Geriatric Grand Rounds. Managing Behavioural and Psychological Symptoms of Dementia (BPSD) in Patients with Alzheimer s Disease

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1 Geriatric Grand Rounds Visit web sites: Tuesday, April 14, :00 noon Dr. Bill Black Auditorium Glenrose Rehabilitation Hospital In keeping with Glenrose Rehabilitation Hospital policy, speakers participating in this event have been asked to disclose to the audience any involvement with industry or other organizations that may potentially influence the presentation of the educational material. Disclosure will be done both verbally and using a slide or handout. for handouts, poster, schedule, subscription: for on-demand archive of previous presentations: Managing Behavioural and Psychological Symptoms of Dementia (BPSD) in Patients with Alzheimer s Disease Medical Director, Geriatric Psychiatry and Associate Professor University of Manitoba Geriatric Psychiatrist, St. Boniface Hospital, Winnipeg, Manitoba Conflicts Today s Learning Objectives Id vs Superego Funding for this talk from Lundbeck Also have received funding within the past year from Pfizer, Novartis, Janssen and Wyeth for presentations No ongoing research funding from Pharma Following this presentation, participants will : Recognize the spectrum of BPSD and it s complexity Understand the role of psychotropic medication within a comprehensive best practice approach to BPSD Be aware of some pragmatic tools to support care strategies Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 1 of 20

2 BPSD Symptom Clusters BPSD Symptom Clusters Apathy Aggression Physical aggression Verbal aggression Aggressive resistance to care Pacing Repetitive actions Dressing/undressing Restless/anxious Agitation Apathy Aggression Physical aggression Verbal aggression Aggressive resistance to care Pacing Repetitive actions Dressing/undressing Restless/anxious Agitation Withdrawn Lacks interest Amotivation Sad Tearful Hopeless Irritable/screaming Guilty Anxious Suicidal Euphoria Pressured speech Irritable Mania Hallucinations Delusions Misidentification Suspicious Psychosis Withdrawn Lacks interest Amotivation Sad Tearful Hopeless Irritable/screaming Guilty Anxious Suicidal Euphoria Pressured speech Irritable Mania Hallucinations Delusions Misidentification Suspicious Psychosis Depression Depression Group Discussion Questions Prevalence of BPSD What BPSDs do you most commonly see in your practice? What are the consequences of BPSD? Estimated to affect 63% of community-dwelling patients with dementia 1,2,3 Symptoms are increasingly prevalent and disturbing in severe AD 4 In particular, agitation and aggressive behaviours affect roughly 2/3 of patients with severe AD 4 Also common in severe AD: depression, apathy, anxiety, delusions, and hallucinations 4 1. Cohen-Mansfield et al. Int Psychogeriatr 1995;7: Hogan DB et al. Alzheimers Dement 2007;3: Jost BC. J Am Geriatr Soc 1996;44(9): Herrmann N et al. Alzheimers Dement 2007;3: Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 2 of 20

3 Meet Henry: A 74-Year-Old Recently Admitted to Long-Term Care (LTC) Case Study: Henry Admitted to nursing home 6 weeks ago 3 weeks prior to admission, Henry s wife (and attentive caregiver) passed away Henry has a 4-yr history of Alzheimer s disease (AD) 2-yr history of donepezil 10 mg OD, no other AD meds Current MMSE = 20/30 Requires assistance for dressing and hygiene 6 feet tall, 180 pounds, no mobility problems Henry: Medical History and Other Current Medications This Morning... Long-term history of high BP Taking HCTZ 25 mg qd and enalapril 5 mg qd Chronic lower back pain Taking Tylenol #2 as needed and Naproxyn 500 mg TID Esophageal reflux Taking Ranitidine 75 mg BID and Diphenhydramine 50 mg after evening meal Previous cataract surgery A fight breaks out at Henry s breakfast table The cause of the fight is unclear Henry assaults another resident, who falls to the ground and breaks his arm Henry is screaming; everyone is upset Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 3 of 20

