The goal of this webinar was to help physicians and healthcare professionals differentiate delirium, terminal restlessness, and dementia-related agitation and aggression in patients near the end of life.
The goal of this webinar was to educate professionals on hospice eligibility and care planning options for patients with dementia who are nearing the end of life, and their families.
Advanced Lung Disease: Prognostication and Role of HospiceVITAS Healthcare
The goal of this webinar was to educate physicians and healthcare professionals about the medical management of advanced lung disease (ALD) and the value of advance care planning (ACP) for end-of-life patients.
Evaluation and Management of Behaviors in Persons with Cognitive ImpairmentVITAS Healthcare
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.
Chronic Obstructive Pulmonary Disease (COPD) is the third-leading cause of death in America, yet less than 9 percent of those patients near the end of life are admitted to hospice. These slides looks at the effects of COPD and other Advanced Lung Diseases (ALD) and how palliative care and hospice can improve patient care and clinical outcomes.
NOTICE:
This Webinar was intended to provide general educational information only. The information presented should not be viewed as specific medical advice regarding a particular patient. It is always a medical provider’s responsibility to individually assess and evaluate each patient before providing that patient medical advice or initiating any medical intervention.
The who, what, where, why and how of end-of-life care. A continuing education webinar presented by VITAS Healthcare on March 15, 2018. For more information or future webinars, please visit: https://www.vitas.com/partners/continuing-education
The goal of this webinar was to help hospice and healthcare professionals understand the history, philosophy, and practice of hospice and palliative care.
This webinar provides resources and guidance on effective conversations with patients and families about their goals, wishes, and values for end-of-life care.
The goal of this webinar was to educate professionals on hospice eligibility and care planning options for patients with dementia who are nearing the end of life, and their families.
Advanced Lung Disease: Prognostication and Role of HospiceVITAS Healthcare
The goal of this webinar was to educate physicians and healthcare professionals about the medical management of advanced lung disease (ALD) and the value of advance care planning (ACP) for end-of-life patients.
Evaluation and Management of Behaviors in Persons with Cognitive ImpairmentVITAS Healthcare
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.
Chronic Obstructive Pulmonary Disease (COPD) is the third-leading cause of death in America, yet less than 9 percent of those patients near the end of life are admitted to hospice. These slides looks at the effects of COPD and other Advanced Lung Diseases (ALD) and how palliative care and hospice can improve patient care and clinical outcomes.
NOTICE:
This Webinar was intended to provide general educational information only. The information presented should not be viewed as specific medical advice regarding a particular patient. It is always a medical provider’s responsibility to individually assess and evaluate each patient before providing that patient medical advice or initiating any medical intervention.
The who, what, where, why and how of end-of-life care. A continuing education webinar presented by VITAS Healthcare on March 15, 2018. For more information or future webinars, please visit: https://www.vitas.com/partners/continuing-education
The goal of this webinar was to help hospice and healthcare professionals understand the history, philosophy, and practice of hospice and palliative care.
This webinar provides resources and guidance on effective conversations with patients and families about their goals, wishes, and values for end-of-life care.
Deciding When Hospice Care is Needed | VITAS HealthcareVITAS Healthcare
The goal of this webinar is to help healthcare professionals address the specific challenges of end-of-life care when determining a terminal prognosis, so they can provide the optimum care for the patient and family during the final stages of life.
The goal of this webinar was to help hospice and healthcare professionals understand the history, philosophy, and practice of hospice and palliative care.
Advanced Lung Disease: Prognostication and Role of HospiceVITAS Healthcare
The goal of this webinar was to educate physicians and healthcare professionals about the medical management of advanced lung disease (ALD), the value of advance care planning (ACP), and the benefits of hospice for end-of-life patients.
Define and understand the types of advanced lung disease (ALD)
Discuss the impact of ALD on patients, family, and the health system
Describe the symptom burden of ALD
Appreciate factors associated with a poorer prognosis in ALD
Identify guidelines for referral to Hospice
Review the medical management of ALD
The goal of this webinar was to help hospice and healthcare professionals understand the ethics and application of artificial nutrition and hydration (ANH) for patients near the end of life.
The goal of this webinar was to educate healthcare professionals about the differences between palliative and curative care while exploring the history and philosophy of the hospice movement.
A case study of a 66-year-old patient provides the backdrop for two potential clinical scenarios—sepsis and post-sepsis syndrome—and explores the natural history and indicators of poor prognosis in both conditions.
Respiratory Symptoms in the Terminally Ill PatientVITAS Healthcare
The goal of this webinar was to educate healthcare professionals on interventions for cough, dyspnea, hemoptysis, and the “death rattle” in patients with end-of-life respiratory symptoms.
The goal of this webinar was to help hospice and healthcare professionals understand the ethics and application of artificial nutrition and hydration (ANH) for patients near the end of life.
The goal of this webinar was to educate healthcare professionals about the differences between palliative and curative care while exploring the history and philosophy of the hospice movement.
