This document provides an overview of evaluating behavioral dysfunction in geriatric patients. It begins with definitions of key terms like geriatrics, gerontology, and behavioral and psychological symptoms of dementia (BPSD). It then discusses common types of behavioral dysfunction seen in older adults like agitation, irritability, delusions and hallucinations. The document outlines the approach to evaluation, including assessing for medical causes, psychiatric illnesses, and environmental stressors. Differential diagnoses like delirium, dementia, and mood disorders are explored. Assessment tools for conditions like BPSD are also mentioned. The "ABCs" model of antecedents, behavior, and consequences is described as a framework for understanding and intervening in problematic behaviors in older

1. Evaluation of geriatric
patient with behavioural
dysfunction
1
By Dr. Wasim
Under guidance of
Dr. Sanjay Jain Sir

2. Outline
Definitions
Behavioral dysfunction in geriatric patients
Evaluation
Differential diagnosis
Disorders / syndrome
2

3.  Geriatrics– specialty which includes: the study of disease in
later life and the care and treatment of older persons.
 Gerontology– study of the processes of aging; all aspects.
(logy – study of ; gero - Greek term elders)
[Association for Gerontology in Higher Education (2004)]
 Old age- Period of life when impairment of physical
and mental functions becomes increasingly manifested
in comparison to the previous years of life.
3

4.  According to WHO, most developed countries
have accepted the chronological age of 65 years
and above as a definition of 'elderly' or older
persons. According to UN,60+years will be referred elderly.
 Geriatric Psychiatry- branch of medicine concerned with
prevention, diagnosis & treatment of physical and psychological
disorders in the elderly and with the promotion of longevity.
 Behavior-refers to an individual’s observable actions or the
way in which one acts or conducts oneself, especially towards
others.
4

5.  In developed countries with higher life expectancies older
adults are generally categorized in three age segments:
 Young old: aged 55-65 years;
 Old: aged 66-85 years,
 Oldest old: aged 85 years and above. (Carey, 2003)
 In India age categorizations have been done as following :
 young-old: 60 to 70 years;
 old-old: 70 to 80 years and
 oldest-old: 80 years and above
(Venkoba Rao, 1993; Irudaya Rajan, 2003)
5

6. Behavioral dysfunction in geriatric
patients
 Agitation/aggression
 Irritable behaviour
 Delusion
 Hallucination
 Wandering behaviour
 Disinhibited Behaviour
 Repetitive Behaviour
 Hoarding
 Screaming, Crying
 REM sleep behavioural disorder
6

7. Agitation
 Excessive motor or verbal activity that is
1) One of the following
 Disruptive
 Unsafe
 Distressing to the patient
2) Interferes with care and
3) Is not because of need
 Generally, is a poor descriptor of behavior
 Appears similar despite great variety of causes
 Need to make diagnosis, not focus only on symptoms
 When severe, may be the target for urgent intervention
7
Cohen-Mansfield et al, 1996; Tariot et al, 1994
Cohen- Mansfield Agitation Inventory. www.medafile.com/zyweb/CMAI.htm

8. Behavior Diagnosis: Pitfalls
 Many etiologies can present with the same behaviors (Example
of fever)
 Co-existence of multiple risk factors present in any one
resident: disease, medications, changed environment, etc.
 The key is to have a process to evaluate the resident for the
behavior.
General Approach to Behaviors
 Clearly characterize target symptoms
 Standard medical evaluation to identify possible medical
disorder
 Differential diagnosis of behavior cause
 The A,B,C’s of Behavior Intervention [Antecedent, Behavior, Consequences]
 Document, Document, Document
 Non-pharmacologic intervention 8

9. 9
Approach
Delirium
BPSD Schizophrenia spectrum Dis
Other psychotic disorder
Mood Disorder
Pt presenting with
Behavioural
Dysfunction
Cognition
Intact
Impaired

10. 10
On the basis of onset and course of
behavioural problem
Abrupt / Acute
Fluctuating course
Delirium, Other mental disorder due to
brain damage and dysfunction and to
physical disease,
Chronic
BPSD(Except Vascular dementia)
Schizophrenia, PDD
Episodic
course
Continuous
course
BAD

11. Differential for Behavior Causes
 Dementing disorders
 Frontal Lobe impairment
 Delirium
 Medical Causes
 Primary psychiatric illness
- Affective disorder (Depression)
- Anxiety disorder
- Psychotic disorder
 Environment/Stressors
11

12. 12

13. Medical Evaluation
 Medical/Psychiatric History
 Medication: excess, withdrawal, ADR
 Physical evaluation: urinary retention, fecal impaction
(constipation), pain, dental problems, GERD, angina,
OA, Hearing or vision impairment
 Mental Status Exam
 Lab studies/oximetry
 Imaging Studies
13

14. Good Target Symptoms
 Anxiety
 Insomnia
 Delusions (stressful)
 Hallucinations (stressful)
 Dysphoria/Depression
 Compulsive behaviors
 Agitation/Aggressiveness
 Motor restlessness
 Pain
Poor Target Symptoms
 Exit-seeking
 Pacing & Wandering
 Perseverant vocalizations
 Hoarding/Stealing
 Inappropriate sexual
touching
 Non-stressful delusions
 Disrobing
14