4 Group Discussion Question With Any New-Onset Behavioural Issue... Henry is immediately started on an antipsychotic. What do you think of this treatment approach? Delirium Psychological Issues Side Effect of Medication RULE OUT Depression Physical Triggers Environmental Triggers Possible Causes of Delirium The Big 3 1. DRUGS* Any new drug (beware additive anticholinergics) 2. Infection 3. Metabolic The Little 3 1. Pain 2. Urinary retention/infection 3. Fecal impaction/loading Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 4 of 20

5 Ruling Out Possible Causes for Henry s BPSD If you Choose an Antipsychotic Consider medical illness: Urinary tract infection or other infection Poorly controlled pain PRN s used causing confusion Start low and go slow, but be persistent Counsel substitute decision-maker about risks and alternatives and chart How could you start Henry on an antipsychotic? Check labs: Electrolytes Creatinine Glucose Hemoglobin Urinalysis Establish baseline frequency and severity, then risperidone 0.25mg BID for one week Review target symptom and any extrapyramidal symptoms If beneficial, continue with plan being to taper in the next few months If not beneficial, either discontinue or titrate up BPSDs are Associated with Poor Patient Outcomes... BPSDs are Associated with Poor Patient Outcomes... More rapid cognitive and functional decline 1 Chicken Use of antipsychotic medication 2,5 Increased physical frailty and mortality 1,5 Earlier placement in long-term care (up to 2 years earlier) 3,4 Or Egg Increased caregiver burden 5 1. Hermann N et al. Alzheimers Dement 2007;3: Margallo-Lana M et al. Int J Geriatr Psychiatry 2001;16(1): Phillips VL, Diwan S. J Am Geriatr Soc 2003;51: Hogan DB et al. Alzheimers Dement 2007;3: Herrmann N, Gauthier S. CMAJ 2008;179(12): Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 5 of 20

6 Cardiovascular Risks Associated with Antipsychotics In 2005: FDA issued black box warning about increased risk of MI and CVA Health Canada sent an advisory to HCPs In 2007: Prospective trial showed no risk of death In early 2009, risk of death found in: U.S. retrospective analysis (n=276,907) U.K. prospective study (n=165) with up to 42 months follow-up Raivio MM, et al. Am J Geriatr Psychiatry 2007;15(5): Ray WA, et al. N Engl J Med 2009;360: Ballard C, et al. Lancet Neurol 2009;8(2): Risk of Sudden Cardiac Death Higher with Antipsychotics: Retrospective Study Risk of Sudden Cardiac Death Higher with Antipsychotics: Retrospective Study New England Journal of Medicine, January 2009 Retrospective cohort study of U.S. Medicaid enrollees Pts taking typical (n=44,218) or atypical (n=46,089) antipsychotics, or matched controls (186,600) Adapted from Ray WA, et al. N Engl J Med 2009;360: Adjusted Incidence Rate Ratios Overall For Low Dose For High Dose p-value (low vs. high) Typical p<0.001 Atypical p=0.01 Incident Rate Ratio Low Dose Moderate Dose High Dose 3,5 p= p< ,5 2 1,5 1 0,5 0 Typical Antipsychotics Agent Atypical Antipsychotic Agent No. of Deaths No. of Person-Years 21,438 33,671 31,626 10,435 41,513 27,641 Incidence-Rate Ratio % CI Adapted from Ray WA, et al. N Engl J Med 2009;360: Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 6 of 20