Respiratory Symptoms in the Terminally Ill PatientVITAS Healthcare
This webinar educates healthcare professionals on interventions for cough, dyspnea, hemoptysis and the “death rattle” in patients with end-of-life respiratory symptoms.
Pain management: An Interdisciplinary Approach | VITAS HealthcareVITAS Healthcare
Pain management is first and foremost in a hospice patient’s plan of care. Hospice provides comfort and quality of life near the end of life, and hospice providers are experts at managing pain. The goal of this webinar is to help healthcare professionals understand all aspects of a patient’s pain as a symptom near the end of life, and how to utilize an interdisciplinary approach to provide the most effective pain management.
This webinar provides expert guidance and clear answers to common myths about hospice care. Learn about the history and philosophy of hospice care, common hospice prognoses, who pays for hospice, and the difference between hospice and palliative care. Explore the four levels of care and the role of the interdisciplinary hospice team to provide medical, psychosocial and spiritual solutions that support quality of life at the end of life for patients and families. Learn how advance directives can ensure patients are referred to hospice care early in the disease process to enjoy its full benefits.
The goal of this webinar is to help the healthcare professional understand how to identify patients with advanced Dementia/Alzheimer’s who may be eligible for the Medicare hospice benefit, and how the timely use of hospice care can address many of the challenges and complications experienced by these patients as they approach the end of life.
The goal of this webinar is to educate professionals on strategies for recognizing and addressing the unique physical, emotional, and behavioral manifestations of grief and loss among healthcare and other helping professionals.
The goal of this webinar was to educate physicians and healthcare professionals about hospice eligibility and benefits for patients with advanced cardiac disease (ACD).
A Change in Behavior: Delirium, Terminal Restlessness, or Dementia, A Pragmat...VITAS Healthcare
This webinar leverages evidence-based data to help physicians and healthcare professionals differentiate delirium, terminal restlessness and dementia-related agitation in patients as they near the end of life.
Assessment and Management of Disruptive Behaviors in Persons with DementiaVITAS Healthcare
This webinar helps physicians conduct a systematic evaluation for behavioral changes in persons with dementia. It offers approaches for developing a comprehensive care plan for disruptive behaviors.
Deciding When Hospice Care is Needed | VITAS HealthcareVITAS Healthcare
The goal of this webinar is to help healthcare professionals address the specific challenges of end-of-life care when determining a terminal prognosis, so they can provide the optimum care for the patient and family during the final stages of life.
The goal of this webinar was to help hospice and healthcare professionals understand the history, philosophy, and practice of hospice and palliative care.
Advanced Lung Disease: Prognostication and Role of HospiceVITAS Healthcare
The goal of this webinar was to educate physicians and healthcare professionals about the medical management of advanced lung disease (ALD), the value of advance care planning (ACP), and the benefits of hospice for end-of-life patients.
Define and understand the types of advanced lung disease (ALD)
Discuss the impact of ALD on patients, family, and the health system
Describe the symptom burden of ALD
Appreciate factors associated with a poorer prognosis in ALD
Identify guidelines for referral to Hospice
Review the medical management of ALD
The goal of this webinar was to help hospice and healthcare professionals understand the ethics and application of artificial nutrition and hydration (ANH) for patients near the end of life.
The goal of this webinar was to educate healthcare professionals about the differences between palliative and curative care while exploring the history and philosophy of the hospice movement.
A case study of a 66-year-old patient provides the backdrop for two potential clinical scenarios—sepsis and post-sepsis syndrome—and explores the natural history and indicators of poor prognosis in both conditions.
Respiratory Symptoms in the Terminally Ill PatientVITAS Healthcare
The goal of this webinar was to educate healthcare professionals on interventions for cough, dyspnea, hemoptysis, and the “death rattle” in patients with end-of-life respiratory symptoms.
The goal of this webinar was to help hospice and healthcare professionals understand the ethics and application of artificial nutrition and hydration (ANH) for patients near the end of life.
The goal of this webinar was to educate healthcare professionals about the differences between palliative and curative care while exploring the history and philosophy of the hospice movement.
Respiratory Symptoms in the Terminally Ill PatientVITAS Healthcare
This webinar educates healthcare professionals on interventions for cough, dyspnea, hemoptysis and the “death rattle” in patients with end-of-life respiratory symptoms.
Pain management: An Interdisciplinary Approach | VITAS HealthcareVITAS Healthcare
Pain management is first and foremost in a hospice patient’s plan of care. Hospice provides comfort and quality of life near the end of life, and hospice providers are experts at managing pain. The goal of this webinar is to help healthcare professionals understand all aspects of a patient’s pain as a symptom near the end of life, and how to utilize an interdisciplinary approach to provide the most effective pain management.
This webinar provides expert guidance and clear answers to common myths about hospice care. Learn about the history and philosophy of hospice care, common hospice prognoses, who pays for hospice, and the difference between hospice and palliative care. Explore the four levels of care and the role of the interdisciplinary hospice team to provide medical, psychosocial and spiritual solutions that support quality of life at the end of life for patients and families. Learn how advance directives can ensure patients are referred to hospice care early in the disease process to enjoy its full benefits.