15. 15
Dementia
A syndrome (a collection of signs & symptoms) of progressive
decline in multiple areas of cognitive function which eventually
produces significant deficits in self-care and social and
occupational performance. (AMDA Dementia CPG 1998)
BPSD (Behavioural and Psychological Symptoms of Dementia)-
 A heterogeneous range of psychological reactions, psychiatric
symptoms, and behaviors occurring in people with dementia of
any etiology.
 Any verbal, vocal, or motor activities not judged to be clearly
related to the needs of the individual or the requirements of the
situation.
 An observable phenomena (not just internal)

16.  90% of patients affected by dementia will experience
Behavioral and Psychological Symptoms of Dementia (BPSD)
that are severe enough to be labeled as a problem during the
course of their illness.
Most common:
 Agitation (75%)
 Wandering (60%)
 Depression (50%)
 Psychosis (30%)
 Screaming and violence (20%)
16

17. 17

18. 18

19. Inappropriate behaviours in BPSD-
Physical Verbal
 Hitting Threats
 Pacing Accusations
 Kicking Name-calling
 Biting Obscenities
 Pushing Complaining
 Spitting Attention-seeking
 Scratching Screaming
Predictors of aggressive behavior –
Premorbid history of aggression –
Troubled premorbid relationship between caregiver and pt.
patient – Multiple problems.
19
Cohen-Mansfield et al, 1996; Tariot et al, 1994

20. 20
Assessment scales for BPSD
1) NPI (Neuropsychiatric Inventory)
2) BEHAVE-AD (Behavioral pathology in Alzheimer's
disease rating scale)
3) CMAI (Cohen Mansfield Agitation Inventory)
4) CSDD (Cornell Scale for Depression in Dementia)
5) CBI (Cambridge Behavioural Inventory)
6) FBI (Frontal Behaviour Inventory)

21. 21

22. 22

23. Frontal Lobe Impairment
 Mood lability or inappropriate affect
 Poor impulse control
 Verbally rude
 Episodically physically aggressive
 Perseverative
 Restless/grabbing/reacts strongly to stimuli
 Difficult to redirect
 Sexually inappropriate/aggressive
 Not psychotic behavior, but poor impulse control
 Seen in multiple types of disease processes like SDAT,
Vascular dementia, Multiple sclerosis, EtOH disease
23

24. Delirium
24
A state of acute confusion, inattention, and altered level of
consciousness (LOC), usually abrupt in onset (over several hours
to several days).
Common Delirium Triggers
 Acute illness, Heart or lung disease, Infections, Poor nutrition ,
Endocrine disorders, MEDICATIONS, Alcohol use.
Fluctuations in alertness & mental functioning manifested by
inattention, Anxiety, Hallucinations, Disorientation, Tremors,
Delusions, Incoherence.

25. Risk Factors for Delirium
 Predisposing factors
Comorbidities
Alcoholism
Chronic pain
History of baseline lung, liver, kidney,
heart, or brain disease
Terminal illness
Demographic factors
Age older than 65 years
Male sex
 Precipitating factors
Acute insults
Dehydration, Fracture, Hypoxia
Infection, Ischemia (e.g., cerebral,
cardiac),Medications, Metabolic
derangement, Poor nutrition
Severe illness, Shock, Surgery
Uncontrolled pain, Urinary or stool
retention
Environmental exposures
Intensive care unit setting, Sleep
deprivation, Tethers
Geriatric syndromes
Dementia, Depression, Elder abuse
Falls,History of delirium,Malnutrition
Polypharmacy, Pressure ulcers
Sensory impairment
Premorbid state
Inactivity
Poor functional status
Social isolation
 Delirium-inducing medications
High risk
Anticholinergics , BZDS
Dopamine agonists
Moderate to low risk
Antibiotics (e.g., quinolones,
antimalarials, isoniazid, linezolid ,
macrolides) Anticonvulsants,
Antihypertensives (e.g., beta
blockers, clonidine ), Antivirals (e.g.,
acyclovir,interferon),Corticosteroids
Low-potency antihistamines
Metoclopramide , TCAs 25

26.  A syndrome, not a final diagnosis
 Fluctuating level of alertness
 Difficult to assess with dementia
 Must identify etiology to treat appropriately
 If psychotic, time-limit use of antipsychotics
Assessment Scale-
 CAM (confusional assessment method)
26

27. 27

28. Distinguishing Delirium from Dementia
28
Delirium
 Acute onset, usually
occurring over days or less
 Global disorder of attention &
cognition
 Level Of Consciousness:
Hypoactive, hyper-active or
both
 Generally lasts days to weeks
 Usually reversible
 Prominent physiologic
changes
Dementia
 Gradual onset that cannot be
dated
 Attention fairly normal initially
 Level Of Consciousness:
normal until final stages
 Chronically progressive over
months or years
 Irreversible/reversible
 Minimal physiologic
changes

