treatment modalities for the management of distressed behaviors in elderly nursing home residents jeanne jackson-sieg

1. 1 Treatment Modalities for the Management of Distressed Behaviors in Elderly Nursing Home Residents

2. 2 Definitions �Behavior� refers to an individual�s observable actions. �Cognition� refers to any personal activities related to organizing memory, sensation, and thinking �Mental status� refers to an individual�s overall level of alertness, activation, and responsiveness to the outside world. AMDA Dementia CPG 1998

3. 3 Incidence of Behaviors Apathy (72%) Agitation (60%) Anxiety (45%) Irritability (42%) Motor restlessness (38%) Disinhibition (36%) Sleep disturbance (24%) Depression (23%) Delusions (22%) Hallucinations (10%)

4. 4 Distressed Behaviors in Nursing Homes Increases stress between patients and caregivers1 Create intensive and costly levels of treatment1 Increase morbidity and mortality 1 Lead to public health problems that contribute to the enormous cost of treating dementia1 Increase risk of overmedication and restraints This slide reviews the common consequences of distressed behavior in elders. This problem has been well studied and impacts on the patient, the caregiver(s), government regulations and society as a whole. These outcomes emphasize the need for accurate diagnosis of the distressed behavior as well as the importance of optimum treatment to minimize the numerous negative outcomes. The overall message is that distressed behavior represents a problem in the quality of life for all concerned. This slide reviews the common consequences of distressed behavior in elders. This problem has been well studied and impacts on the patient, the caregiver(s), government regulations and society as a whole. These outcomes emphasize the need for accurate diagnosis of the distressed behavior as well as the importance of optimum treatment to minimize the numerous negative outcomes. The overall message is that distressed behavior represents a problem in the quality of life for all concerned.

5. 5 �Agitation� Excessive motor or verbal activity that is 1 One of the following Disruptive OR Unsafe OR Distressing to the patient Interferes with care and Is not because of need Generally, is a poor descriptor of behavior Appears similar despite great variety of causes Need to make diagnosis, not focus only on symptoms When severe, may be the target for urgent intervention It is important to look at the semantics of how we describe behavioral distress. Agitation is a commonly used word in LTC but lends itself to varied interpretation. One nurse may describe a behavior as �agitation� while another nurse views the same behavior as �typical for demented residents� and therefore does not see the behavior as a problem. Understanding the cause of agitation with specific detail. Additionally, documentation that is more specific and descriptive to allow better monitoring of both the interventions and behavior pattern. Also, when we use the vague term agitation, prn use is often sporadic depending on the person viewing the behavior. The actual definition of �agitation� is listed per Cohen Mansfield. By using a general term such as agitation, we risk getting a general type of treatment plan. A analogy would be �pain�. While we know that pain can be treated with any pain medication, the best treatment always involved determining the etiology of the pain allowing maximally appropriate and therefore effective interventions . On stage, I often role play the elder woman who yells �Help Me!!!!� Then another,then another (sometimes audience members help by joining the �help me� role play. Every provider recognizes many of their past and current patients. Then quarry the audience about possible etiologies for this general type of behavior (sometimes called agitation) and the extremely wide differential diagnosis becomes apparent. From confusion, to needing to go to the bathroom, to constipation, to psychosis etc.. Thus our job goes beyond �treating the symptoms� and into the investigation to find the driving forces resulting in the distress we are treating. It is important to look at the semantics of how we describe behavioral distress. Agitation is a commonly used word in LTC but lends itself to varied interpretation. One nurse may describe a behavior as �agitation� while another nurse views the same behavior as �typical for demented residents� and therefore does not see the behavior as a problem. Understanding the cause of agitation with specific detail. Additionally, documentation that is more specific and descriptive to allow better monitoring of both the interventions and behavior pattern. Also, when we use the vague term agitation, prn use is often sporadic depending on the person viewing the behavior. The actual definition of �agitation� is listed per Cohen Mansfield. By using a general term such as agitation, we risk getting a general type of treatment plan. A analogy would be �pain�. While we know that pain can be treated with any pain medication, the best treatment always involved determining the etiology of the pain allowing maximally appropriate and therefore effective interventions . On stage, I often role play the elder woman who yells �Help Me!!!!� Then another,then another (sometimes audience members help by joining the �help me� role play. Every provider recognizes many of their past and current patients. Then quarry the audience about possible etiologies for this general type of behavior (sometimes called agitation) and the extremely wide differential diagnosis becomes apparent. From confusion, to needing to go to the bathroom, to constipation, to psychosis etc.. Thus our job goes beyond �treating the symptoms� and into the investigation to find the driving forces resulting in the distress we are treating.

