Vanderbilt & atom Alliance Webinar Series

Vanderbilt & atom Alliance Webinar Series

Vanderbilt University Medical Center Vanderbilt University Center for Quality Aging atom Alliance

Session #2: Dementia & Behavioral Disturbances Session #3: Psychopharmacology in the Nursing Home Session #4: Principles of Non-pharmacologic Management & the Formulation of Behavioral Care Plans Session #5: The Implementation of Behavioral Strategies & the Management of Pharmacologic Interventions Session #6: Addressing Barriers to Change: the Perspective of Psychiatry, Nursing, and Medical Directors

Chat Monitor: Britt Kuertz, RDN Brittany.t.kuertz@vanderbilt.edu 615-936-1499 Moderator: Emily Hollingsworth, MSW Emily.k.hollingsworth@vanderbilt.edu 615-936-2718

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Paul Newhouse, MD

Paul Newhouse, MD Director, Vanderbilt Center for Cognitive Medicine, Jim Turner Chair in Cognitive Disorders Department of Psychiatry, Vanderbilt University

Become familiar with common dementing disorders and their clinical symptoms. Describe common behavioral problems in dementia Understand the context in which behavioral disturbances occur in dementia patients

Clinical Picture of Behavioral Problems in Dementia A 51 year old, A.D. is admitted to the longterm care facility for being unmanageable at home.. Her husband reports that she has loss of memory, delusions, and temporary vegetative states. She will drag sheets across the house, and scream for hours in the middle of the night. On examination, she has a cluster of symptoms that include reduced comprehension and memory, as well as language disturbance, disorientation, unpredictable behavior, paranoia, auditory hallucinations, and severe social impairment. Auguste Deter November, 1902 Her condition steadily deteriorates despite treatment with memory loss, speech difficulty, confusion, suspicion, agitation, wandering and screaming to becoming bedridden, incontinent, and unaware of her surroundings. She dies and her brain is sent for autopsy by Dr Alois Alzheimer Recently, her tissue was reexamined and found to show a rare familial Alzheimer s Disease gene mutation (PS1).

Dr Alois Alzheimer More Recent Cases of Alzheimer s Disease Alzheimer s disease (AD) refers to the neurodegenerative brain disorder regardless of clinical status 16 Thursday, March 19, 15 AD can be conceptualized as having two major stages Preclinical (presymptomatic) Symptomatic Prodromal (MCI) Dementia of the Alzheimer type

A global impairment of higher cortical functions including memory, capacity to solve problems of daily living, performance of learned perceptuomotor skills, correct use of social skills and control of emotional reactions. Multiple Cognitive Deficits: Memory dysfunction: especially new learning, a prominent early symptom At least one additional cognitive deficit aphasia, apraxia, agnosia, or executive dysfunction Cognitive Disturbances must be sufficiently severe to cause impairment of occupational or social functioning Must represent a decline from a previous level of functioning

Symptom Trouble remembering new information 46% Difficulty with complicated tasks 27% Trouble responding to problems 14% Frequently getting lost or trouble staying oriented 18% Trouble expressing thoughts, ideas, or following conversations 21% Change in personality or behavior 25% CHS Alzheimer s Disease Caregiver Project: Wave 6, 2000

Cognitive function Time? 0 y Time (y) 10 y MCI MMSE 24 30 Mild subjective/ objective memory loss Normal function Mild AD MMSE 20 23 Forgetfulness Repetitive questions Daily function impaired Moderate AD MMSE 10 19 Progression of cognitive deficits Short-term memory loss Word-finding difficulties Severe AD MMSE 0 9 Agitation Altered sleep patterns Total dependence: dressing, feeding, bathing

MILD STAGE Forgetfulness, difficulty learning new information Difficulty planning meals, managing finances, taking medications on schedule Symptoms sometimes mistaken for depression Ability to perform activities of daily living (ADL) usually maintained Sources: Galasko D. Eur J Neurol. 1998;5(suppl 4):S9-S17. Cefalu C, Grossberg GT. Diagnosis and Management of Dementia. Leawood, Kan: American Academy of Family Physicians; 2001.

MODERATE STAGE Short- and Long- term memory impairment Difficulty performing tasks (e.g., following written notes, using the shower or toilet) Agitation, behavioral symptoms appear (e.g., restlessness, wandering, delusions, hallucinations) Deficits in intellect and reasoning (e.g., poor judgment, forgets manners) Sources: Galasko D. Eur J Neurol. 1998;5(suppl 4):S9-S17. National Institute on Aging Alzheimer s Disease Education and Referral Center. Available at: http://www.alzheimers.org/unraveling/unraveling.pdf. Accessed April 6, 2005.