The goal of this webinar is to help the healthcare professional understand how to identify patients with advanced Dementia/Alzheimer’s who may be eligible for the Medicare hospice benefit, and how the timely use of hospice care can address many of the challenges and complications experienced by these patients as they approach the end of life.
The goal of this webinar is to educate professionals on strategies for recognizing and addressing the unique physical, emotional, and behavioral manifestations of grief and loss among healthcare and other helping professionals.
The goal of this webinar was to educate physicians and healthcare professionals about hospice eligibility and benefits for patients with advanced cardiac disease (ACD).
A Change in Behavior: Delirium, Terminal Restlessness, or Dementia, A Pragmat...VITAS Healthcare
This webinar leverages evidence-based data to help physicians and healthcare professionals differentiate delirium, terminal restlessness and dementia-related agitation in patients as they near the end of life.
Assessment and Management of Disruptive Behaviors in Persons with DementiaVITAS Healthcare
This webinar helps physicians conduct a systematic evaluation for behavioral changes in persons with dementia. It offers approaches for developing a comprehensive care plan for disruptive behaviors.
The goal of this webinar was to educate healthcare professionals about the differences between palliative and curative care while exploring the history and philosophy of the hospice movement.
Advanced Lung Disease: Prognostication and Role of HospiceVITASAuthor
The goal of this webinar was to educate physicians and healthcare professionals about the medical management of advanced lung disease (ALD), the value of advance care planning (ACP) and the benefits of hospice for end-of-life patients.
Fall prevention for the Elderly Population | VITAS HealthcareVITAS Healthcare
The goal of this presentation is to learn the reasons for falls and to develop effective fall prevention strategies.
Objectives:
- Describe the incidence of falls in the elderly patient
- Define conditions contributing to falls
- Identify risk factors related to falls
- Explain and complete the basic fall assessment
- Describe the team approach to reduce falls
Palliative Care vs. Curative Care - December 2023VITASAuthor
The goal of this webinar was to educate healthcare professionals about the differences between palliative and curative care while exploring the history and philosophy of the hospice movement.
Key tools can quickly facilitate goals-of-care (GOC) conversations, advance care planning, and hospice referrals amid the ED’s time constraints and high-acuity challenges.
The clinical case study of a patient with advanced COPD who has multiple comorbid
conditions and develops sepsis provides the backdrop for two potential clinical pathways—
sepsis and post-sepsis syndrome—and explores the natural history and indicators of poor prognosis
in both conditions.
Mobility is Medicine
Loretta Schoen Dillon, PT, DPT, MS
Director of Clinical Education and Clinical Associate Professor
UTEP Physical Therapy Program
Mano y Corazón Binational Conference of Multicultural Health Care Solutions, El Paso, Texas, September 27-28, 2013
The Value Proposition of Hospice | VITASVITASAuthor
The goal of this webinar was to help hospice and healthcare professionals discover the evidence-based benefits of hospice care, while gaining key insights on hospice eligibility guidelines, how hospice differs from other types of care, and how the Medicare Hospice Benefit helps patients facing advanced illness.
Patient Directed Care; Why it’s important and what does it really mean?Spectrum Health System
Understanding the importance of effective patient centered communication for patient engagement and improved health outcomes. Will discuss the importance of patient directed care and its relationship to the quadruple aim. Will discuss the barriers and a framework for conversations that are critical to patient directed care and cultural competency.
When Decision-Making Is Imperative: Advance Care Planning for Busy Practice S...VITAS Healthcare
Complex, chronically ill patients present an opportunity to discuss and implement hospice and palliative care. Many elderly patients who present to the ED and other busy practice settings are hospice-eligible because of functional decline and multi-morbidity. Key tools can quickly facilitate goals-of-care (GOC) conversations, advance care planning, and hospice referrals amid time constraints and high-acuity challenges.
Enhancing Access, Quality, and Equity for Persons With Advanced IllnessVITASAuthor
This diverse panel examined various facets of healthcare access, equity, and inclusion as it
relates to individuals in underserved communities who are coping with advanced illness. Based on their
decades of experience in end-of-life care, as well as evidence-based data and a compelling case study
of a Filipino-American US Navy Veteran, panel members shared strategies on how to mitigate
current barriers, including ensuring patients are granted timely access to hospice and palliative
services and that appropriate levels of care are provided.
Heart failure is the leading cause of death in the US, yet accounts for less than 20 percent of hospice admissions. The goal of this webinar is to teach healthcare professionals to recognize what were once routine and manageable exacerbations as signs of unstable terminal illness, and to understand why hospice improves quality of life when proven treatments no longer can can.
HOW TO SAVE MONEY ON YOUR HEALTHCARE: An Integrative Medicine ApproachLouis Cady, MD
In this webinar, the fourth in a series of five from Dr. Louis Cady and the Cady Wellness Institute, we focus on the actual dollars and cents of health care expenditures, and the societal and PERSONAL costs of poor health maintenance behavior. We examine the essentially passive US medical system, that would rather drug a symptom than fix the underlying problem.