6. 6 Agitation and Aggression in Dementia There are many terms more descriptive than the word �agitation�. This is a partial list of the adjectives used in the Cohen-Mansfield Agitation Inventory. We want to encourage the use of such words rather than the more general term �agitation�. It may be helpful to copy and laminate this list to post in the nursing stations to help the nurses use more descriptive language in describing behaviors. A copy of the Cohen Mansfield Agitation Inventory is available at www.medafile.com/zyweb/CMAI.htm. (This is a lilly sponsored website). One can use this inventory to determine the intensity and frequency of particular behaviors initially and in response to attempted interventions. There are many terms more descriptive than the word �agitation�. This is a partial list of the adjectives used in the Cohen-Mansfield Agitation Inventory. We want to encourage the use of such words rather than the more general term �agitation�. It may be helpful to copy and laminate this list to post in the nursing stations to help the nurses use more descriptive language in describing behaviors. A copy of the Cohen Mansfield Agitation Inventory is available at www.medafile.com/zyweb/CMAI.htm. (This is a lilly sponsored website). One can use this inventory to determine the intensity and frequency of particular behaviors initially and in response to attempted interventions.

7. 7 Behavior Diagnosis: Pitfalls Many etiologies can present with the same behaviors (Example of fever) Co-existence of multiple risk factors present in any one resident: disease, medications, changed environment, etc. The key is to have a process to evaluate the resident for the behavior

8. 8 General Approach to Behaviors Clearly characterize target symptoms Standard medical evaluation to identify possible medical disorder Differential diagnosis of behavior cause The A,B,C�s of Behavior Intervention Antecedent, Behavior, Consequences Document, Document, Document Non-pharmacologic intervention

9. 9 Good Target Symptoms Anxiety Insomnia Delusions (stressful) Hallucinations (stressful) Dysphoria/Depression Compulsive behaviors Agitation/Aggressiveness Motor restlessness Pain

10. 10 Poor Target Symptoms Exit-seeking Pacing & Wandering Perseverant vocalizations Hoarding/Stealing Inappropriate sexual touching Non-stressful delusions Disrobing

11. 11 Medical Evaluation Medical/Psychiatric History Medication: excess, withdrawal, ADR Physical evaluation: urinary retention, fecal impaction (constipation), pain, dental problems Mental Status Exam Lab studies/oximetry Imaging Studies

