2:45 3:45pm Caring for the Older Patient Handling Behavioral Issues Presenter Disclosure Information The following relationships exist related to this presentation: Samir Sabbag, MD, has no financial relationships to disclose. SPEAKER Samir Sabbag, MD Off-Label/Investigational Discussion In accordance with pmicme policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations. Caring for the Elderly: Managing Behavioral Issues Samir Sabbag, MD Geriatric Psychiatrist Assistant Professor of Clinical Psychiatry University of Miami Miller School of Medicine Learning Objectives Describe the role of the healthcare provider in managing behavioral issues in patients with dementia. Discuss management of behavioral problems in dementia using non-pharmacologic and pharmacologic approaches. Address driving issues in elderly patient with mild dementia Demographic Transition Epidemiology Dementia is a highly prevalent condition By 2045, average life expectancy in the US will be 80 years By 2030, almost 20% of Americans will be 65+ By 2030, proportion of older Hispanics will nearly double from 5.6% to 10.9% In 2010, the total number of people with dementia worldwide was 35.6 million 1 Projected to nearly double in the next 20 years Alzheimer s disease (AD) is the most common cause of dementia Prevalence of dementia in the community Almost 1% in 65- to 69-year-olds >30% in 85 years and older 2 1. World Health Organization, 2010 2. Breteler MM et al; Haemostasis 1998 1
Epidemiology Role of the Health Care Provider Up to 90% of dementia patients demonstrate behavioral issues at some point 1 Cache County Study 2 24% of dementia patients were agitated or aggressive in the last month Five-year prevalence ranged from 13%-24% In a recent study 1, health care providers found themselves to be highly involved in dementia home care Unfortunately, most caregivers rated their involvement to be insufficient 1. Int Psychogeriatr Assoc. Int Psychgeriatr 2000, 12 (suppl 1):1-424 2. Steinberg M et al; Int J Geriatr Psychiatry 2008 1. Scand J Prim Health Care. 2009;27(1):31-40 Behavioral Issues in Dementia What is a behavioral issue? Traditionally: Cognitive Function Main focus of interest in treatment and research of people with dementia It is becoming increasingly recognized that noncognitive symptoms 1 Are the most disturbing to families and caregivers May seriously impact on the patient's well-being, and the informal caregivers and providers' approaches to managing the patient. 1. Adv Psychiatric Treatment 2004;10:171 9. Behavioral Problem/Inappropriate Behavior Inappropriate verbal, vocal or motor activity that is not judged by an outside observer to be an obvious outcome of the needs or confusion of the individual 1 Four main subtypes 2 Physically aggressive behaviors Physically non-aggressive behaviors Verbally non-aggressive agitation Verbal aggression 1. Cohen-Mansfield et al; J Am Geriatr Soc 1986 2. Cohen-Mansfield et al; Int Psychogeriatr 1995 Pharmacological Treatment Non-Pharmacologic Interventions No FDA-approved treatment Off-label use of psychotropic medications for aggression and agitation 1 Antipsychotic medications Side effects Black Box Warning - increased mortality in the elderly 2 Step 1: Find cause of agitation Pain Discomfort Loneliness Boredom Medical illness Environmental stressors Step 2: Modify it through individualized interventions Discomfort management Physical environment 1. Levenson S; Caring for the ages 2003 2. Wang et al; N Engl J Med 2005 2
Treatment Algorithm for Agitation and Aggression in Demented Patients 1 What is your role as a provider? Severe, persistent or recurrent agitated or aggressive behavior Elicit history from caregivers Low dose atypical antipsychotics Non-pharmacologic Protocols Optimize management with cognitive enhancers or antidepressants Address uncovered issues based on the evaluation Make sure that caregivers Are provided with adequate information Know where to look for help Know how to manage common situations Know when more skilled care is needed Review med list, pain, medical conditions, environmental changes, boredom, discomfort, loneliness, fear, level of stimulation in their home. 1. Adapted from Salzman et al; Consensus Statement on Treatment Options. J Clin Psychiatry, June 2008 Make Home Safe Bladder and Bowel Problems Keep rooms uncluttered with clear walkways around furniture Don't move furniture around Remove throw rugs to prevent tripping Use locks on doors and cupboards - lock up dangerous objects and substances. Install handrails, tub mats and other assistive devices in the bathroom Provide adequate lighting, especially at night Rule out a medical condition (e.g. UTI) Encourage elderly patient to use the bathroom on a regular schedule (e.g. Q2h) Restrict liquids prior to bedtime Remove or cover objects that can be confused with the toilet Consider using absorbent pads or briefs Educate the caregiver on how the patient is not able to control their incontinence Provide Activities Help Avoid Confusion During early stages, patients may be aware of losing mental and functional abilities Fear, depression, anxiety Feel they are a burden to their caregivers Patient should remain active and involved Take advantage of their remaining activities Allow them to make decisions Support efforts to remain independent, even if tasks are not done in a timely manner or perfectly Tailor tasks to patient s abilities Give them tasks, but do not push them too far Use familiar objects to help recognize location Label often used rooms bathrooms Provide visual cues to time and place Keep regular routines for daily activities Focus on consistency keep objects in the same place Keep floor surfaces uncomplicated avoid patterns Avoid mirrors for decorating may cause anxiety if they don t recognize their own reflection 3
