UTIs – Diarrhea – Dizziness • QTc prolongation Dextromethorphan- Quinidine Considerations
  46. 46. • 30mg to 120mg ATC and q2 PRN • NO DATA AVAILABLE • Many clinicians, health systems and long- term care facilities embrace the treatment • Adverse Reactions – Respiratory depression – Stevens-Johnson syndrome – Anemia, TTP and blood dyscrasias – Withdrawal symptoms with abrupt withdrawal – Lethargy and drowsiness – Nausea, vomiting, and hepatitis Phenobarbital
  47. 47. • Describe the behavior • Investigate the underlying contributors/causes • Create intervention (non-pharmacologic and pharmacologic) • Evaluate the intervention’s effectiveness Summary: DICE
  48. 48. • 61-year-old with Huntington’s Disease who presents to the hospice inpatient unit (IPU) with impulsivity and agitation - Has not slept in two days; is more confused, pacing, eating food out of garbage • Patient recently admitted to hospice with functional decline, falls, weight loss, dysphagia and worsening behaviors • Interventions to date: Haldol 5mg every six hours and every two hours as needed, mirtazapine 30mg at night, sertraline 50mg daily, lorazepam 1mg every six hours and one hour as needed, amantadine 200mg daily • Urinalysis and bloodwork were unremarkable. Patient was transferred to the IPU for further management of impulsivity and agitation Case 1:
  49. 49. • Describe: Huntington's with impulsivity and agitation/restlessness • Investigate: Medication regimen • Create: – Discontinue amantadine, mirtazapine and sertraline – Decrease Haldol 1mg every 6 hours and Lorazepam 0.5 every 8 hours and PRN – Start Trazadone 50mg morning and 100mg QHS and PRN, start Citalopram 10mg twice daily • Evaluate 1: – Increase Trazadone 100mg morning and 200mg QHS – Start dextromethorphan and quinidine • Evaluate 2: – Continue current treatment and discharge home to wife Case 1: (Cont.)
  50. 50. • 86-year-old with cerebral atherosclerosis with recent functional decline - In the past two weeks: bedbound, fall, stage II sacrum, poor appetite, weight loss, and increased agitation/aggression • Daughter took patient out of ALF after patient hit and tried to bite several staff - Patient spends most of the day yelling, swearing, kicking; is very restless in bed • Comorbidities: hard of hearing, poor vision, arthritis, peripheral vascular disease, history of stroke, hypertension, depression, and heart failure • Bloodwork and urinalysis were unremarkable. Patient admitted to hospice and transferred to the IPU for management of vocalizations and agitation/aggression. • Medications: sertraline 100mg daily Case 2:
  51. 51. • Describe: Agitation and aggression, including hitting and biting, worse when patient is approached, touched or moved • Investigate: Pain, hearing loss and vision loss • Create: –APAP 1,000mg every 6 hours. Corrective glasses and hearing aids. Speak to patient before approaching. Trazadone 25mg morning and 50mg night and PRN, morphine 5mg PRN • Evaluate 1 –Citalopram 10mg twice daily –Increase Trazadone 50mg morning and 100mg evening • Evaluate 2 –Risperidone 0.5mg twice daily Case 2: (Cont.)
  52. 52. Questions
  53. 53. Alzheimer’s Association (2019). Alzheimer’s & Dementia. Retrieved from https://www.alz.org/alzheimers_disease_facts_%20and %20_%20figures.asp Alzheimer’s Association. Facts and Figures (2019). Retrieved from https://www.alz.org/alzheimers_disease_facts_and_figures.asp. Antonsdottir, I. M., Smith, J., Keltz, M., & Porstensson, A.P. (2015). Advancements in the treatment of agitation in Alzheimer’s disease. Expert Opinionn on Pharmacotherapy, 16(11):1649-1656. https://doi.org/10.1517/14656566.2015.1059422. Ayalon. L., Gum, A. M., Feliciano. L, & Arean, P. A. (2006). Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: a systematic review. Archives of Internal Medicine, 166(20): 2182-8. doi: 10.1001/archinte.166.20.2182. Ballard, C.G., et al. (2009). Management of agitation and aggression associated with Alzheimer’s Disease. Nature Reviews Neurology, 5(5): 245-55. doi: 1038/nrneurol.2009.39 Cohen-Mansfield, J., Thein, K., Marx, M. S. (2014). Predictors of the impact of non-pharmacologic interventions for agitation in nursing home residents with advanced dementia. Journal of Clinical Psychiatry, 75(7):e666-671. doi: 10.4088/jcp.13M08649. References
  54. 54. Cummings, J. L., et al. (2015). Effect of Dextromethorphan-Quinidine on agitation in persons with Alzheimer disease dementia. A randomized clinical trial. JAMA 314(12): 1242-54. doi: 10.1001/jama.2015.10214. Gitlin, et al., (2006). A randomized trial of a multicomponent home intervention to reduce functional difficulties in older adults. Journal of the American Geriatric Society Society, 54(5): 809-16. doi: 10.1111/j. 1532-5415.2006.00703.x. Karantzoulis, S., Galvin, J. E. (2011). Distinguishing Alzheimer's disease from other major forms of dementia. Expert Review of Neurotherapeutics, 11(11): 1579–91. doi: 10.1586/ern.11.155. Meehan, K. M., et al. (2002). Comparison of rapidly acting intramuscular olanzapine, lorazepam, and placebo: A double-blind, randomized study in acutely agitated patients with dementia. Neuropsychopharmacology, 26(4): 494-504. doi:10.1016/S0893-133X(01)00365-7. Meeks, T. W., & Jeste, D. V. (2008). Beyond the Black Box: What is The Role for Antipsychotics in Dementia?. Current Psychiatry, 7(6), 50–65. References
  55. 55. Mitchell S.L. et al. (2009). The clinical course of advanced dementia. New England Journal of Medicine (361)1529-1538. doi: 10.1056/NEJMoa0902234. Schneider, L. S., et al. (2006). Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease. The New England Journal of Medicine, 355(15), 1525-1538. doi:10.1056/NEJMoa061240. References (Cont.)
  56. 56. Evaluation and Management of Behaviors in Dementia Joseph W. Shega, MD

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