SEVERE STAGE May lose language function and mumble or speech may be unintelligible Behavioral symptoms common (e.g., refuses to eat, cries out inappropriately) Failure to recognize family or faces Difficulty with all essential ADL (e.g., eating, toileting, walking) Source: Gwyther LP. Caring for People With Alzheimer s Disease: A Manual for Facility Staff. 2nd ed. Washington, DC and Chicago, Ill: American Health Care Association and the Alzheimer s Association; 2001.

Activities of Daily Living Years Mild Moderate Severe 0 2 4 6 8 10 Keep Appointments Use the Telephone Obtain Meal/Snack Travel Alone Use Home Appliances Find Belongings Select Clothes Dress Groom Maintain Hobby Dispose of Litter Clear Table Walk Eat 25 20 15 10 5 0 MMSE Score Progressive Loss of Function Adapted from Galasko D, et al. Eur J Neurol. 1998;5(suppl 4):S9-S17.

Safety (driving, compliance, cooking, etc.) Family stress and misunderstanding (blame, denial) Early education of caregivers of how to handle patient (choices, getting started) Advance planning while patient is competent (will, proxy, power of attorney, advance directives) Specific treatments: May slow underlying disease process, (disease-modifying treatments now under study) Standard treatment may delay nursing home placement longer if started earlier May slow conversion from Mild Cognitive Impairment to AD

Patient initially diagnosed with AD Patient s first diagnosis other than AD 35% No 72% 14% 14% Yes 28% 9% 7% 21% Source: Consumer Health Sciences, LLC. Alzheimer s Caregiver Project. 1999. Dementia (not AD) Depression Normal aging Stroke No diagnosis Other

Clinical features of FTD include decline in personal hygiene and grooming, mental rigidity and inflexibility, distractibility and impersistence, Common cause of early onset dementia 1:1 with AD 45-64 years More common than AD below 60 years hyperorality and dietary changes, perseverative and stereotyped behavior, and utilization behavior

Lack of concern for loved one s illness Cruelty to children, animals, elderly Lack of concern when others are sad Rude comments to others Lose respect for intrapersonal space Disgusting behaviors Diminished response to pain

Presence of dementia, gait/balance disorder, prominent hallucinations and delusions, sensitivity to traditional antipsychotics, and fluctuations in alertness Neuropsychological tests do not reliably differentiate DLB from AD Brain shows cortical Lewy bodies (alpha synuclein)

Fluctuating cognition with pronounced variations in attention and alertness Occurs in 80-90% of DLB, only 20% of AD Recurrent visual hallucinations that are typically well formed and detailed can involve scenes and bizarre situations can start with misinterpretations and are usually short often occur at night Spontaneous motor features of parkinsonism: slow gait, increased muscle tone, tremor

Management Goals 1. Preserve cognition and reduce decline 2. Maintain quality of life 3. Maximize function and maintain dignity 4. Treat mood and behavior problems 5. Refer, educate, and counsel Source: Cefalu C, Grossberg GT. Diagnosis and Management of Dementia. Leawood, Kan: American Academy of Family Physicians; 2001.

(Secondary Prevention) Cholinesterase inhibitors are the mainstay of therapy 3 oral drugs currently on the market Though some patients experience immediate improvement, most prominent effect is cognitive stabilization Functional improvement may follow cognitive enhancement or stabilization Positive effects of these agents appear to be sustained but fade over long periods

Feldman et al. Poster presented at the 8 th International Montreal/Springfield Symposium on Advances in Alzheimer Therapy, 2004

.Randomization to donepezil continuation or placebo. Neuropsychiatric Inventory total score (NPI) (n ~ 96) Holmes et al, 2004

Total NPI change from baseline -8-6 -4 P=.0303 P=.0083 P=.0005 Clinical improvement -2 0 2 4 Aricept (n=144) Placebo (n=146) 0 4 8 12 18 24 Endpoint Study week Clinical decline Significant differences were observed for the domains of depression, anxiety, and apathy (P.0166). Adapted with permission from Feldman et al. Neurology. 2001;57:613-620. Gauthier et al. Int Psychogeriatr. 2002;14:389-404.