12. 12 Medical Illness Illnesses: GERD, angina, OA, etc. Medication side effects Chronic pain Constipation Hearing or vision impairment Sleep deprivation Dental problems Common medical problems may be sub-optimally managed. For example, some distressed patients in the dining room may be responding to reflux or ulcer pain. Chronic pain (Osteoarthritis) is grossly under-treated in LTC. Prn medications are notoriously underused if the patient is unable to state that they are in pain. Empiric pain medication trials of 2 �3 wks can monitored by po intake, ambulation, cooperation with personal care, sleep, and mood. Constipation with giving MOM after day 3 may require an uncomfortable and frightening suppository/enema, risking increased anxiety regarding why or what is being done. A reasonable policy is that if a per rectal intervention (suppository/enema) is needed, increased po bowel meds are needed. Hearing impairment increases paranoia if cognition is limited (sometimes this happens to the cognitively intact as well). Placement of a dead hearing aid battery actually worsens hearing impairment due to physical blockade. Verify (squeaking) active hearing aid batteries. Encourage ophthalmologic assessment and treatment for cataracts. Sleep deprivation worsens many symptoms. Sometimes the noisy patients need the treatment rather than the roommate with insomnia. Dental hygiene will be poor if cooperation with oral hygiene is difficult. Dentists may not visualize problems but do not obtain X-rays due to lack of cooperation. Dry socket, abscess, fractured teeth may go unrecognized and untreated unless patients are medicated to allow X-rays. Common medical problems may be sub-optimally managed. For example, some distressed patients in the dining room may be responding to reflux or ulcer pain. Chronic pain (Osteoarthritis) is grossly under-treated in LTC. Prn medications are notoriously underused if the patient is unable to state that they are in pain. Empiric pain medication trials of 2 �3 wks can monitored by po intake, ambulation, cooperation with personal care, sleep, and mood. Constipation with giving MOM after day 3 may require an uncomfortable and frightening suppository/enema, risking increased anxiety regarding why or what is being done. A reasonable policy is that if a per rectal intervention (suppository/enema) is needed, increased po bowel meds are needed. Hearing impairment increases paranoia if cognition is limited (sometimes this happens to the cognitively intact as well). Placement of a dead hearing aid battery actually worsens hearing impairment due to physical blockade. Verify (squeaking) active hearing aid batteries. Encourage ophthalmologic assessment and treatment for cataracts. Sleep deprivation worsens many symptoms. Sometimes the noisy patients need the treatment rather than the roommate with insomnia. Dental hygiene will be poor if cooperation with oral hygiene is difficult. Dentists may not visualize problems but do not obtain X-rays due to lack of cooperation. Dry socket, abscess, fractured teeth may go unrecognized and untreated unless patients are medicated to allow X-rays.

13. 13 Differential for Behavior Causes Dementing disorders Frontal Lobe impairment Delirium Medications Toxic personality syndrome Pain

14. 14 Differential for Behaviors (cont.) Primary psychiatric illness - Affective disorder (Depression) - Anxiety disorder - Psychotic disorder - Personality disorder Environment/Stressors

15. 15 Definition: Dementia Memory loss with sequelae that demand more time, more staff, and more interventions. As we look at the patient, do not lose track of the potential causes of dementia. Planning must look to cause to plan for effect.Memory loss with sequelae that demand more time, more staff, and more interventions. As we look at the patient, do not lose track of the potential causes of dementia. Planning must look to cause to plan for effect.

16. 16 Dementia Incidence of 1-2% at 65-70 years of age, increasing to >30% after 85 Up to 80% of NF residents have some degree of dementia The resultant decline in functional capacity is the chief cause of NF admission

17. 17 Dementia Categories Alzheimer�s disease (65%) Lewy Body dementia (7%) AD w/vascular disease (10%) AD w/Lewy bodies (5%) Vascular dementia (5%) Other: Infectious, EtOH, etc. (8%)

18. 18 Definition: Dementia of the Alzheimer Type (DAT) Over 4,500,000 Alzheimer�s Patients in USA About half are diagnosed About half of those are treated - with any kind of treatment Memory loss is severe and progressive - decline in ADLs and increase in behaviorsOver 4,500,000 Alzheimer�s Patients in USA About half are diagnosed About half of those are treated - with any kind of treatment Memory loss is severe and progressive - decline in ADLs and increase in behaviors

19. 19 DAT 60-80% of dementia that occurs in those >65 years old Slow, insidious decline in multiple cognitive skills Relatively well preserved motor function early in disease course CT/MRI normal, or atrophy, perhaps with mild white matter changes No biological markers - diagnosed at autopsy Etiology: genetics (APO e4) + ?

