Behavior Problems: in Long Term Care and Assisted Living

Transcription

1 Behavior Problems: Dementia and Mental Illness in Long Term Care and Assisted Living Module III Dr. David A. Smith, M.D., FAAFP, CMD mmlearn.org is a program of Morningside Ministries

2 Cell Phones and Pagers Please turn your cell phones off or turn the ringer down during the session. If you must answer a call, please be considerate of other attendees and leave the room before you begin to have your conversation.

3 Presenter: Dr. David A. Smith, M.D., FAAFP, CMD

4 Approved for Contact Hours Participants must be present for the entire program Participants are required to sign in (or register online) Participants will be required to complete an evaluation form at conclusion of presentation (for learner-paced, completion of a post-test).

5 EVALUATION SHEET After viewing online, you are required to complete your post-test/evaluation test/evaluation form.

6 Disclosures No conflicts of interest were evident in the development of content for this activity by planning committee members or presenters. No commercial support was received by EMTI at Morningside Ministries for this activity.

7 Disclosures Non-Endorsement of Products No Off-Label Use is related to the content of this activity.

8 Want To Ask a Question or Make a Comment Click on the Ask bubble at the top of the presentation to ask a question.

9 What do you think? Your feedback is important to us. Click on SURVEY in the upper right of the presentation screen. It will take less than 5 minutes.

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11 Module III Behavior Problems in LTC: Testing

12 Mental Capacity for: Decision Making» Personal» Medical» Financial Testamentary Capacity Capacity to Stand Trial

13 Quantifying and Following Cognitive Deficit it Mini Mental Status Exam-MMSE (Dementia) St.Louis University Mental Status-SLUMS (MCI, Dementia) Confusion Assessment Method- CAM (Delirium)

14 Diagnosing & Following Major Depression Beck Depression Inventory» Beck AT, Ward CH, Mendelson M, et.al.(1961) An inventory for measuring depression. Archives of General Psychiatry 4:53-63 Hamilton Depression Scale» Hamilton M (1960) A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry y 23: 56-62

15 Diagnosing & Following Major Depression Geriatric Depression Scale(short & long)» Yesavage JA, Brink TL, Rose TL, et. al.(1983)development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research 17: Cornell Scale» Alexopoulos GS Abrams RC Young RC et al (1998) Cornell» Alexopoulos GS, Abrams RC, Young RC et.al. (1998) Cornell Scale for Depression in Dementia. Biological Psychiatry 23: cont d

16 Mania Scale Others:» Bech P, Rafaelsen OJ, Kramp P. Bolwig TG (1978) The Mania Raing Scale: scale contruction and inter-observer agreement. Neuropharmacology 17: Functional Pain Scale Hamilton Anxiety Scale Assessment Scales in Old Age Psychiatry Burns A, Lawlor B, Craig S. Martin Dunitz Ltd.Distributed by: Blackwell Science Inc., Commerce Place, 350 Main St.,Malden MA 02148

17 Objectifying Nursing Assessment of Behavioral Problems (Meeting Goals) Each shift: Rate your pain as a caregiver in response to resident behavior of on a zero to 10 scale. Initial your score.

18 Minnie has delusions of worms crawling out of her skin and from under her fingernails. She is scratching herself raw and complains constantly to staff of worms. Before drug A 7,10,8,8,7,6,10 After drug A 10,7,8,6,8,10,7 (no ADR) After drug A increased- 7,8,10, 8,10, 6,7, (no ADR) After drug B 6,8,6,5,7,7,5,6 (no ADR) What Now?

19 Using Scales Trained interviewers/raters (but it s easy) Trigger from MDS items Trigger from identification of potential problem by team or team member

20 Using Scales Set time to retest to evaluate efficacy of therapy!! Objectification of what is poorly handled by subjective assessment Need a doctor s order or not?

21 Behavior Problems in LTC: Pharmacologic Therapy

22 Drugs for Dementia Cholinesterase Inhibitors» donepizil» rivastigmine» galantamine» tacrine NMDA I hibit NMDA Inhibitors» memantine

23 Grid for Treatment of Dementia and Psychiatric Disorders Causing Behavior Problems Cognition i problems ChI and/or memantine Depression antidepressant Depression with psychosis antidepressant/aap t/aap Delirium rapid acting AAP or haloperidol Psychosis AAP

24 Grid for Treatment of Dementia and Psychiatric Disorders Causing Behavior Problems cont d Mania or Bipolar illness mood stabilizer Chronic Anxiety disorder SSRI, buspirone Acute or situational i anxiety Bd Bzd (short (h acting/only phase 2) Appropriate chemical restraint Bzd (short acting/ Appropriate chemical restraint Bzd (short acting/ only phase 2)

25 Drug Treatment & Titration Issues Determine target symptom(s) Establish treatment goals prospectively Mandated d Informed Consent Therapeutic Window

26 Drug Treatment & Titration Issues Time to steady state Objective symptom monitoring- efficacy Monitor for ADRs Set time for GDR/DC or plan life-long treatment consistent with CPG s cont d

27 Task Define appropriate and inappropriate chemical restraint (Hint: remember OBRA Guidelines)

28 Task : Chemical Restraint What s wrong with this? Haldol 0.5-1mg po or IM q 4 hrs PRN agitation. T.O. Dr. R. Jones/B. Bruse RN

29 To maximize the resident s physical and mental well-being or slow decline Behavior Diagnostic hypothesis Rx drug / non-drug Follow-up by objective symptom monitoring measure target behavior before & after treatment to steady state nullifies inter-rater variability Follow-up side effects, overall function, length of Rx

30 Evidence-based Pharmacologic Treatment of Dementia Cholinesterase inhibitors tacrine (Cognex) donepizil (Aricept) rivastigmine (Exelon) galantamine (Reminyl) Claims for improving behavior exaggerated Think of maximizing cognitive function as a requisite for most normal behavior

31 Evidence-based Pharmacologic Treatment of Dementia NMDA receptor antagonist memantine (Namenda) cont d Claims for improving behavior exaggerated Think of maximizing cognitive function as a requisite for most normal behavior

32 Pharmacologic Treatment of Dementia with Negative Evidence Ginko Vit. E Estrogen Selegiline NSAIDS Chelation

33 Thank you!