Where PASRR and Dementia Meet

Transcription

1 Where PASRR and Dementia Meet Department of Psychology University of Nevada, Reno

2 Overview What are the challenges in detecting and effectively responding to dementia & psychiatric related symptoms in elderly persons in long term care? How do degenerative cognitive disorders interact with psychological disorders? Describe strategies for detecting: Reversible behavioral health problems Excess disability Strategies for reducing excess disability & promoting quality of life

3 What is healthy behavior? Behavioral repertoire is supported Excess disability is prevented Behavioral functioning is as good as it gets Variety of behaviors are available to residents for Doing what they want to do given circumstances Accessing gratifying & pleasurable experiences Coping with a challenging environment Motivation for behavior is positive Person s behavior is not chronically motivated by escape or avoidance of aversive consequences

4 What we know from research on behavioral health promotion Its good to have lots of behaviors available Evidence-based behavioral health strategies promote behavioral variability People who s behavior is chronically motivated by escape and avoidance of negative experiences are stressed and unhappy Access to pleasurable activities is vital for contentment and preventing depression

5 Barriers to behavioral health and quality of life in dementia Communication loss Misattributing preventable behavior changes to organic disorder Stigma

6 Barriers to detecting behavioral health problems Deficits in communication ability Loss of ability to understand and label internal (private) experiences Pain Discomfort Fear Boredom Sensory impairment Changes in affect, cognition, and behavior due to adverse events mimic declines due to dementia

7 Misattribution of behavior: Consequences Behavior changes conceptualized as noncognitive symptoms of dementia Treatment: Reduce or eliminate the symptom Lack of treatment for reversible conditions such as: Infection Medication adverse effect Injury Delirium Excess disability Premature death

8 Alternative view: Assume any precipitous behavior change in dementia is due to an adverse event Rule out reversible condition: Medical (e.g., medication side effect, pain, infection, injury) Emotional distress (depression, fear, boredom) Environmental (abuse, punishment, overly demanding environment)

9 Excess disability and challenging behaviors Behavior Frequency Challenging behaviors Adaptive behaviors Time

10 Risk factors for excess disability: Pain Pain Estimates of the prevalence among SNF residents are as high as 80% High prevalence of pain comes hand-in-hand with age-associated health problems Fractures Arthritis Osteoporosis Neuropathic pain Pressure sores

11 Pain management in residents with dementia versus residents without dementia Patients with a cognitive impairment diagnosis and a pain-related diagnosis prescribed significantly less analgesic medication than patients with similar pain-related diagnoses but no cognitive impairment diagnosis and dosage prescribed to the patients with a cognitive impairment diagnosis was significantly lower than to patients without the cognitive impairment diagnosis (Horgas & Tsai; 1998; Reynolds, et al., 2008)

12 Outcomes of undertreated pain in older adults Depression and anxiety Sleep disturbances Nutritional disturbances Functional disability Impaired cognition Social isolation Disruptive or aggressive behavior Overall decrease in quality of life Higher mortality and morbidity rates (American Geriatrics Society Panel on Persistent Pain in Older Persons, 2002)

13 Risk factors for excess disability: Sensory deficits Sensory problems Hearing deficits Visual deficits With decline in verbal abilities communication, person with dementia loses ability to recognize sensory deficit and compensate for it Environment becomes increasingly threatening Illustration: Visual disorders

14 Normal vision

15 Cataract

16 Glaucoma

17 Diabetic retinopathy

18 Macular degeneration

19 Risk factors for excess disability: Psychological History of adversity, punishment, and stigma Persons with psychiatric diagnoses Decades long history of adversity Persons with cognitive impairment Self-stigmatization early in disease process Stigmatization and aversive social experiences (e.g., years of corrective feedback) SNF admission: Unfamiliar environment when least able to cope Adaptive, self-protective behaviors perceived as disturbances or problems by staff

20 Case example 1 82 year old man with advanced Alzheimer s disease and a history of PTSD due to combat and POW trauma experiences Retired accountant MMSE = 8 Referred for evaluation due to swearing and aggressive behavior during caregiving Administered Risperdal, Ativan, Zoloft Prior to developing dementia he had coped with trauma symptoms by avoiding crowds, closed spaces

21 Regardless of diagnosis: Focus on adaptive behavior and preventing excess disability Loss of behavior is inevitable Dementia Support existing behavior Prevent excess disability Chronic Psychological Disorders Limited and fragile behavioral repertoire Support existing behavior Prevent excess disability Promote new behavior