20. Shiozaki et al:J Neurol Neurosurg Psych: V67:1999 Dementia with Lewy Bodies (DLB) DLB more recently accounts for 15 - 20% of all dementia Hallmark feature: widespread Lewy bodies throughout the neocortex with Lewy bodies and cell loss in the subcortical nucleii with distinctive pattern of neuritic degeneration on autopsy More males than females Age of onset: 50 � 83 Insidious onset progressing to profound dementia Generally, most practitioners are more comfortable with the assessment and treatment of Alzheimer�s and Vascular Dementia. Dementia with Lewy Bodies is a newly defined diagnosis that is worthy of specific discussion. While the memory impairment may resemble Alzheimer�s disease, additional characteristics are present that aid in the diagnosis. Demographics and prevalence data is reviewed in this slide. The major reason to be increasingly concerned about this type of dementia is that while psychotic symptoms are common, this group of patients can have a very severe reaction to some antipsychotics. The exact symptomatology and further explanation of the neuroleptic sensitivity will be discussed in the next slides. Additionally, there is some evidence that AChIs may be first line treatment. Lewy bodies are neuronal inclusions of abnormally phosphorylated neurofilaments aggregated with ubiquitin and alpha synuclein. In Parkinson's Disease, Lewy bodies and neuronal loss occurs primarily in the brain stem nucleii, most particularly in the substania nigra. Dementia with Levy Bodies has Lewy Bodies in the same places as Parkinson's disease but also in paralimbic and neocortical areas. This affects the cholinergic projection neurons with a distinctive pattern of neuritic degeneration. Additionally, DLB has very very few tangles which are a required in the diagnosis of Alzheimer�s disease. Generally, most practitioners are more comfortable with the assessment and treatment of Alzheimer�s and Vascular Dementia. Dementia with Lewy Bodies is a newly defined diagnosis that is worthy of specific discussion. While the memory impairment may resemble Alzheimer�s disease, additional characteristics are present that aid in the diagnosis. Demographics and prevalence data is reviewed in this slide. The major reason to be increasingly concerned about this type of dementia is that while psychotic symptoms are common, this group of patients can have a very severe reaction to some antipsychotics. The exact symptomatology and further explanation of the neuroleptic sensitivity will be discussed in the next slides. Additionally, there is some evidence that AChIs may be first line treatment. Lewy bodies are neuronal inclusions of abnormally phosphorylated neurofilaments aggregated with ubiquitin and alpha synuclein. In Parkinson's Disease, Lewy bodies and neuronal loss occurs primarily in the brain stem nucleii, most particularly in the substania nigra. Dementia with Levy Bodies has Lewy Bodies in the same places as Parkinson's disease but also in paralimbic and neocortical areas. This affects the cholinergic projection neurons with a distinctive pattern of neuritic degeneration. Additionally, DLB has very very few tangles which are a required in the diagnosis of Alzheimer�s disease.

21. 21 Required: Cognitive Decline with decreased social or occupational functioning A diagnosis of Probable DLB requires 2 of the following (Possible DLB requires only one of the following): Fluctuating cognition with pronounced variation in attention and alertness 1 Recurrent visual hallucinations that are typically well formed and detailed� Spontaneous motor features of parkinsonism DLB Core Features When the core features of DLB are examined, it is clear that the diagnosis could easily be missed. As cognition fluctuates, the caregiver report may differ from your observations. Very well formed visual hallucinations are present that the patient can usually articulate. It is often these hallucinations that have lead to a trial of neuroleptic. Typically, the parkinsonism symptoms are present before any exposure to neuroleptics. The rate of cognitive decline is similar to Alzheimer�s disease and the rate of worsening of parkinsons symptoms is similar to Parkinson�s disease. Due to the fluctuating alertness, DLB may be confused with a delirium superimposed on a Alzheimer�s or vascular dementia. It is important to get a full history to help distinguish them. Additionally, the presence of parkinsonism or a history of sensitivity to antipsychotics may provide diagnostic clues. Some interesting things about the common visual hallucinations seen in DLB include 1) they often see small people and children, 2) the hallucinations are usually mute, and 3) they are not frightened of these people. Ask the audience if they have seen any of these characteristics. When the core features of DLB are examined, it is clear that the diagnosis could easily be missed. As cognition fluctuates, the caregiver report may differ from your observations. Very well formed visual hallucinations are present that the patient can usually articulate. It is often these hallucinations that have lead to a trial of neuroleptic. Typically, the parkinsonism symptoms are present before any exposure to neuroleptics. The rate of cognitive decline is similar to Alzheimer�s disease and the rate of worsening of parkinsons symptoms is similar to Parkinson�s disease. Due to the fluctuating alertness, DLB may be confused with a delirium superimposed on a Alzheimer�s or vascular dementia. It is important to get a full history to help distinguish them. Additionally, the presence of parkinsonism or a history of sensitivity to antipsychotics may provide diagnostic clues. Some interesting things about the common visual hallucinations seen in DLB include 1) they often see small people and children, 2) the hallucinations are usually mute, and 3) they are not frightened of these people. Ask the audience if they have seen any of these characteristics.