Wandering Communication Potentially dangerous Medical ID bracelet Find out why the patient wanders Trying to find a familiar object This was their routine Lock outside doors, use alarms that indicate when patient goes outdoors or into unsafe areas Provide a safe place for wandering enclosed yard Communicating can be very challenging Evaluate for hearing or vision problems Don t argue offer reassurance and help focus attention on something else Use short, simple, familiar words Present one idea at a time Use a calm tone of voice Use touch to reassure and show that you are listening Pay attention to patient s tone of voice and gestures for cues as to what they are feeling Case Issues with Driving 79 y/o CM who comes to your office with his daughter. Patient has been complaining about memory loss and you and his daughter have noticed him having gradual worsening concentration. Daughter states patient has had frequent close calls when driving and, when driving with him, noticed that he drives slower than before. She has found some scrapes and dents on the car. A few weeks ago, dad got lost and she had to pick him up at a gas station far away from their home. Patient states he is able to drive very well and becomes upset by his daughter even bringing this up. Allowing an elderly person to drive is a controversial topic As health care providers we are usually asked by family to get involved Taking away driving privileges may reduce independence But it may also be important if it is no longer safe The American Academy of Neurology recommends not driving when moderate Alzheimer s is present Memory is more impaired Complex activities are impaired Issues with Driving Issues with Driving At early stages of dementia, driving performance should be evaluated Family should ride along with them to detect issues Those with mild Alzheimer s may continue to drive for a year or two 1 Evaluate for adequate vision, hearing, coordination Safe Driving requires the ability to Make quick decisions Use good judgment Remember the rules of the road You may perform a visual exam in your office 20/50 with a minimal field vision of 130 degrees 1 In Florida, drivers over 79 years old are required to pass a vision test and may be required to take a written examination at the time of renewal 1 1. Neurology, 70(14): 1171-1178 1. Florida Department of Motor Vehicles 4
Warning Signs of Impaired Driving Forgetting how to get to familiar places Ignoring traffic signs Confusing the break and gas pedal Driving too slow or too fast Stopping at the wrong times (i.e. green light) Confused or overwhelmed during driving Making bad or too slow decisions while driving Noticing other drivers honk a lot Dents or scrapes in the car Not looking when changing lanes Taking much longer than it used to get somewhere What should you do next? Any physician, person or agency having knowledge of any licensed driver s mental of physical ability to drive is authorized to report such knowledge to the Department of Highway Safety and Motor Vehicles 1 An investigation is started Can include a vision test, driving and written tests Restrictions could be applied to their driver s license 1. Florida State 322.126 Nursing Home Placement Nursing Home Placement Even with the best care, someone with dementia will progressively decline Level of care increasingly progresses as well Basic activities become more difficult for the patient to do on their own Caregiver will eventually be unable to provide physical, emotional or financial care Making the decision about placement is often very difficult Have the caregivers consider the following Are they able to provide a structured, safe environment? People with dementia will eventually need an increasing level of care and assistance Using adult day care programs and part time help may prolong relative s stay at home Caregiver s physical and emotional health is important for the person being cared for Deciding to place someone in a Nursing Home is not a sign of failure as a cargiver How to make the decision? How to make the decision? Reasons to consider a Nursing Home Patient has become disruptive/dangerous to caregiver or household Caregiver s health is at risk Burden of caregiving is too great and they don t have anyone to help them Nursing home may offer a safer, more controlled environment Patient has other medical problems that require skilled nursing care Reasons to consider keeping a relative at home Caregiver concerned about health declining at nursing home Patient will receive less individual attention Feelings of guilt or anxiety Cost Waiting list at the facility 5
Summary When behavioral issues arise, first investigate causes for agitation and attempt to modify them through non-pharmacologic approaches Provide caregivers with education on how to manage common situation, where to look for help and when skilled care is needed Questions? Discuss driving issues with patient and family, and provide further assessment if patient poses a danger to self or others. 6