22 Priority: Preserve residents behavioral repertoires Prevent challenging behaviors While preserving adaptive behavior Avoid any intervention that causes premature loss of behavior aka Restraint Detect and reverse excess disability Emphasize verbal impairment reduces the ability to selfreport Monitor declines in adaptive Tragic consequences of misattribution of behavior change to cognitive impairment rather than a reversible condition Assess and treat pain and adverse events

23 Detecting excess disability (Slaughter & Bankes, 2007)

24 Case example 2: Elderly woman with advanced dementia and a history of bipolar disorder MMSE = 0 Referred for evaluation due to crying, loud moaning, disturbing other residents at night Administered antidepressant medication and Depakote for several months Described by nursing staff as unresponsive to medication Assessment: Severe dental decay, history of migraine headaches Resident hold sides of her jaw when she moans

25 Behavioral health prescription for long term care facilities Preserve residents fragile behavioral repertoires Build in system for detecting and reversing excess disability Identify and reduce factors that cause fear and escape motivated behavior in residents Example: Resistance to care is often motivated by fear Promote access to preferred activities

26 Building environments that promote behavioral health Staff education: Caregiving basics Building staff s own resilience and ability to manage the stress of caregiving Promote mindfulness and stress management techniques Knowing the facts about cognitive and psychiatric disorders and how they affect behavior Describe dementia and subtypes What is normal behavioral loss vs. excess disability Example: Confusing medication side effects with symptoms of diagnosed disease

27 Staff education: Communication Persons with dementia become very sensitive to nonverbal cues, such as tone of voice, facial expression, body gestures, and mood. If staff are angry, afraid, or upset residents are more likely to act the same

28 Staff education: Understanding challenging behaviors Changes in affect and behavior labeled behavior problems are not a normal symptom of cognitive impairment Aggression Wandering Disruptive vocalizations Screaming Agitation Crying Residents with degenerative dementia eventually become unable to label and communicate their internal psychological or physiological states. May respond to conditions such as pain, infection, adverse medication reactions, and fear with changes in affect, behavior, or cognition that resembles the decline expected due to degenerative dementia.

29 Staff education: Monitoring adaptive behavior to detect excess disability At admission identify stable, frequent, longstanding behaviors for each resident Joking Eye contact and hand-shaking Flirting Tinkering Precipitous change in these behaviors is a signal to rule out an adverse event

30 Behavior Checklist

31 Case example: Resident referred for behavior problem crying Eye Contact and Crying in a Two Week Period Behavior frequency UTI diagnosed Crying Eye Time (days)

32 Consequences of misattributing behavior changes The first line intervention for many behavioral and affective changes due to untreated or undertreated adverse event is often psychotropic drugs This is problematic because: Not treating the problem Older people are at increased risk of adverse drug interactions (Katona, 2001) Risks of polypharmacy Age-related change in drug metabolism

33 Pharmacological interventions for behavioral and affective changes Possible adverse psychotropic interventions in older adults Sedation Increased cognitive impairment Incontinence Increased risk for falls Delirium Extrapyramidal symptoms Higher mortality rate (Schneider, et al., 2006)

34 Drugs that can cause depression Antianxiety drugs Antihypertensive drugs Antiparkinsonian drugs Corticosteroids and other hormones 4/13/2011 Jane E. Antonuccio Fisher, Ph.D. 34

35 Increased mortality in elderly receiving long term antipsychotic medication Months (Ballard et al, 2009)

36 Excess disability and challenging behaviors Behavior Frequency Challenging behaviors Adaptive behaviors Time

37 Staff education: Positive approaches to challenging behaviors (see Fisher, et al., 2008) After ruling out adverse event The contextual ABCs of dementia care Searching for Clues Part 1: Antecedent Interventions Searching for Clues Part 2: Consequent Interventions Designing restraint free interventions Maintain behavior Increase access to pleasant consequences

38 Assess context of problem behavior to understand its function or purpose Resident 1: Antecedent = Alone at table Resident 2: Antecedent = Noisy, crowded classroom Behavior Crying Resident 1: Consequence = Staff attends to resident; Access social reinforcement Resident 2: Consequence = Staff moves resident to quiet area; Escape from an aversive situation

39 Increase access to pleasurable activities Promoting freedom in long term care facilities Emphasize role of personal history and current preferences Observe behavior of those who cannot describe preferences Behavior demonstrates what words cannot Behavioral activation: Promoting pleasurable activities (Lewinsohn & Graf, 1973) Pleasant events menus can be very helpful (Lewinsohn, 1974)