22. 22 Dementia with Lewy Bodies Treatment Issues Up to 80% of DLB patients have hypersensitivity to neuroleptics. Prescribe antipsychotics only when absolutely necessary and under strict monitoring Provisional evidence suggests that patients may respond more preferentially to AChI therapy Concomitant depression 35% of DLB vs. 16% of AD Much as with Alzheimer�s disease, the only guaranteed diagnostic approach is through brain autopsy where the classic Lewy Bodies can be seen. The insidious onset, the progressive dementing process and the concomitant depressive and psychotic symptoms do make this a more difficult diagnosis. In this type of dementia consider Acetylcholinesterase inhibitors as there is provisional evidence that in DLB the psychotic symptoms may be improved as well as the cognitive benefits we are seeking. Much as with Parkinson�s disease, depression if fairly common. Much as with Alzheimer�s disease, the only guaranteed diagnostic approach is through brain autopsy where the classic Lewy Bodies can be seen. The insidious onset, the progressive dementing process and the concomitant depressive and psychotic symptoms do make this a more difficult diagnosis. In this type of dementia consider Acetylcholinesterase inhibitors as there is provisional evidence that in DLB the psychotic symptoms may be improved as well as the cognitive benefits we are seeking. Much as with Parkinson�s disease, depression if fairly common.

23. 23 Frontal Lobe Impairment: Sx Mood lability or inappropriate affect Poor impulse control Verbally rude, caustic, bigoted, etc. Episodically physically aggressive Perseverative Restless/grabbing/reacts strongly to stimuli Difficult to redirect Sexually inappropriate/aggressive The bulleted symptoms are the common ones seen in Frontal Lobe Impairment. These types of symptoms can occur from any type of dementia, particularly when the frontal lobe is involved. It is important to differentiate these symptoms and note that they are not in fact truly psychotic symptoms, but rather simply the acting out of very common impulses. Generally, frontal lobe impairment should be considered if poor impulse control is predominant and there is no evidence of psychosis. Historically, treatment with antipsychotics or benzodiazepines were the only options. Over the last decades, mood stabilizers have been added to the armamentarium. Treatment options currently include both nonpharmacologic and pharmacological approaches. The bulleted symptoms are the common ones seen in Frontal Lobe Impairment. These types of symptoms can occur from any type of dementia, particularly when the frontal lobe is involved. It is important to differentiate these symptoms and note that they are not in fact truly psychotic symptoms, but rather simply the acting out of very common impulses. Generally, frontal lobe impairment should be considered if poor impulse control is predominant and there is no evidence of psychosis. Historically, treatment with antipsychotics or benzodiazepines were the only options. Over the last decades, mood stabilizers have been added to the armamentarium. Treatment options currently include both nonpharmacologic and pharmacological approaches.

