Reality, as perceived by the patient, constitutes the reality of the situation. My Mother s Doing What???!!

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1 My Mother s Doing What???!! Management & Treatment of Dementia Related Behaviors Objectives Describe the prevalence, etiology of dementia related behaviors that include physical outbursts & sexual hyperactivity. Recognize nonpharmacologic & pharmacologic therapies Jody Agins MSN, RNP, FNP/GNP-BC jodyjfk@gotpharm.com Discuss follow up & avenues for long-term stabilization Agitation & Psychiatric Emergencies This Speaker has no disclosures Any condition that dangers self or others Increases morbidity & mortality 30% all admitted hospitalized elderly $100 billion annually on delirium in the hospital % of elderly in ICU on ventilation Delirium in ICU: very strong predictor of dying with threefold rise of death within a year More than half of postoperative surgical pts 80% have treatable, reversible factors Reality, as perceived by the patient, constitutes the reality of the situation Common Causes of Agitation Muddied Waters

2 Renal Function and Fluid Imbalance Dehydration Electrolyte Imbalance Low serum albumin Renal Failure Acute or chronic Circulation & oxygenation Hypotension CV disease CHF Acute MI AA repair Low H / H Hypoxemia Sensory, Neurological & Functional Impairment Sensory disturbances Neurological disease Cognitive impairment Low activity levels Altered mobility Sleep / wake disturbances Poorly managed pain Urinary incontinence Head injury Metabolism, Infection, Trauma Metabolic disturbances Nutritional deficiency Abnormal glucose Liver dysfunction cirrhosis Abnormal body temperature Fractures & falls Orthopedic surgery Any infection (UTI) Emergency hospital admission Co-morbidities Drugs Psychoactive drugs Anticholinergic / CNS side effects Drug or alcohol abuse Toxicity Withdrawal Narcotic use Most Common Older Adult Agitation States Delirium Agitation: secondary to dementia Disinhibition & Sexual Behaviors > 4 medications

3 First thoughts History & Medication Review Time course of mental status changes? Association with other events? Pre-existing impairments of cognition or sensory modalities? Staff or family issues????? Any medications added, changed or stopped Diagnostics / Lab testing CBC CMP TSH, B-12, LFTs Ammonia level? RPR, HIV, CMV Infection workup (UA, CXR) + / - blood culture ECG CT; MRI / MRA head Epidemiology Delirium Common condition especially in dementia Organic etiology: 95% Death rate: 10-30% Up to 50% within following year Delirium is a medical emergency Psychomotor Variants of Delirium I WATCH DEATH Hyperactive: wild ~ 25% Hypoactive: pleasantly confused ~ 50% Mixed delirium with sundowning I Infection W Withdrawal A Acute metabolic T C H Trauma CNS pathology Hypoxia D Deficiencies E Endocrine A Acute vascular / MI T Toxins - drugs H Heavy metals

4 Things to AVOID RESTRAINTS - physical or chemical High dose or IV Haldol Excess anticholinergics or sedatives Can trigger or maintain PRN analgesics Premature label of dementia Stopping cholinesterase inhibitors Aricept, Razadyne, Exelon Pharmacological Treatment of Identifiable, Organic Causes Sleep - Short acting Benzo s (Ativan 0.5 mg) - Trazodone 25 mg, Remeron mg Pain - Non-narcotic analgesics - Acetaminophen, Ibuprofen Alcohol withdrawal delirium Thiamine, Folate, Librium Infection Broad spectrum antibiotic Chronic Agitation In Dementia Agitation in Dementia Non Organic Cause Occurs in ~ 80% Psychosis occurs ~ 50% Physical aggression Hitting, kicking, biting Physical non-aggression Aggressive pacing Verbal aggressive agitation Cursing or screaming Centers for Medicare & Medicaid Services (CMS) Medication guidelines for facilities Restricted for psychotic disorders or specific, non-psychotic behavior with dementia Agitated behaviors: kicking, continuous screaming, biting, delusions Danger to self or others RT behaviors Document specific behaviors & need for medications & dosage OBRA87 Omnibus Budget & Reconciliation Act Otherwise known as the Nursing Home Reform Law Requires every nursing home to provide care and services in order for each resident to attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being. Free from physical and chemical restraints, & be treated with dignity & respect