Great attention is paid on not shaming the patient or the doctors as they exist in the current system. Both groups "do not know what they do not know." Confirmation bias is rampant.
This webinar points the way to living a more vital, energetic life, with a minimum of cost, grief, and misery.
The goal of this webinar is to educate physicians and healthcare professionals about hospice eligibility and benefits for patients with advanced cardiac disease (ACD) who have a prognosis of ≤6 months. Through evidence-based data and a review of case studies, attendees understand the benefits of advance care planning, complex modalities for high-acuity cardiac patients, how to manage symptoms, address pain and provide comfort and dignity near the end of life.
Similar to A Change in Behavior: A Pragmatic Clinical Guide to Delirium, Terminal Restlessness, and Dementia (20)
The goal of this webinar was to help hospice and healthcare professionals understand the ethics and application of artificial nutrition and hydration (ANH) for patients near the end of life.
Assessment and Management of Disruptive Behaviors in Persons With DementiaVITAS Healthcare
This webinar helps physicians conduct a systematic evaluation for behavioral changes
in persons with dementia. It offers approaches for developing a comprehensive care plan for
disruptive behaviors. These methods incorporate caregiver education and non-pharmacologic
interventions followed by pharmacologic management.
Pain Management in the Context of an Opioid Epidemic: Considerations and Tool...VITAS Healthcare
This presentation details how to conduct a comprehensive pain assessment, considerations when prescribing analgesics, and when opioids may be appropriate.
Understanding Pain Management and Daily Practice ManagementVITAS Healthcare
Supported by evidence-based data, this webinar helped physicians and healthcare professionals gain greater understanding of the multifaceted applications of pain management in the context of palliative hospice care.
The goal of this webinar was to educate healthcare professionals about advance directives and advance care planning,
including the types and purposes of legal documents that govern patients’ decisions and
preferences.
The goal of this webinar was to help healthcare professionals improve care coordination for patients with advanced illness and to reduce hospital readmissions and length of stay (LOS).
The goal of this webinar was to educate physicians and healthcare professionals about hospice eligibility and the benefits of hospice for patients with advanced cardiac disease (ACD).
The goal of this webinar was to equip healthcare professionals with an understanding of military veterans’ unique medical, emotional, and spiritual needs as they near the end of life.
The goal of this webinar was to equip healthcare professionals with an understanding of military veterans’ unique medical, emotional, and spiritual needs as they near the end of life.
Advanced Lung Disease: Prognostication and Role of HospiceVITAS Healthcare
The goal of this webinar was to educate physicians and healthcare professionals about the medical management of advanced lung disease (ALD), the value of advance care planning (ACP) and the benefits of hospice for end-of-life patients.
The clinical case study of a patient with advanced COPD who has multiple comorbid conditions and develops sepsis provideD the backdrop for two potential clinical pathways—sepsis and post-sepsis syndrome.
Understanding Pain Management and Daily Practice ManagementVITAS Healthcare
Supported by evidence-based data, this webinar helped physicians and healthcare professionals gain greater understanding of the multifaceted applications of pain management in the context of palliative hospice care.
The goal of this webinar was to help hospice and healthcare professionals understand the ethics and application of artificial nutrition and hydration (ANH) for patients near the end of life.
The goal of this webinar was to educate healthcare professionals about advance directives and advance care planning, including the types and purposes of legal documents that govern patients’ decisions and preferences.
The goal of this webinar was to help healthcare professionals improve care coordination for patients with advanced illness and to reduce hospital readmissions and length of stay.
The goal of this webinar was to educate physicians and healthcare professionals about hospice eligibility and the benefits of hospice for patients with advanced cardiac disease (ACD).
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Struggling with intense fears that disrupt your life? At Renew Life Hypnosis, we offer specialized hypnosis to overcome fear. Phobias are exaggerated fears, often stemming from past traumas or learned behaviors. Hypnotherapy addresses these deep-seated fears by accessing the subconscious mind, helping you change your reactions to phobic triggers. Our expert therapists guide you into a state of deep relaxation, allowing you to transform your responses and reduce anxiety. Experience increased confidence and freedom from phobias with our personalized approach. Ready to live a fear-free life? Visit us at Renew Life Hypnosis..
Navigating the Health Insurance Market_ Understanding Trends and Options.pdfEnterprise Wired
From navigating policy options to staying informed about industry trends, this comprehensive guide explores everything you need to know about the health insurance market.
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...
A Change in Behavior: A Pragmatic Clinical Guide to Delirium, Terminal Restlessness, and Dementia
1. A Change in Behavior:
A Pragmatic Clinical Guide
to Delirium, Terminal
Restlessness, and Dementia
The information in the pages that follow is considered by VITAS® Healthcare Corporation to be confidential.