24. 24 Frontal Lobe Impairment Not psychotic behavior, but poor impulse control Seen in multiple types of disease processes - SDAT - Vascular dementia - Multiple sclerosis - EtOH disease

25. 25 Frontal Lobe Impairment: Non-Pharmacologic Management Maintain professional distance Exaggerated manners, professional attire Emphasize courtesy, avoid overly friendly Communicate concretely, no open ended comments Define the activity, give few and clear choices Shape the behavior, acknowledge improvements Medication when needed: Safety concerns Not responsive to nonpharmacologic interventions Remember, non-pharmacological management should always be a part of a treatment plan, whether or not medication is also utilized. When a resident has frontal lobe impairment, nonpharmacologic interventions can be extremely valuable. The use of a more formalized approach, emphasizing the professional roles of staff may actually help the patient to control their behavioral responses (much like having a nun join a party). You may find that use of extreme manners such as please, sir/Mam, Mr./Mrs., thank you, as well as concrete requests (Good morning sir, I am Betty, your certified nursing assistant for today. Would you prefer your bath now or in an hour?) are more helpful than the more informal, open ended approach (Hi Joe, are you ready for your bath?) Medications become appropriate and useful when non pharmacologic interventions fail to control the behavior alone or when the individual�s behavior poses a risk of danger to the resident or other residents and staff in the facility.Remember, non-pharmacological management should always be a part of a treatment plan, whether or not medication is also utilized. When a resident has frontal lobe impairment, nonpharmacologic interventions can be extremely valuable. The use of a more formalized approach, emphasizing the professional roles of staff may actually help the patient to control their behavioral responses (much like having a nun join a party). You may find that use of extreme manners such as please, sir/Mam, Mr./Mrs., thank you, as well as concrete requests (Good morning sir, I am Betty, your certified nursing assistant for today. Would you prefer your bath now or in an hour?) are more helpful than the more informal, open ended approach (Hi Joe, are you ready for your bath?) Medications become appropriate and useful when non pharmacologic interventions fail to control the behavior alone or when the individual�s behavior poses a risk of danger to the resident or other residents and staff in the facility.

26. 26 Definition: Delirium Delirium can have medical causes - UTI, Pain Transient is key word here. We can expect this to go away BUT we must be prepared to ID early and act fast. Delirium can have medical causes - UTI, Pain Transient is key word here. We can expect this to go away BUT we must be prepared to ID early and act fast.

27. 27 Delirium: Symptoms Fluctuations in alertness & mental functioning manifested by inattention Anxiety Hallucinations Disorientation Tremors Delusions Incoherence

28. 28 Common Delirium Triggers Acute illness Heart or lung disease Infections Poor nutrition Endocrine disorders MEDICATIONS Alcohol use

29. 29 Delirium A syndrome, not a final diagnosis Fluctuating level of alertness Difficult to assess with dementia Must identify etiology to treat appropriately If psychotic, time-limit use of antipsychotics A diagnosis of delirium should always include a search for the cause. The criteria of fluctuating alertness, acute or subacute onset, and psychotic symptoms should prompt a thorough investigation. By investigating and treating the cause, we may better predict how long the increased confusion and other psychotic symptoms can be expected. Is is critical that the antipsychotics be used for only the period of time necessary Additionally, some deliriums are the result of compounding factors such as multiple anticholinergic medications which will appear much less dramatically and perhaps slower than a significant infectious process. In these cases, the delirium will present with a subacute rather than an acute onset. A diagnosis of delirium should always include a search for the cause. The criteria of fluctuating alertness, acute or subacute onset, and psychotic symptoms should prompt a thorough investigation. By investigating and treating the cause, we may better predict how long the increased confusion and other psychotic symptoms can be expected. Is is critical that the antipsychotics be used for only the period of time necessary Additionally, some deliriums are the result of compounding factors such as multiple anticholinergic medications which will appear much less dramatically and perhaps slower than a significant infectious process. In these cases, the delirium will present with a subacute rather than an acute onset.

