Workshop cases answers

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1 Workshop cases answers BPSD Workshop: case histories Case 1: Mrs DM Scenario This is an 83 year old lady diagnosed with multi infarct dementia in Lives with husband and the couple are supported by family members. Husband reports that his wife is getting worse and is frequently waking up at night and getting up. She misplaces items and then accuses family member of taking them. Over the last few months she has started to see young people in the trees in the garden. She is worried in case they fall out. More recently she is hearing the sound of a child crying which she finds quite distressing and has also seen the child down the road. Her relatives were aggravating her by insisting to her that her experiences were unreal. Current Medications: simvastatin 40mg od, aspirin 75 mg od medical history; nil of note Mrs DM answers Medical review to rule out acute on chronic confusion: bloods and MSU Support husband with advice not to challenge her about these hallucinations as they are real to her. Undertake carers assessment for husband to identify ways by which he could be supported in her care. Medical review Bloods and MSU - normal Prescribed Risperdal 0.25mg nocte licensed for agitation in dementia. Only prescribed after discussing risks of taking this medication with her relatives and explaining possible side effects. Ongoing medical review Contact was made within first two weeks to get feedback on her response to this medication. Continued use will be reviewed within 12 weeks. Social support Relatives were provided with psycho-education on dementia to inform them on what to expect and provide them with coping strategies such as gentle reality orientation. 1

2 Case 2: Mr MB Scenario This is an 81 year old man with severe AD dementia. He has been living alone for the last 6 years since his wife died. He has a carer who attends to his welfare between the hours of 8:30am and 5:30 pm 6 days a week. He is generally amiable with his main carer but has been known to throw water over her on occasions out of the blue. On the one day that this carer is not around a care agency sends in a carer to observe the same routine as his main carer. He has been known to be verbally and physically aggressive to the one day a week carers and has been known to walk around in the neighbourhood on the days when they attend to his care. In spite of his severe expressive dysphasia, severe decline in his power of recall and total dependence on his carers for his basic hygiene and dressing, he remains able to find his way around in the neighbourhood. Mr MB Answers He was initially placed on Olanzapine by his GP to help address his behaviour to his one day carers but he became excessively sedated on this medication. This medication was withdrawn and changed to Sodium Valproate which seemed to calm him down and make him more amenable to care until he pulled a knife on one on the one day carers. The carers withdrew their services. Next steps He was admitted to hospital in the interest of his health and safety and safety of others. Recall patient has no mental capacity to cater for himself Revise his care package and medical treatment. Use his hospital admission as an opportunity to put together a package to accommodate his needs 24 hour supported accommodation for supervision and support he requires. assess his response to medications aimed at reducing his verbal and physical aggression. Communicate with primary care clinicians about rationale for any changes and follow up. Review his physical health Rule out acute on chronic confusional state 2

3 Case 3: Mrs A: Scenario This is an elderly frail female patient with dementia who was known to local community mental health trust and a private GP. She lived alone, was a life long smoker and was admitted to hospital with fractured neck of femur. She was extremely anxious on the ward and refused to engage with rehabilitation. Drugs on admission: quetiapine, mirtazapine, thyroxine, and pregabalin Mrs A: Answers What might have happened to her? Delirium identified, anxiety can be reduced by ensuring good sensory awareness by ensuring hearing aid and her spectacles were available to her. Encouraging engagement in activities ( e.g. reminiscence/familiar object around her Encouraging good sleep pattern (using milky drinks at bedtime, exercise during the day if possible ) rather than using night sedation Advice was offered to family and ward about delirium and management What else can be explored? Questionable prescriptions Meds rec revealed that pregabalin had been stopped several months previously. Nicotine withdrawal Patches were provided Adverse drug effects that could be contributing to her conditions She had hyponatraemia aggravated by antidepressants,mental state improved when corrected with delirium resolving. Community team was recommended to review quetiapine and mirtazapine after discharge. Outcome Anxiety resolved and she was discharged home with care package 3

4 Case 4: Mr B Scenario This 71 year old man, with known history of vascular dementia after a stroke 2 years age=o, was admitted to hospital with a UTI. Despite treatment his mood was described by staff as irritable and he began hitting staff and swearing at them when they got him up in the morning. He settled as the day progressed. The nurse asks for medication to resolve this issue Medication review reveals that he was commenced on codydramol for pain 2 weeks prior to the referral. Mr B Answers Investigate, Educate Check for Underlying infection, Unresolved pain Depression, Adverse effects of prescribed medication. Advice staff to check no underlying infection Gently educate staff on how prescribing drugs without getting to the bottom of the problem is not helpful.reminding her how poor prescribing is viewed by CQC and how inappropriate prescribing can lead to complaints can be helpful Reflect Review pattern to his aggression ABC (antecedents, behaviour, consequences) chart showed that it only happened with female staff and was worse the earlier he got up. Note: his life history information indicated a very private man who had never had any girl friends and who was a keen supporter of Arsenal He was also a person who never liked to get up early Act On investigation, he was discovered to be very constipated: laxative were prescribed, fluids and exercise recommended. He was not felt to be in pain and he was put on regular paracetamol instead of co dydramol. Staff were given information about his life history which allowed them to modify his care. Staff got him up last Whenever possible used male staff to treat him When helping him wash and dress they used to talk about the latest Arsenal match Outcome: he became less aggressive 4

5 Good Practice Checklist for Pharmacological Management of BPSD Consider, where appropriate, and document the following: At Initiation 1. Define target symptom(s), including history, severity and frequency 2. Exclude possible underlying cause(s), e.g. pain, infection, drug-induced 3. Consider aggravating or alleviating factors 4. Consider non-pharmacological approaches, if appropriate 5. Document reason(s) for pharmacological management, e.g. severe distress 6. Consider cardiovascular risk factors, when initiating antipsychotics 7. Ensure baseline physical health monitoring, including relevant blood tests 8. Discuss with service user/carers, i.e. risks versus benefits, & if off-label use 9. Document details of treatment, i.e. medicine name, dose and frequency 10. Confirm next review, ideally within two weeks At Review 1. Assess changes in target symptom(s), including severity and frequency 2. Assess for any side-effects, including any necessary management 3. Ensure physical health monitoring completed, including obs & blood tests 4. Consider medication cessation or reduction, if appropriate and rationale From Gurdeep Major, Lead pharmacist for Older Adults, Central and North West London Hospitals Trust 5

6 Mnemonic for review of all BPSD patients PAIDS: why this patient, why this way and why now? P- Physical Health problems to rule out an acute on chronic confusional state A - Is the BPSD activity related I Is the BPSD intrinsic to the dementia i.e. is the dementia progressing D Is the BPSD related to depression, hallucinations. S Is the BPSD due to poor stimulation. From Dr Oluwatoyin (Deji) Sorinmade Consultant Older Adult Psychiatristand Patricia Higgins, Ward Manager Oxleas Foundation NHS trust 6