Behavior Problems: Dementia and Mental Illness in Long Term Care and Assisted Living Module III Dr. David A. Smith, M.D., FAAFP, CMD mmlearn.org is a program of Morningside Ministries
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Presenter: Dr. David A. Smith, M.D., FAAFP, CMD
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Module III Behavior Problems in LTC: Testing
Mental Capacity for: Decision Making» Personal» Medical» Financial Testamentary Capacity Capacity to Stand Trial
Quantifying and Following Cognitive Deficit it Mini Mental Status Exam-MMSE (Dementia) St.Louis University Mental Status-SLUMS (MCI, Dementia) Confusion Assessment Method- CAM (Delirium)
Diagnosing & Following Major Depression Beck Depression Inventory» Beck AT, Ward CH, Mendelson M, et.al.(1961) An inventory for measuring depression. Archives of General Psychiatry 4:53-63 Hamilton Depression Scale» Hamilton M (1960) A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry y 23: 56-62
Diagnosing & Following Major Depression Geriatric Depression Scale(short & long)» Yesavage JA, Brink TL, Rose TL, et. al.(1983)development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research 17: 37-49 Cornell Scale» Alexopoulos GS Abrams RC Young RC et al (1998) Cornell» Alexopoulos GS, Abrams RC, Young RC et.al. (1998) Cornell Scale for Depression in Dementia. Biological Psychiatry 23: 271-84 cont d
Mania Scale Others:» Bech P, Rafaelsen OJ, Kramp P. Bolwig TG (1978) The Mania Raing Scale: scale contruction and inter-observer agreement. Neuropharmacology 17: 430-1 Functional Pain Scale Hamilton Anxiety Scale Assessment Scales in Old Age Psychiatry Burns A, Lawlor B, Craig S. Martin Dunitz Ltd.Distributed by: Blackwell Science Inc., Commerce Place, 350 Main St.,Malden MA 02148
Objectifying Nursing Assessment of Behavioral Problems (Meeting Goals) Each shift: Rate your pain as a caregiver in response to resident behavior of on a zero to 10 scale. Initial your score.
Minnie has delusions of worms crawling out of her skin and from under her fingernails. She is scratching herself raw and complains constantly to staff of worms. Before drug A 7,10,8,8,7,6,10 After drug A 10,7,8,6,8,10,7 (no ADR) After drug A increased- 7,8,10, 8,10, 6,7, (no ADR) After drug B 6,8,6,5,7,7,5,6 (no ADR) What Now?
Using Scales Trained interviewers/raters (but it s easy) Trigger from MDS items Trigger from identification of potential problem by team or team member
Using Scales Set time to retest to evaluate efficacy of therapy!! Objectification of what is poorly handled by subjective assessment Need a doctor s order or not?
Behavior Problems in LTC: Pharmacologic Therapy
Drugs for Dementia Cholinesterase Inhibitors» donepizil» rivastigmine» galantamine» tacrine NMDA I hibit NMDA Inhibitors» memantine
Grid for Treatment of Dementia and Psychiatric Disorders Causing Behavior Problems Cognition i problems ChI and/or memantine Depression antidepressant Depression with psychosis antidepressant/aap t/aap Delirium rapid acting AAP or haloperidol Psychosis AAP
Grid for Treatment of Dementia and Psychiatric Disorders Causing Behavior Problems cont d Mania or Bipolar illness mood stabilizer Chronic Anxiety disorder SSRI, buspirone Acute or situational i anxiety Bd Bzd (short (h acting/only phase 2) Appropriate chemical restraint Bzd (short acting/ Appropriate chemical restraint Bzd (short acting/ only phase 2)
Drug Treatment & Titration Issues Determine target symptom(s) Establish treatment goals prospectively Mandated d Informed Consent Therapeutic Window
Drug Treatment & Titration Issues Time to steady state Objective symptom monitoring- efficacy Monitor for ADRs Set time for GDR/DC or plan life-long treatment consistent with CPG s cont d
Task Define appropriate and inappropriate chemical restraint (Hint: remember OBRA Guidelines)
Task : Chemical Restraint What s wrong with this? Haldol 0.5-1mg po or IM q 4 hrs PRN agitation. T.O. Dr. R. Jones/B. Bruse RN
To maximize the resident s physical and mental well-being or slow decline Behavior Diagnostic hypothesis Rx drug / non-drug Follow-up by objective symptom monitoring measure target behavior before & after treatment to steady state nullifies inter-rater variability Follow-up side effects, overall function, length of Rx
Evidence-based Pharmacologic Treatment of Dementia Cholinesterase inhibitors tacrine (Cognex) donepizil (Aricept) rivastigmine (Exelon) galantamine (Reminyl) Claims for improving behavior exaggerated Think of maximizing cognitive function as a requisite for most normal behavior
Evidence-based Pharmacologic Treatment of Dementia NMDA receptor antagonist memantine (Namenda) cont d Claims for improving behavior exaggerated Think of maximizing cognitive function as a requisite for most normal behavior
Pharmacologic Treatment of Dementia with Negative Evidence Ginko Vit. E Estrogen Selegiline NSAIDS Chelation
Thank you!