5 Omnibus Budget and Reconciliation Act of 1987 MUST attempt decrease in antipsychotic meds, including antidepressants, sleep meds every 6 months Nuedexta Dextromethorphan & Quinidine Cleveland Clinic published % reduction in dementia related behaviors 26% reduction placebo Disinhibition & Sexual Behaviors Disinhibition: lack of restraint, including disregard for social conventions, impulsivity Discussing personal issues with strangers Making inappropriate comments (sometimes sexual) Standing uncomfortably close to others Taking food from other people s plates Taking clothes from other residents rooms Disinhibition & Sexual Behaviors Possible causes Damage to frontal lobes Misinterpreting caregiver s interaction or misidentifying caregiver Discomfort or irritation clothing too warm or tight, genital irritation, urinary retention or infection Medications (especially dopaminergic) Need for attention, gratification or intimacy Disinhibition & Sexual Behaviors Non-pharmacological Redirecting Verbal then physical Identify behavior & remind it s unacceptable Remind them who you are Choose clothing that opens in back Assign manual activities Folding towels Disinhibition & Sexual Behaviors Medications SSRIs Mood & impulse control Antiandrogens, estrogen, medroxyprogesterone acetate, leuprolide Cimetidine Antiandrogen properties Cholinesterase inhibitors Neuroleptics Benzodiazepines often increase disinhibition

6 What about Antiepileptics for Long Term Management??? Carbamazepine (Tegretol) Chemically related to TCAs Target: Verbal & physical aggression Black Box Warning Drug-induced bone marrow suppression CYP450 pathway (CYP3A4) inducer May increase metabolism of many other drugs Warfarin, estrogen, some statins, anticholinergics Carbamazepine (Tegretol) Side effects Sedation Tremor & ataxia Nausea Hyponatremia Leukopenia Hepatic toxicity Bradycardia & conduction delays Absorption decreased in NG feeding Mix with equal volume of dilutent Valproate Sodium (Depakote) Target: Agitation, aggression Has an anti-manic effect in older adults Protein bound Caution use in liver disease Monitor: CBC, LFT s, ammonia level? Drug-drug interactions: Increase levels: TCAs & SSRIs: Decreased levels: phenytoin & carbamazepine Valproate Sodium (Depakote) Prolonged half-life in older adults Side effects Sedation Tremor & ataxia Weight gain Thrombocytopenia GI disturbances- N / V, diarrhea Minimize with slow dose titration & low dosing Dosing & Lab Considerations

7 Lamotrigine (Lamictal) Stevens-Johnson syndrome Risk very low for older patients (0.03%) Side effects Agitation Anxiety Concentration problems Confusion Depression Irritability Mania Other Medications & Lamictal Medications that lower plasma level Phenobarbital & primidone: ~ 40% Estrogen: ~ 50% Depakote Can double plasma levels of Lamictal Dose should be ~ 1/2 usually initially prescribed Tegretol Facilitates metabolism Dose may need to be increased Lithium Interactions have not been reported Gabapentin (Neurontin) Not metabolized, no liver precautions Eliminated as unchanged drug by renal system Adjust dose with compromised renal function < 3% protein bound Elimination half-life: 5-7 hrs Very low adverse effects Somnolence, dizziness, fatigue, psychosis Great in pain management as well Namenda & Aricept, Razadyne, Exelon Considerations Cholinesterase Inhibitors Apathy, depression, anxiety Memantine (NMDA-Glutamate Receptor Antagonist) Delusions, hallucinations, agitation/aggression CMS: Antipsychotic Initiative Pharmacologic Treatment Reminders In the Older Adult Initiative to Improve Behavioral Health and Reduce the Use of Antipsychotic Medications in Nursing Homes Residents

8 CMS: Antipsychotic Initiative Only diagnoses carved out to use antipsychotics Schizophrenia Huntington s Chorea Tourette syndrome CMS: New Goals Set for 2017 Some States already set their own State specific goals Target reduction in short stay use of antipsychotic medication use Surveyor Guidance & F tags Separate Dementia Care Practices F309 (includes QI for pain, hospice, etc.) & separate out antipsychotic use from other unnecessary drug use currently addressed in F329 Second Generation Antipsychotics How Do We Switch? Better response & tolerability Less EPS / TD All metabolized in liver P450 precautions Decrease dose with liver dysfunction Black Box: entire class RT use in dementia behaviors Increased risk of death CVA Hyperglycemia pneumonia Urgent Medications Zyprexa M-tab (Onset of action also ~ 15 minutes) Risperidone M-tab Aripiprazole (Abilify) M-tab, liquid, IM Haloperidol IM Ziprasidone (Geodon) IM: Has not been evaluated in elderly patients Suspension Behaviors for which drugs WILL NOT HELP wandering, pacing hoarding or rummaging apathy

9 Pharmacologic Approaches Remember treat underlying source first Make sure you re treating the right thing! Depression, dementia, bipolar, schizophrenia Start low, go slow. BUT GO Don t be afraid to push doses or add adjunct medications Meds control agitation, restlessness, hostility Not impaired memory or indifference