2. CME
Provider
Information
Satisfactory Completion
Learners must complete an evaluation form to receive a certificate
of completion. You must participate in the entire activity as partial
credit is not available. If you are seeking continuing education
credit for a specialty not listed below, it is your responsibility to
contact your licensing/certification board to determine course
eligibility for your licensing/certification requirement.
Physicians
In support of improving patient care, this activity has been
planned and implemented by Amedco LLC and VITAS®
Healthcare. Amedco LLC is jointly accredited by the
Accreditation Council for Continuing Medical Education
(ACCME), the Accreditation Council for Pharmacy Education
(ACPE), and the American Nurses Credentialing Center
(ANCC), to provide continuing education for the healthcare
team. Credit Designation Statement – Amedco LLC designates
this live activity for a maximum of 1 AMA PRA Category 1
CreditTM. Physicians should claim only the credit commensurate
with the extent of their participation in the activity.
3. 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.
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: 06/06/2021 – 06/06/2024. 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 01/31/2023.
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. Objectives
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
5. Background: Dementia Epidemiology
Alzheimer's Association. (2021). 2021 Alzheimer's Disease Facts and Figures. Available at: https://www.alz.org/media/Documents/alzheimers-facts-and-figures.pdf
• 2021 US Alzheimer’s estimate:
6.2 million
– 72% are ages 75+
– 2/3 are women
• Dementia cases projected for
2050: 12.7 million Americans
• Estimated lifetime risk for
Alzheimer’s dementia at age
65+ is 21.1% for women and
11.6% for men
• One in 9 Americans aged
65+ has Alzheimer's dementia
• Between 2000-2019,
Alzheimer’s-related deaths
increased 145%
6. Background:
Dementia
Near the
End of Life
• 1 in 3 older adults who die each
year have a diagnosis of dementia
• Alzheimer’s kills more Americans
than breast cancer and prostate
cancer combined
• Dementia is the fifth-leading cause
of death in persons over 65
• > 500,000 deaths a year in US
are attributed to dementia
Alzheimer's Association. (2021). 2021 Alzheimer's Disease Facts and Figures. Available at:
https://www.alz.org/media/Documents/alzheimers-facts-and-figures.pdf
7. Effect of COVID-19 Pandemic on Deaths
from Alzheimer’s Disease
Alzheimer's Association. (2021). 2021 Alzheimer's Disease Facts and Figures. Available at: https://www.alz.org/media/Documents/alzheimers-facts-and-figures.pdf
8. 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 disease
Alzheimer's disease
Heart disease
Cancer
Aldridge, M., et al. E. (2017). Epidemiology and patterns of care at the end of life: Rising complexity,
shifts in care patterns and sites of death. Health Affairs, 36(7), 1175-1183.
9. Mitchell, S., et al. (2009). The clinical course of advanced dementia. New England Journal of Medicine (361), 1529-1538.
Symptoms of End-Stage Dementia
0
5
10
15
20
25
30
35
40
Dyspnea Pain Pressure ulcers Aspiration Agitation
Residents
With
Symptoms
(%)
Distressing Symptoms
Months Before Death (no. of residents alive during interval)
> 9-12 > 6-9 > 3-6 0-3
10. 4.3%
11.2% 15.2%
44.3%
38.2%
13.3%
32.6%
30.3%
30.0%
31.4%
82.3%
56.0% 54.5%
25.7%
30.4%
Normal cognition Mild cognitive
impairment
Mild dementia Moderate
dementia
Severe dementia
No symptoms
1-2 symptoms
3+ symptoms
Neuropsychiatric Symptoms (NPS)
by Stage of Cognitive Impairment
Radue, R., et al. (2019). Neuropsychiatric symptoms in dementia. In Handbook of Clinical Neurology (Vol. 167, pp. 437-454). Elsevier.
11. Case 1
• 61-year-old with Huntington’s disease who
presents to the hospice inpatient unit (IPU)
with impulsivity and agitation
– Has not slept in 2 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
6 hours and every 2 hours as needed,
mirtazapine 30mg at night, sertraline 50mg
daily, lorazepam 1mg every 6 hours and
1 hour as needed, amantadine 200mg daily
• Urinalysis and bloodwork were unremarkable;
patient was transferred to the IPU for further
management of impulsivity and agitation
12. Case 2
• 86-year-old with cerebral atherosclerosis and
recent functional decline
– In the past 2 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
13. Guiding
Principles
• Identify dementia etiology as symptoms
and treatments vary
• Differentiate delirium, terminal restlessness,
and dementia-related behavior
• 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
14. Most Common Etiologies of Dementia
Alzheimer’s Association. Differentiating dementias. In Brief for Healthcare Professionals, (7). Retrieved from: https://www.alz.org/media/Documents/inbrief-differentiating-dementias.pdf
Karantzoulis, S., & Galvin, J. (2011). Distinguishing Alzheimer's disease from other major forms of dementia. Expert Review of Neurotherapeutics, 11(11), 1579–91.
