An Approach to Dementia-related Behaviours at the End of Life. Elisabeth Drance MD FRCP(C) Ger. Psych Clinical Associate Professor Psychiatry UBC

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1 An Approach to Dementia-related Behaviours at the End of Life Elisabeth Drance MD FRCP(C) Ger. Psych Clinical Associate Professor Psychiatry UBC

2 Objectives List the common behaviours occurring in late stage dementia Use an organized comprehensive individualized approach to assessing these behaviours Identify most common causes of behavioural symptoms arising in late stage dementia Explore nonpharmacological & pharmacological interventions for behaviours occurring in late stage dementia

4 Natural History of Alzheimer Disease FAST - 7 Stage Scale Stage 6 Moderately Severe Dementia Requires assistance with dressing Requires assistance with bathing, hygiene Requires assistance with toileting Increasing frequency of urinary & fecal incontinence Behaviours fear, delusional ideation, verbally & physically responsive behaviours, sleep cycle fragmentation Average duration years

5 Natural History of Dementia Fast Scale Stage 7 Severe Dementia Markedly diminished speech eventually to point of single syllable words or non word vocalization. Decline in ambulatory ability Decline in postural reflexes Loss of ability to smile High risk for aspiration, infections, skin break down Average duration years

6 Personhood honouring care Advanced dementia makes it: Hard to access the person living with the disease Easy to overlook the remaining abilities of the person living with dementia Easy to nullify the emotional experience of the person living with dementia Easy to objectify the person living with dementia leading to disrespect, distancing, outpacing etc.

7 Dementia demands Person- Centered Care VIPS Model V Values and promotes rights of all people I Individualized Care according to individual needs P Taking the perspective of the person living with dementia (Empathy) S Supportive Social Psychology Dawn Brooker University of Worcester

8 Dementia-related Behaviours Stage 7 Delirium-related behaviours Responsive behaviours during care (Resistiveness to care Refusing Care) Verbally responsive (aggressive) Physically responsive (passive resistance or aggressiveness) Vocalizing calling, moaning, screaming

9 Volicer et al; JAMDA :

10 Approach: Identifying Unmet Needs All behaviour has meaning. All behaviour in dementia is an attempt to communicate need. Needs can range from the most physical to the most existential We are the detectives..

11 P.I.E.C.E.S. Assessment Framework 3 Question Template 1. What has changed? Be specific. 2. What are the risks & possible causes? Physical 5 D s of Physical Intellectual 7 A s of Dementia Emotional Psychiatric sx & syndromes Capabilities Environment (Physical & Interpersonal) Social 3. What is the plan?

12 BC s BPSD Algorithm (BPSD behavioural and psychological symptoms of dementia) www. bcbpsd.ca

13 Responsive Behaviours During Care Common causes in Advanced Dementia Physical - PAIN, PAIN, PAIN, PAIN - Delirium - Response to Touch Intellectual Aphasia Expressive & Receptive Altered Perception Amnesia Executive dysfunction - dominance of fight-flight response

15 Responsive Behaviours During Care Common causes in Advanced Dementia Physical - PAIN, PAIN, PAIN, PAIN - Delirium - Response to Touch Intellectual Aphasia Expressive & Receptive Altered Perception Amnesia Executive dysfunction - dominance of fight-flight response

16 Responsive Behaviours During Care Common Causes in Advanced Dementia Emotional/Psychiatric Depression Capabilities Expecting too much or too little from the individual Response to music, touch, Environment (Physical & Interpersonal) Overstimulating environment too many people talking at once, usually to each other Physical setting eg temperature Interpersonal environment Mindless caregiving Social life story contributions traumas, coping styles, responses to stress,

17 Mindful Caregiving Preparing for care knowing the person & care plan Knowing what the person needs to feel safe and secure Self awareness before starting care Connecting relationally before care knowing the way in (music, touch etc) Understanding person s communication abilities Avoiding outpacing Watching for early signs of discomfort & fightflight response Stop and go technique

18 Pharmacological approaches when and what? Assess for pain & treat Assess for major psychiatric contributors & treat (depression/psychosis) Designing an individualized plan for care interactions key If no pain/depression, medications are used to dampen fight-flight response in the short term, while care plan developed and implemented.

19 KEY POINTS: Early recognition of behavioural change during care is key. Pushing through repeatedly worsens the behaviour. Most of the interventions for people with responsive behaviours during care are NONPHARMACOLOGICAL unless pain/depression are obvious causes

20 Pharmacological approaches to Responsive Behaviours During Care When and What? 1. Pain medications Acetaminophen, Opioids 2. SSRIs 3. Trazodone 4. Lorazepam pre-care to dampen fightflight over-response 5. Antipsychotics delusional misinterpretation of care interactions.

21 Summary Advanced Dementia comprises Stages 6&7 FAST staging Most common behavioural symptoms relate to delirium, depression, and progression of dementia. Vocalizations & Responsive Behaviours are most common PIECES - Comprehensive assessment required to develop individualized care plan Pain and Depression are common contributors to the picture Nonpharmacological interventions are based on the need for relational connection, mindful caregiving interactions, and stimulation of working parts of brain with music & touch.

October 28, Geriatrics Update Course. Lesley Wiesenfeld, MD, MHCM, FRCPC. Managing BPSD. Geriatric Psychiatrist, Mount Sinai Hospital

October 28, Geriatrics Update Course. Lesley Wiesenfeld, MD, MHCM, FRCPC. Managing BPSD. Geriatric Psychiatrist, Mount Sinai Hospital October 28, 2016 Geriatrics Update Course Managing BPSD Lesley Wiesenfeld, MD, MHCM, FRCPC Geriatric Psychiatrist, Mount Sinai Hospital Disclosures ~No Pharmaceutical or Industry Support ~ No Health Without