29. Common Medical causes of agitation in
geriatric patients
 Medication
 Drug-drug interaction
 Accidental misuse
 CNS toxic side effect
 Systemic disturbance(medication induced electrolyte
imbalance)
 UTI, RTI, COPD, Constipation
 Poor nutrition and decrease oral intake and food.
 Recent stroke
 Occult Head trauma if patient felt recently Pain
 Alcohol and other substances withdrawal or intoxicated
condition.
29

30. Primary psychiatric illness in geriatric
patients
Affective disorder(depression)-
 Psychotic features (delusions or hallucinations or both) occur in
about 25% of elderly patients with major depression, and
subjects who reported feelings of worthlessness or guilt were
the most likely to have psychotic features.(Ohayon and Schatzberg
2002).
 Most studies find that depressive symptoms are more severe
in patients with psychotic features than in those without
psychosis.
 Suicide attempts are probably not more frequent. (Lykouras et al.
2002).
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31. Peculiar feature of elderly depression:
 Depressed or sad mood, is usually less prominent or absent in
elderly subjects.
 More likely to report irritable mood
 Emotional reactivity and responsiveness to external positive
events are usually preserved
Other differences from adult depression include
 Higher rate of somatisation,
 Weight loss,
 Guilt feeling,
 Melancholia,
 Hypochondriasis and
 Psychosis
31

32. Anxiety-
 Awareness of the physiologic reactions of the “fight or flight”
responses
 May be triggered by internal or external factors
 May be triggered by issues considered “irrelevant” to others but
are real to the sufferer
 Anxiety symptoms are far more common than anxiety disorder
 Think Differential Diagnosis:
Psychosis/Depression/Delirium/Pain/GAD
 Medications: Caffeine, Bronchodilators, Pseudoephedrine
 Medical illness: Hyperthyroidism, Cardiac arrhythmias (Atrial
fibrillation, PVC’s, etc)
32

33. 33
late life anxiety symptoms are actually much more prevalent than depressive
symptoms. Though many symptoms are distinctive, common symptoms between
the disorders can cause diagnostic errors. See the chart below:

34.  Older adults with anxiety also complain of cognitive (e.g.,
memory and attention) and behavioural (e.g., poorer sleep and
appetite) symptoms more often than younger persons suffering
from anxiety.
Prevalence...
 GAD = 7.3%
 Phobias = 3.1%
 Panic D/O = 1.0%
 Obsessive-compulsive disorders = 0.6%
 GAD are the most common anxiety disorder among older
people, with Phobias being slightly less prevalent in the older
population. Other anxiety disorders, such as Obsessive-
Compulsive Disorder (OCD) and Post-Traumatic Stress
Disorder (PTSD), are relatively uncommon in later life.
34

35. Psychotic disorder-
 Late-onset psychotic symptoms may also result from a
psychiatric cause (e.g., schizophrenia, delusional disorder,
depression, bipolar disorder).
 Patients with a history of thought or mood disorders may have a
re-emergence of symptoms later in life as part of a remitting
and relapsing course.
 The first onset of psychosis may occur in the setting of late-
onset schizophrenia or a primary mood disorder, such as
depression with psychotic features. A careful evaluation to rule
out delirium and dementia is required prior to making a
diagnosis of a thought or affective disorder.
35

36. The ABC’s of Behavior Intervention
 “A” = The Antecedent Events
 “B” = The Behavioral Event
 “C” = The Consequences
36
Slattery et al, Annals of Long Term Care 1999

37. The Antecedent Event
(Behavior events are rarely unprovoked)
 Triggers that occurred before or even caused the behavioral
event.
 Modifying triggers is best approach for cognitively impaired,
because memory loss interferes with learning consequences.
 Five Categories of Triggers-
1) Physical Triggers: pain, impaired sight or hearing, fecal
impaction/constipation, needs changing or repositioning, etc.
2) Emotional Triggers: worried, afraid, distressed, etc.
3) Environmental Triggers: too much or too little lighting, noise,
temperature, activity levels, etc.
4) Task Triggers: difficulty when challenged by a specific task like bathing,
dressing or eating, etc.
5) Communication Triggers: difficulty understanding others or expressing
37

38. Environment/Stressors
Stressors Losses
Decreased control
Environment Crowding
Level of stimulation
Premorbid personality Identity
Activities
Caregiver issues Burnout, need for respite
Education & expectations
Approach Concrete with flexibility
Respect, redirection
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Areas to Consider Examples

39. 39
The Behavioral Event
Defined as any behavioral episode that is disruptive or adverse, or
that jeopardizes the safety of the resident, other persons, or
objects in the environment.

40. The Consequences
 Includes all actions or occurrences encountered after the
episode or as an outcome of the event.
 A cognitively intact resident learns to repeat behaviors that are
“rewarded”, for example, if they get attention from staff.
Caregivers must consistently reward desired behavior.
 Cognitively impaired residents don’t remember the “rewards”,
so it’s best to focus on changing the antecedents or triggers.
40

41. Thank you
41