40 Case example: Embedding pleasurable activities to reduce resistance to care Preventing aggression in persons with dementia

41 When does aggression occur? Aggression occurs when task demands are presented to resident (e.g., during caregiving) Unfamiliar person, in an intimate setting, disrobing the fearful resident increases the effectiveness of escape as a reinforcer Behavior that has resulted in escaping aversive situations in the past is likely to occur Limited repertoire for escaping Aggression is most efficient response for terminating aversive stimuli its adaptive

42 Goals of intervention Alter the aversive properties of the caregiving situation Reduce motivation to engage in escape behavior (i.e., aggression) Prevent further reduction of the patient s repertoire Intervention must be simple, quick, and easy for caregiver to maintain

43 Mrs. B: Background information 89 year old woman with diagnosis of dementia Mini-Mental (MMSE) score = 0 Physical aggression: Scratching Verbal aggression: Screaming and swearing at caregivers Highly distressed and crying during caregiving

44 Identifying preferences Preference assessment (W. Fisher, et al. 1992): Identify preferred activities and objects for severely impaired residents Caregiver interview Generate menu of potential stimuli Systematically present paired items to patient and record which items they choose (e.g., visual orientation, touch)

45 Stimulus Preference Record Sheet Resident: Date: Presentations #1 Stuffed Dog vs. Pink Baby Doll #2 Stuffed Cat vs. Lullaby Light #3 Pink Baby Doll vs. Baby Video #4 Dog Video vs. Stuffed Dog #5 Baby Video vs. Stuffed Cat Items DogCatBaby Vid.Dog Vid. Lul. Light Baby Doll Raw Rank

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49 Mrs. B: Preference assessment results Baby video Dog video Music box Baby doll Stuffed toy dog Wrapped package

50 Intervention Brief preference assessment immediately prior to each caregiving session Resident allowed free access to the preferred object or video for one minute prior to caregiving Staff instructed to orient resident to the preferred object throughout session (e.g., Aren t those babies cute? ) After one minute of exposure to preferred object, staff begin disrobing resident while continuing to orient her to the object

51 Mrs. B: Physical Aggression Aggressive acts per minute Baseline Treatment Baseline Treatment Sessions

52 Thank you! Department of Psycholgy/298 University of Nevada, Reno Reno, Nevada

53 Literature cited American Geriatrics Society (2002). Panel on Persistent Pain in Older Persons. Ballard, C., Hanney, M.L., Douglas, S., McShane, R., Kossakowski, K., et al. (2009). The dementia antipsychotic withdrawal trial (DART- AD): Long-term follow-up of a randomized placebo-controlled trial. The Lancet Neurology, 8, Fisher, W., Piazza, C.C., Bowman, L.G., Hagopian, L.P., Owens, J.C., & Slevin, I. (1992). A comparison of two approaches for identifying reinforcers for persons with severe and profound disabilities. Journal of Applied Behavior Analysis, 25, Fisher, J.E., Drossel, C., Ferguson, K., Cherup, S., & Sylvester, M. (2008). Restraint free care of persons with dementia. In: D.Gallagher-Thompson, A. Steffen & L.W. Thompson (Eds.). Handbook of behavioral and cognitive therapies with older adults, pp New York: Springer.

54 Horgas, A.L., & Tsai, P.F. (1998). Analgesic drug prescription and use in cognitively impaired nursing home residents. Nursing Research, 47, Katona, C.L.E., (2001). Psychotropic and drug interaction in the elderly patient. International Journal of Geriatric Psychiatry, 16, S86-S90. Lewinsohn, P.M. (1974). A behavioral approach to depression. In R.M. Friedman, & M.M. Katz (Eds.), The psychology of depression: Contemporary theory and research. New York: Wiley. Lewinsohn, P.M., & Graf, M. (1973). Pleasant activities and depression. Journal of Consulting and Clinical Psychology, 41,

55 Reynolds, K.S., Hanson, L.C., DeVellis, R.F., Henderson, M., & Steinhauser, K.E. (2008). Disparities in pain management between cognitively intact and cognitively impaired nursing home residents. Journal of Pain Symptom Management, 35(4), Schneider, L. S., Tariot, P. N., Dagerman, K. S., Davis, S. M., Hsiao, J. K., Ismail, M. S., et al. (2006). Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease. The New England Journal of Medicine, 355(15), Slaughter, S., & Bankes, J. (2007). The Functional Transitions Model: Maximizing ability in the context of progressive disability associated with Alzheimer s disease. Canadian Journal on Aging, 26 (1),