7 Risk of Mortality Higher with Atypical Antipsychotics: Prospective Trial Risk of Mortality Higher with Atypical Antipsychotics: Prospective Trial The Lancet, e-pub January, 2009 U.K. randomized, placebo-controlled, parallel, two-group treatment discontinuation trial Continue antipsychotics for 12 months (n=83) vs. switch to placebo (n=82) + long-term follow-up Probability of Survival 12-month 24-month 36-month 42-month Antipsychotic 70% 46% 30% 26% Placebo 77% 71% 59% 52% Overall hazard ratio = 0.58; p=0.03 Kaplan-Meier Survival Estimate Cumulative survival (%) Number at risk (deaths) Continue treatment Placebo Placebo Continue treatment HR 0.58 (95% CI 0.35 to 0.95); Log-rank p= (19) 64 (15) 45 (13) 49 (3) 20 (6) 29 (6) 9 (1) 19 (2) 4 (0) 8 (1) Adapted from Ballard C, et al. Lancet Neurol 2009;8(2): Adapted from Ballard C, et al. Lancet Neurol 2009;8(2): Antipsychotics and stroke risk Madness of modern medicine Douglas and Smeeth s study of the risk of stroke with antipsychotic drugs highlights modern medicine s flawed perspective.1 Medicine once served to make patients better, alleviating symptoms and healing disease. Now it seems to have degenerated into a risk reducing, patient stratifying, life years adding bioscience disregarding the individual patient s needs. To deny a patient good treatment for disturbing and harassing complaints because of worries about possible side effects is unethical. Nobody would question prescribing morphine for terminal analgesia. Patients at the end of their life with dementia related behavioural problems should be able to expect proper treatment. To withhold this treatment for spurious and debatable reasons is "madicine." Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 7 of 20

8 Risperidone and Olanzapine similar Placebo worst Norwegian Nursing Home Study: Symptoms Persisted Despite Psych Treatment Risperidone and Quetiapine similar Olanzapine worst 1-year study of 1,163 nursing home patients (80% had dementia) 84% were symptomatic at some point during the year Most patients (75 to 88%) who were taking antidepressants, antipsychotics or psychotropics at baseline continued taking these throughout the year Despite psychiatric medication, baseline symptoms generally persisted over the year Selbaek G et al. Am J Geriatr Psychiatry 2008;16(7): Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 8 of 20

9 60 How Likely are meds to be stopped? Prev Persist Incidence % of patients on med n at start and end of study Antidepressants 79% Antipsychotics 75% Any Psychotropic 88% 10 0 Irritability Apathy Aggression Delusions Depression DART Randomized discontinuation of antipsychotics in patient with dementia Setting UK nursing or residential homes Randomized to standard dosing 12 month duration Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 9 of 20

10 SO. IF they increase risk of stroke, they increase risk of death, they increase risk of falls AND they have limited efficacy. WHY Are they used so often? P.I.E.C.E.S. Framework to Understand and Address BPSD Complexity P hysical problem or discomfort I ntellectual/cognitive changes E motional C apabilities E nvironment S ocial/cultural Non-Pharmacological Interventions Environmental interventions 1 Validation therapy 2 Best friend approach 3 Simulated presence therapy 4 Pet therapy Activities, exercise, social interaction Behaviour modification (e.g., scheduled toileting) 1. Moak GS. The Clinical View: Geriatric psychiatry in long term care. 2004;2(2): Feil N, et al. The Validation Breakthrough Bell V, Troxel D. The Best Friend Approach to Alzheimer Care Woods P,Ashley J. Geriatr Nurs 1995;16(1):9-14. Cont d... Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 10 of 20

11 Effective Non-Pharmacological Interventions Bright light therapy Environmental white noise (e.g., soft background music or lullabies) Music therapy: may lessen some symptoms and improve QoL 1,2 Snoezelen multisensory interventions (involving fibreoptic lights and touch): can provide relief from acute or chronic pain by offering distraction 3 Stimulates passive pts, soothes agitated pts Aromatherapy (lemon balm or lavender oil) can sometimes be an alternative to neuroleptics 2 1. Raglio A, et al. Alz Dis Assoc Dis. 2008;22(2) Alzheimer s Society. Complementary and alternative medicine and Dementia. Available at: alzheimers.org.uk/factsheet/ Burns A, et al. BMJ 2002;325: Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 11 of 20