Most common reason for institutional placement Agitation is the most common reason for psychiatric consultation In study by Cummings, only 12% of patients did not have a behavioral problem. Most common reason for caregiver distress

Jots, B. C. and Grossberg, G. T. (1996) The evolution of psychiatric symptoms in Alzheimer s disease: a natural history study. J. Am. Geriatr. Soc. 44, 1078 1081

Apathy: Decreased motivation, indifference Disrupted Mood: Depression, mania-like. Psychosis: 50-70% of patients; paranoia, visual hallucinations Agitation: Caused by anxiety or psychosis Aggression: Loss of impulse control Wandering: Searching, disorientation

APATHY Most common behavioral change Decreased motivation, indifference Associated with frontal hypoperfusion (medial frontal, supraorbital, anterior frontal areas) Not related to depression Cummings 1998

PSYCHOTIC SYMPTOMS Cross sectional studies: 20-50% Longitudinal studies: 50-70% Common Delusions: theft, infidelity, pseudo-capgras-type delusion (thinking spouse or family member is someone else), phantom boarder. Hallucinations tend to be visual rather than auditory Cummings 1998

Patients with dementia experience both hallucinations and delusions Usually less complex than the delusions seen in schizophrenia or mood disorder Common delusions in dementia: Belief that one s belongings have been stolen Conviction that one is being persecuted Belief that one s spouse is unfaithful

MOOD CHANGES Mood symptoms are frequent and may be secondary to impairment of mood regulatory systems in the brain (e.g. emotional incontinence) Major depressive disorder (MDD) is uncommon MDD may precede diagnosis of Alzheimer s disease or vascular dementia Cummings 1998

AGITATION Excessive motor or verbal activity that is: Disruptive OR Unsafe OR Distressing to the patient Interferes with care and Is not because of need Appears similar despite great variety of causes Cohen-Mansfield et al., 1996; Tariot et al., 1994

AGITATION Correlates with anxiety in mildly demented patients Correlates with psychosis in moderately demented patients Correlation to breakdown of mood and/or behavioral regulation in severely demented patients Modified from Cummings 1998

SUNDOWNING Agitation associated with late afternoon or evening Causes: Fatigue Circadian factors Lack of sensory stimulation Need for security, protection Modified from Reichman et al

WANDERING Disorientation Restlessness Searching Sundowning Fear Medication-induced akathisia Modified from Reichman et al

AGGRESSIVITY Can be in response to environment or spontaneous Verbal and physical Can occur without delusions or hallucinations May be resistant to conventional pharmacotherapy

Which of the following is not a common behavioral symptom in Alzheimer's disease? A. Apathy B. Psychosis C. Aggression D. Shaking E. Fear F. Anxiety

Fear - disorientation, abandonment, confusion Over-stimulation Lowered frustration tolerance Loss of impulse control Inability to recognize family, caregivers Disorientation to time or place Disrupted routine Forgetting of appropriate behaviors Modified from Reichman et al

Personal Pain Infection Sensory Loss Psychosis Environmental Transfers Family Visits Personal Care/Bathing Medications Chronological Awakening Meal Times Middle of the Night Late Afternoon Bedtime Modified from Reichman et al

Unmet physical needs? Pain? Infection/illness? Thirsty? Hungry? Tired? Sleep disturbance? Medication side effects? Sensory impairment? Constipation? Incontinence?

Unmet psychological needs? Loneliness, boredom? Apprehension, fear, worry? Emotional discomfort? Lack of enjoyable activities? Lack of socialization? Loss of intimacy?

Cause related to social environmental? Too many people, too much noise? Too little to do? Expectations for performance are too high? Communication is unclear? Caregiver approaches aren t adjusted to level of ability?

Cause related to physical environment? Physical surroundings are not understandable? TV, radio, PA systems confusing? Pictures, photographs, reflections misunderstood? Lacks appropriate signage or cues to way-find, be independent? Lacks meaningful activities? Lacks natural walking paths, daily exercise?

Cause related to other Psychiatric illness? Depression? Anxiety? Delirium? Psychosis? Other mental illness? Overlapping syndromes are common!!

Altered or fluctuating level of alertness Sudden change in behavior suggests delirium Acute or subacute onset Look for infection, new medications, and any anticholinergic medications Dementia patient is VERY susceptible to delirium

Abrupt changes in behavior in a previously stable patient with dementia may indicate: A. Delirium B. Infection C. Metabolic disturbance D. Drug interaction E. All of the above

Agitation should be assessed for causative factors A. TRUE B. FALSE

Dementia is a syndrome: Most common cause is Alzheimer s Disease Other dementias with behavioral disturbances include Frontotemporal dementia, Lewy-Body dementia, vascular dementia Behavioral disturbances are a core feature of dementia and can be expected in most patients The context (environmental, personal, physical, psychological) will often determine whether and how behavioral disturbances are expressed

Emily Hollingsworth Emily.K.Hollingsworth@vanderbilt.edu Britt Kuertz Brittany.T.Kuertz@vanderbilt.edu Project Website: www.vanderbiltantipsychoticreduction.org Vanderbilt Center for Quality Aging 615-936-1499 www.vanderbiltcqa.org for other resources