Pathophysiology
Amyloid plaques and
neurofibrillary tangles
Pathophysiology
Combination of
Alzheimer’s disease and
vascular disease
Pathophysiology
Alpha-synuclein
protein
Pathophysiology
Tau protein
Mixed Dementia = > 1 Neuropathology – Prevalence Unknown
15. Dementia
Etiology
Considerations
• 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
Ringman, J., & Schneider, L. (2019). Treatment options for agitation in dementia.
Current Treatment Options in Neurology, 21(7), 30.
16. Guiding
Principles
• 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
17. Definition of Delirium
Ayalon, L., et al. (2006). Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia:
A systematic review. Archives of Internal Medicine, 166(20), 2182-2188.
Inouye, S., et al. (1990). Clarifying confusion: The confusion assessment , C., method: A new method for detection of delirium. Annals of Internal Medicine, 113(12), 941-948.
Acute Onset and Fluctuating
Course + Inattention,
plus either
Altered Level of
Consciousness
Disorganized
Thinking
Delirium
19. Dementia
Behaviors
Thought and
Perceptual
Disturbances
• Delusions
• Paranoia
• Hallucination
Mood
Disturbances
• Anxiety
• Depression
• Irritability
Ringman, J., & Schneider, L. (2019). Treatment options for agitation in dementia.
Current Treatment Options in Neurology, 21(7), 30.
Activity Disturbance
• Agitation
• Aggression
• Wandering
• Purposeless
hyperactivity
• Apathy
• Impulsivity
• Socially inappropriate
behavior
• Sleep problems
• Repetitive behavior
20. Guiding
Principles
• 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
21. Ringman, J., & Schneider, L. (2019). Treatment options for agitation in dementia. Current Treatment Options in Neurology, 21(7), 30.
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
22. Guiding
Principles
• 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
23. Ringman, J., & Schneider, L. (2019). Treatment options for agitation in dementia. Current Treatment Options in Neurology, 21(7), 30.
Behaviors in
Dementia
and Health-
Related
Outcomes
• 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
24. Guiding
Principles
• 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
25. Dementia
Behavior
Models
• 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
Ayalon, L., et al. (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.
26. Non-
Pharmacologic
Approaches
for Persons
With Dementia:
Inconclusive
Evidence
• 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
Ayalon, L., et al. (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.
27. Non-
Pharmacologic
Approaches for
Persons With
Dementia
Evidence Exists in 2 or More Randomized
Clinical Trials (RCTs)
• Physical activity positively impacts
depression and sleep
• Hand massage
• Personalizing the bathing experience
Ayalon, L., et al. (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.
Gitlin, L., et al. (2006). A randomized trial of a multicomponent home intervention to reduce functional difficulties in
older adults. Journal of the American Geriatric Society, 54(5), 809-16. doi: 10.1111/j.1532-5415.2006.00703.
28. Non-
Pharmacologic
Approaches
for Caregivers:
Most Robust
Evidence
• Engage in problem-solving with a family caregiver:
– Identify precipitating and modifiable causes
of symptoms
– Deploy efforts to modify these causes with
selected non-pharmacologic strategies
• Explore caregiver programs:
– REACH II and REACH VA: Coping approaches and
tailored behavioral management
– The Tailored Activity Program (TAP):
Occupational Therapy
– The 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
Ayalon, L., et al. (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.
29. Non-
Pharmacologic
Environmental
Factors:
Paucity of
RCTs, Positive
Impact
• Overstimulation (e.g., excess noise,
people, or clutter in the home)
• Understimulation (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)
Ayalon, L., et al. (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.
30. Responses
to Non-
Pharmacologic
Interventions
Greater Response
• Higher levels of
cognitive function
• Fewer difficulties
with ADLs
• Speech
• Communication
• Responsiveness
Cohen-Mansfield, Jet al. (2014). Predictors of the impact of non-pharmacologic interventions for agitation in nursing home
residents with advanced dementia. Journal of Clinical Psychiatry, 75(7), 666-671. doi: 10.4088/jcp.13M08649.
Less Response
• Staff barriers
(refuse to participate)
• Patient in pain
31. Guiding
Principles
• 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
32. Dementia
Behaviors and
Pharmacologic
Treatment
Helpful
• Agitation and
aggression
• Psychosis
– Delusions
– Hallucinations
– Paranoia
• Depression
• Irritability
Ballard, C., 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.
Not Helpful
• Day/night reversal
• Calling out
• Repetitive behaviors
• Wandering
• Apathy
• Resistance to care
33. Pharmacologic Treatment of Agitation
Antonsdottir, I., et al. (2015). Advancements in the treatment of agitation in Alzheimer’s disease. Expert Opinion on Pharmacotherapy, 16(11), 1649-1656. https://doi.org/10.1517/14656566.2015.1059422.
Ballard, C., 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.