12 Skills required from Nursing Staff Simple Care? Post-Intervention Establish visual contact Approach the patient slowly, head-on If you fear for your safety, place a chair between you Direct the patient calmly and firmly (e.g., Please look at me ) Gently touch the patient s hand (after asking permission) Recognize what the patient is feeling in order to make him/her feel understood (e.g., You are angry right now ) If needed, remove the patient to a calmer area If de-escalation is needed before you intervene, calmly divert the patient s attention (e.g., Henry, look out the window ) Phaneuf, M. Le vieillissement perturbé : la maladie d Alzheimer. 2 nd ed; Voyer, P. Soins infirmiers aux ainés en perte d autonomie : Une approche adaptée au CHSLD Show empathy (e.g., hold the patient s hand) Distract the patient Suggest a physical activity/task to help patient feel useful Chart what happened Ask yourself why the behaviour manifested, and be ready to play detective in order to figure it out Put a program in place to prevent future crises Treat the patient like a partner in this program (plan for daily interaction and establish daily rituals) Give the patient time to adjust to changes in the routine Adopt a proactive approach Phaneuf, M. Le vieillissement perturbé : la maladie d Alzheimer. 2 nd ed; Voyer, P. Soins infirmiers aux ainés en perte d autonomie : Une approche adaptée au CHSLD Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 12 of 20

13 What Techniques Don t Work? Taking a reactive (vs. proactive) approach Dominating the patient Reprimanding the patient for his/her behaviour Restraining the patient (except in extreme cases) Using medication as a chemical restraint Punishing the patient Touching the patient without warning him/her first and without asking permission Treating the patient like an infant As a member of staff, feeling defeated by the incident Methods: Thirty nursing home residents with frequent,severe behavioral disturbances were observed by research staff before,during, and after multiple, randomized, singleblind exposures to 15-minute audiotapes of simulated family presence (a conversation prepared by a family member about positive experiences from the past), music preferred by the resident in earlier life, and a placebo condition of a reading from a horticultural text. Selected (usually multiple) physical and verbal behaviors were counted as present or absent at regular intervals. All three treatment conditions were compared with usual care. Phaneuf, M. Le vieillissement perturbé : la maladie d Alzheimer. 2 nd ed; Voyer, P. Soins infirmiers aux ainés en perte d autonomie : Une approche adaptée au CHSLD Pharmacological Options for the Treatment of BPSD Benzodiazepines should be used only for short periods as p.r.n. agents. ChEIs & and memantine A trial of a cholinesterase inhibitor and/or memantine can be considered Antidepressants From the Consensus Guidelines: Anxiolytics Before initiating therapy with other forms of pharmacotherapy BPSD for BPSD, clinicians should consider use of the disease-specific treatments. Adapted from the Canadian Consensus Conference on Diagnosis and Treatment of Dementia SSRIs can be used for the treatment of severe depression. Trazodone: Insufficient evidence to recommend for or against the use. Atypical antipsychotics Risperidone and olanzapine can be used for severe agitation, aggression and psychosis. The potential benefit of all antipsychotics must be weighed against the potential risks such as cerebrovascular adverse events and mortality. Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 13 of 20

14 Meta-Analysis of All ChEI Trials with Behavioural Data (to 2001) ChEIs in the Canadian Guidelines Litt search of MEDLINE ( ), PubMed, Cochrane Register, etc. Searched for well-designed trials in mild-tomoderate AD with 1 month use of ChEI Found 16 such trials with neuropsychiatric measures NPI: ChEI improved 1.72 points more than placebo (95% CI, points) ADAS-non-cog: ChEI improved 0.03 points more than placebo (95% CI, points) Modest benefit on neuropsychiatric outcomes There is evidence [from trials of cognition/function/adl] of benefit on neuropsychiatric symptoms... and from one trial designed specifically with behaviour as the primary outcome measure Treatment with ChEIs might improve apathy, depression, anxiety, and psychosis Trinh NH, et al. JAMA 2003;289: Hermann N, et al. Alzheimer Dement 2007;3: Donepezil: Improvement vs. Worsening in Behaviour when Donepezil was Maintained vs. Withdrawn Pts Continuing Donepezil had Improvement in NPI (vs. Worsening for Discontinuing) Randomized withdrawal study, mild-to-mod AD All pts received donepezil for 12 weeks, then either donepezil or placebo for 12 more weeks 134 pts with mild-to-mod AD and marked BPSD Pts who continued donepezil had better NPI scores than withdrawal group (mean change -2.9 vs points; p= 0.02) * * p<0.001 vs. baseline ** p<0.05 for between-group difference * ** ** Holmes C, et al. Neurology 2004;63(2): Adapted from Holmes C, et al. Neurology 2004;63(2): Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 14 of 20