Therapeutic Class Trial Side Effects
Trazodone + RCT Sedation, hypotension
SSRI (citalopram) + RCT Nausea, diarrhea, QTc inc > 20mg daily
Dextromethorphan/quinidine + RCT Falls, dizziness, diarrhea, UTIs
Lorazepam + RCT Sedation, falls, ataxia, agitation
Antipsychotics + RCT Stroke, infection, sz, QTc inc, DM, death
Carbamazepine-Valproic acid
- RCT
- RCT
Sedation, anemia, liver toxicity, sedation
NMDA antagonist - RCT/+obs Constipation, dizziness
AChEI - /+RCT/+obs Nausea, dizziness, weight loss
Cannabinoids - RCT Low dose used, oral form
34. Trazodone
• Several small randomized controlled
trials indicate benefit
– Cochrane review inconclusive evidence
• Dosing: 25-20mg BID-TID and q 2hrs
PRN, maximum dose 400mg daily
• Adverse effects:
– Orthostasis, syncope,
hypotension, dizziness
– Priapism
– SIADH
– Somnolence
– QTc prolongation
Antonsdottir, I., et al. (2015). Advancements in the treatment of agitation in Alzheimer’s disease. Expert Opinion on
Pharmacotherapy, 16(11), 1649-1656. https://doi.org/10.1517/14656566.2015.1059422.
35. Citalopram for Agitation in
Alzheimer’s Disease
Antonsdottir, I., et al. (2015). Advancements in the treatment of agitation in Alzheimer’s disease. Expert Opinion on Pharmacotherapy, 16(11), 1649-1656. https://doi.org/10.1517/14656566.2015.1059422.
Neurobehavioral Rating Scale (NBRS)-Agitation Subscale
No. of participants
Citalopram 94 87 85 86
Placebo 92 84 84 81
36. Citalopram
Considerations
• QTc prolongation, which is dose-dependent
above 20mg
• Starting dose 10mg up to 40mg daily
• Consider twice-daily dosing
– 10mg daily for 2 weeks
– 10mg twice daily thereafter
• Other SSRI side effects
• Onset of action within a week in one study
37. Antipsychotics
• 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
Meeks, T., & Jeste, D. (2008). Beyond the black box: What is the role for antipsychotics in dementia? Current Psychiatry, 7(6), 50–65.
38. Antipsychotics (cont.)
Antipsychotic
Recommended
Dose
Formulations Frequency Characteristics
Risperidone 0.5-2.0mg Tab, liquid, IM 2 times a day
Extrapyramidal
symptoms
Olanzapine 2.5-15mg Tab Daily
Weight gain,
increased sugar
Quetiapine 25-400mg Tab
3 times a day
(unless ER)
Sedating, least
extrapyramidal
Aripiprazole 5-30mg Tab, liquid, IM Daily Less QT
Haloperidol 0.5-5mg
Tab, liquid, IM, IV,
sub q
2-4 times a day
Chlorpromazine 10-200mg Tab, liquid, IV, rectal 2-3 times a day Very sedating
Meeks, T., & Jeste, D. (2008). Beyond the black box: What is the role for antipsychotics in dementia? Current Psychiatry, 7(6), 50–65.
39. Schneider, L., et al. (2006). Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease.
The New England Journal of Medicine, 355(15), 1525-1538.
CATIE-AD
40. CATIE-AD (cont.)
Schneider, L., et al. (2006). Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease.
The New England Journal of Medicine, 355(15), 1525-1538..
41. Schneider, L., et al. (2006). Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease.
The New England Journal of Medicine, 355(15), 1525-1538.
CATIE-AD (cont.)
42. Antipsychotics
Summary
• 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
Meeks, T., & Jeste, D. (2008). Beyond the black box: What is the role for antipsychotics in dementia? Current Psychiatry, 7(6), 50–65.
43. Anxiolytics
• 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
44. Agitation and Dementia: Lorazepam
Meehan, K., 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
-10
-9
-8
-7
-6
-5
-4
-3
-2
-1
0
30 60 90 120
Mean
Change
from
Baseline,
PANSS
Excited
Component
Time (mins)
Olanzapine 5.0 mg IM Olanzapine 2.6 mg IM Lorazepam 1.0 mg IM Placebo IM
45. Common Pharmacologic 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
46. Dextromethorphan-Quinidine for Dementia
Agitation in Alzheimer’s Disease
93 93 90 83 82 83
66 65 65 60 60 60
Cummings, J., et al. (2015). Effect of dextromethorphan-quinidine on agitation in persons with Alzheimer’s disease dementia.
A randomized clinical trial. JAMA, 314(12), 1242-54.
47. Dextromethorphan-
Quinidine
Considerations
• FDA-approved for the treatment of
pseudobulbar affect
• Modulates glutamate, serotonin,
and norepinephrine
• Only 1 randomized controlled trial
to date for agitation
• Side effects include
– Falls
– UTIs
– Diarrhea
– Dizziness
• QTc prolongation
Cummings, J., et al. (2015). Effect of dextromethorphan-quinidine on agitation in persons with Alzheimer’s disease dementia.
A randomized clinical trial. JAMA, 314(12), 1242-54..
48. Phenobarbital
• 30mg to 120mg ATC and q2 PRN
• NO DATA AVAILABLE
• Many clinicians, health systems, and
long-term care facilities embrace
the treatment
• Adverse reactions include:
– Respiratory depression
– Stevens-Johnson syndrome
– Anemia, TTP, and blood dyscrasias
– Withdrawal symptoms with abrupt
withdrawal
– Lethargy and drowsiness
– Nausea, vomiting, and hepatitis
49. Summary:
DICE
• Describe the behavior
• Investigate the underlying
contributors/causes
• Create intervention (non-pharmacologic
and pharmacologic)
• Evaluate the intervention’s effectiveness
Kales, H. et al. (2014). Management of neuropsychiatric symptoms of dementia in clinical settings: Recommendations from a
multidisciplinary expert panel. Journal of the American Geriatrics Society, 62(4), 762–769.
50. Case 1
• 61-year-old with Huntington’s disease who
presents to the hospice inpatient unit (IPU)
with impulsivity and agitation
– Has not slept in 2 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
6 hours and every 2 hours as needed,
mirtazapine 30mg at night, sertraline 50mg
daily, lorazepam 1mg every 6 hours and
1 hour as needed, amantadine 200mg daily
• Urinalysis and bloodwork were unremarkable;
patient was transferred to the IPU for further
management of impulsivity and agitation
51. Case 1
(cont.)
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 0.5mg every 8 hours and PRN
• Start Trazodone 50mg morning and 100mg
QHS and PRN, start Citalopram 10mg twice daily
Evaluate 1:
• Increase Trazodone 100mg morning and
200mg QHS
• Start dextromethorphan and quinidine
Evaluate 2:
• Continue current treatment and discharge
home to wife
52. Case 2
• 86-year-old with cerebral atherosclerosis with
recent functional decline
– In the past 2 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
53. Case 2
(cont.)
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, Trazodone 25mg morning
and 50mg night and PRN, morphine 5mg PRN
Evaluate 1
• Citalopram 10mg twice daily
• Increase Trazodone 50mg morning and
100mg evening
Evaluate 2
• Risperidone 0.5mg twice daily
55. References
Aldridge, M., & Bradley, E. (2017). Epidemiology and patterns of care at the end of life:
Rising complexity, shifts in care patterns and sites of death. Health Affairs, 36(7), 1175-1183.
Alzheimer's Association. (2021). 2021 Alzheimer's Disease Facts and Figures.
https://www.alz.org/media/documents/alzheimers-facts-and-figures.pdf
Alzheimer’s Association. Differentiating dementias. In Brief for Healthcare Professionals,
(7). https://www.alz.org/media/Documents/inbrief-differentiating-dementias.pdf
Antonsdottir, I., et al. (2015). Advancements in the treatment of agitation in Alzheimer’s
disease. Expert Opinion on Pharmacotherapy, 16(11), 1649-1656.
https://doi.org/10.1517/14656566.2015.1059422
Ayalon, L., et al. (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., 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., et al. (2014). Predictors of the impact of non-pharmacologic
interventions for agitation in nursing home residents with advanced
dementia. Journal of Clinical Psychiatry, 75(7), 666-671. doi: 10.4088/jcp.13M08649.
Cummings, J., et al. (2015). Effect of dextromethorphan-quinidine on agitation in persons
with Alzheimer’s disease dementia. A randomized clinical trial. JAMA, 314(12), 1242-54.
doi: 10.1001/jama.2015.10214.
Freemon, F. (1981). Delirium and Organic Psychosis. Organic Mental Disease, 81-94.
Springer, Dordrecht.
Gitlin, L., et al. (2006). A randomized trial of a multicomponent home intervention to
reduce functional difficulties in older adults. Journal of the American Geriatric Society,
54(5), 809-16. doi: 10.1111/j.1532-5415.2006.00703.
56. References
(cont.)
Inouye, S., et al. (1990). Clarifying confusion: The confusion assessment method: A new
method for detection of delirium. Annals of Internal Medicine, 113(12), 941-948.
Kales, H., et al. (2014). Management of neuropsychiatric symptoms of dementia in clinical
settings: Recommendations from a multidisciplinary expert panel. Journal of the American
Geriatrics Society, 62(4), 762–769. doi: 10.1111/jgs.12730.
Karantzoulis, S. & Galvin, J. (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., 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., & Jeste, D. (2008). Beyond the black box: What is the role for antipsychotics
in dementia? Current Psychiatry, 7(6), 50–65.
Mitchell, S., et al. (2009). The clinical course of advanced dementia. New England
Journal of Medicine, (361), 1529-1538. doi: 10.1056/NEJMoa0902234.
Ringman, J., & Schneider, L. (2019). Treatment options for agitation in dementia.
Current Treatment Options in Neurology, 21(7), 30.
Radue, R., et al. (2019). Neuropsychiatric symptoms in dementia. In Handbook of
Clinical Neurology (Vol. 167, pp. 437-454). Elsevier.
Schneider, L., 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.