15 Donepezil: No Benefit on NPI in Moderate-to-Severe AD Donepezil: No Benefit on Behaviour in Severe AD 24-week, placebo-controlled, randomized trial 208 nursing home pts (mean MMSE = 14.4) Nursing Home version of NPI was the primary outcome No significant difference on NPI for donepezil vs. placebo at Week 24 6-month, double-blind, parallel-group, placebo-controlled study 248 nursing home pts (MMSE of 1-10) NPI was a secondary outcome No significant benefit on behaviour Tariot PN, et al. J Am Geriatr Soc 2001;49(12): Winblad B, et al. Lancet 2006;367(9516): Rivastigmine: Effect on Behaviour Comparable to Donepezil in Moderate AD Rivastigmine: No Improvement in Agitation in Severe AD 2-year, randomized, head-to-head comparison of donepezil and rivastigmine 994 nursing home pts (mean MMSE 15.1) NPI was a secondary measure Similar worsening of behaviour seen for both treatment groups Authors note that decline was significantly smaller than would be expected from untreated patients 26-week, double-blind, placebo-controlled, RCT of rivastigmine vs. quetiapine 93 nursing home pts with significant agitation Primary outcomes included agitation Compared with placebo, neither group showed significant differences in improvement on the agitation inventory either at six weeks or 26 weeks Bullock R, et al. Curr Med Res Opin 2005;21(8): Ballard C, et al. BMJ 2005;330(7496):874. Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 15 of 20

16 Rivastigmine: Improvement in Behaviour in Mod to Sev AD Impact of Memantine on Use of Psychotropics in Real World Setting Analysis of data from a 26-week prospective open-label study + 26-week extension 173 nursing home pts with mod-to-sev AD taking rivastigmine 1.5 to 6 mg bid Significant improvements in 10 of the 12 behavioural domains of the Nursing Home version of the NPI (including delusions, hallucinations, anxiety, euphoria) 40% of pts taking antipsychotics reduced dose or discontinued Edwards K, et al. Clin Drug Investig 2005;25(8): Study of all patients in French national health insurance plan taking memantine (n=4,600) Evaluated use of psychotropics before and after a specific event: the first purchase of memantine Database covered, on average, 11.7 months before and 11.2 months after first purchase of memantine Before memantine: Psychotropic use increasing After memantine: Psychotropic use stopped increasing Vidal J-S, et al. Neuroepidemiology 2008;31: Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 16 of 20

17 Pooled-Data Analysis of all 6 Studies of Memantine and Behaviour Memantine Patients Showed an Improvement in Agitation/Aggression Memantine was found to: 1-3 Improve NPI total score Improve some individual items (particularly agitation/aggression) Effect on agitation was seen in patients: With the symptom at baseline (i.e., improvement) Without the symptom at baseline (i.e., delayed emergence) 1. Winblad B, et al. Dement Geriatr Cogn Disord 2007;24: Maidment ID, et al. Annals Pharmacother 2008;42(1): Gauthier S, et al. Int J Geriatr Psychiatry 2008;23(5): Percentage of patients showing improvement at week 24/28 (LOCF) * Delusions Hallucinations Agitation/aggression *p<0.05 * Depression/dysphoria Anxiety Elation/euphoria Apathy/indifference Adapted from Gauthier S et al. Int J Geriatr Psychiatry 2008;23(5): Memantine * Disinhibition Irritability/lability Aberrant motor behaviour Placebo Night-time behaviour Appetite/eating change Memantine Prevented the Emergence of Agitation/Aggression Can Memantine Delay Time to Nursing Home Placement? Percentage of patients remaining asymptomatic at week 24/28 (LOCF) Delusions *p=0.05; **p<0.01; ***p=0.001 Hallucinations *** Agitation/aggression Depression/dysphoria Anxiety Elation/euphoria Apathy/indifference Adapted from Gauthier S et al. Int J Geriatr Psychiatry 2008;23(5): Memantine Disinhibition ** Irritability/lability Aberrant motor behaviour Placebo * Night-time behaviour Appetite/eating change Retrospective analysis of data from AD patients at the Alzheimer s Disease Research Center in Pittsburgh Sub-cohort (created to account for differences related to the year of entry into the study) involved 429 pts enrolled on or after July 29, 1997, with at least one year of follow-up 140 pts used ChEIs + memantine 289 pts used ChEIs only Lopez OL et al. J Neurol Neurosurg Psychiatry. Published online 9 Feb Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 17 of 20

18 Patients Taking Memantine + ChEI Were Seven Times Less Likely to Enter Nursing Home vs. Patients Taking ChEI Alone Proportion of Patients Taking Memantine + ChEI vs. ChEI Alone Entering Nursing Home or Using Sedatives, Anxiolytics, or Hypnotics Survival Distribution Function Relative Hazard 0.13 (95% CI: ) p<0.001* Follow-up time, in years * Derived from fully adjusted Cox model Lopez OL et al. J Neurol Neurosurg Psychiatry. Published online 9 Feb Memantine + ChEIs 2. ChEIs alone Portion of patients entering nursing home Portion of patients taking sedatives, anxiolytics, and hypnotics ChEI monotherapy Lopez OL et al. J Neurol Neurosurg Psychiatry. Published online 9 Feb ChEI + memantine p-value 18% 5% < % 8% Impact of Memantine on Use of Psychotropics in Real World Setting Database covered, on average, 11.7 months before and 11.2 months after first purchase of memantine Researchers evaluated trend line effects Results: Before memantine: Psychotropic use increasing After memantine: Psychotropic use stopped increasing Trend seen for all psychotropics and every subgroup Vidal J-S et al. Neuroepidemiology 2008;31: Similar Decline Seen with all Psychotropics Treatment ß Coefficients (CI) Pre Memantine Post Memantine Any Psychotropic Antidepressants Neuroleptics Anxiolytics Hypnotics (0.025 to 0.036) (0.015 to 0.028) (0.046 to 0.068) (0.017 to 0.031) ( to 0.016) ( to 0.002) ( to 0.005) ( to 0.018) ( to 0.010) ( to 0.007) p value < < < < Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 18 of 20

19 Significant Difference in Neuroleptics Use after Starting Memantine Why Did Psychotropics Increase Sharply at Time of Memantine Purchase? Use Increasing ß=0.057 (CI to 0.068) (p<0.0001) Use decreasing slightly ß= (CI ) May signify abrupt deterioration, which led to simultaneous Rx of more psychotropic drugs and memantine Could be explained (at least partly) by simultaneous purchase of all drugs prescribed in addition to memantine (because interrupting event was first purchase of memantine) Vidal J-S et al. Neuroepidemiology 2008;31: Vidal J-S et al. Neuroepidemiology 2008;31: Continuing with Henry s Case Could Henry s Current Situation Have Been Avoided? Travel Back in Time 6 Weeks Ago: On admission, Henry s grown children warned that he was fussy about personal care, but that their mother had a knack for calming him down He has significant deafness, which makes communication difficult Cont d... Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 19 of 20

20 Could Henry s Current Situation Have Been Avoided? Could Henry s Current Situation Have Been Avoided? Over the Past 6 Weeks: Henry has wandered the unit aimlessly, often irritable Becomes agitated and resistive during personal care Has been sad and occasionally cries, asking where is my wife? Over the Past 2 weeks: Henry has experienced significant changes in his sleep He has become even more agitated and irritable He has had a harder time hearing what the staff are saying Also, for the first time, Henry has been off balance (was he taking all these meds at home?) Cont d... Strategies for Treating Henry Key Take-Home Messages Review his medications and consider changes Stop any that may be unnecessary (e.g., naprosyn, diphenhydramine, codeine and ranitidine) Add potentially helpful meds (e.g. memantine) Look at environmental triggers and interactions that lead to agitation R/O delirium Seek input to determine from family and nursing staff Behaviour is a complex issue A bio-psycho-social approach is essential Environmental and approach strategies may be most effective BUT are difficult to implement Antipsychotics are complex drugs to utilize Memantine is an alternative approach Geriatric Grand Rounds, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada (April 14, 2009) Page 20 of 20

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