30. 30 Delirium 10% of all hospitalized patients 22-38% of hospitalized patients >65 60% of hip fracture cases Up to 75% of hospitalized patients from SNF�s Associated with a 35% increase in hospital mortality Physicians correctly diagnose delirium in less than 20% of cases

31. 31 Distinguishing Delirium from Dementia

32. 32 Depression: Diagnosis Depressed mood for at least 2 weeks Plus At least four of the following: - Insomnia or hypersomnia - Significant weight loss or malnutrition - Fatigue or loss of energy - Decreased ability to concentrate - Psychomotor agitation or retardation - Excessive guilt or feelings of worthlessness - Thoughts of death, suicidal ideation, or a planned or attempted suicidal act - Loss of interest or pleasure in nearly all activities

33. 33 Depression: Diagnosis Geriatric Depression Scale (GDS) Cornell Scale for Depression in Dementia Center for Epidemiologic Studies of Depression (especially for African-American and Native Americans) No direct biologic marker

34. 34 Depression: Elder vs Younger Elders exhibit different symptoms Multiple somatic complaints Fatigue Insomnia Functional loss Irritability Younger: tearfulness, sadness and suicidal indications

35. 35 Depression The most common geriatric psychological disorder Up to 1/3 of NF residents Estimated that PCP�s fail to diagnose depression up to half the time & fail to provide adequate treatment for half of those so diagnosed (Kroenke, AIM. 1997) Closely associated with functional decline & triggering quality indicators

36. 36 Depression Often co-morbid with dementia Common post-stroke � up to 30% Beware �ageism� as a barrier to diagnosis/tx Look for underlying medical/medication causes

37. 37 Depression May be mimicked/caused by ADR - Carbidopa/levodopa - Beta-blockers - Clonidine - Benzodiazepines - Barbituates - Anticonvulsants - H2 blockers

38. 38 Depression� or Dementia� (or Both?) Depression Clear, recent onset Shorter duration Often previous psychiatric history Memory complaints Fluctuating performance Recent and remote memory equally bad Depressed mood precedes memory complaints Dementia Gradual onset Progression over years May not have psychiatric history Minimizes disabilities Tries hard to perform Memory loss greater for recent events Memory loss precedes depression

39. 39 Anxiety: Definition Awareness of the physiologic reactions of the �fight or flight� responses May be triggered by internal or external factors May be triggered by issues considered �irrelevant� to others but are real to the sufferer Anxiety symptoms are far more common than anxiety disorder

40. 40 Anxiety Disorders Think Differential Diagnosis: Psychosis/Depression/Delirium/Pain/GAD Modify environmental triggers if possible Medications: - Caffeine - Bronchodilators - Pseudoephedrine Medical illness - Hyperthyroidism - Cardiac arrhythmias (Atrial fibrillation, PVC�s, etc) The assessment at this point includes a reevaluation of possible missed diagnosis higher in the algorhythm. Even if benzodiazepines are needed short term, they are simply used to temporarily alleviate the distress while we determine the underlying etiology. Other options such as low dose Trazodone (25 mg bid or tid) can be used. If Trazodone is used, it is prudent to check orthostatic BP and Pulse q am for 3days and if over a 20 point change is found, the MD should be contacted. Treatment with Buspirone can be considered although there is little compelling data for this medication in dementia or with elders. Often the most important element is to reconsider the diagnosis of depression, including an empiric time-limited trial if warranted. The assessment at this point includes a reevaluation of possible missed diagnosis higher in the algorhythm. Even if benzodiazepines are needed short term, they are simply used to temporarily alleviate the distress while we determine the underlying etiology. Other options such as low dose Trazodone (25 mg bid or tid) can be used. If Trazodone is used, it is prudent to check orthostatic BP and Pulse q am for 3days and if over a 20 point change is found, the MD should be contacted. Treatment with Buspirone can be considered although there is little compelling data for this medication in dementia or with elders. Often the most important element is to reconsider the diagnosis of depression, including an empiric time-limited trial if warranted.

41. 41 Psychosis Definition Impaired connection to reality Auditory or visual hallucinations or delusions Psychosis is a symptom, not a final diagnosis Differential Diagnosis includes all types of Dementia, Delirium, Drugs (both intoxication and withdrawal), Schizophrenia, Bipolar Mania and Psychotic Depression The diagnosis indicates duration of treatment Psychosis in dementia patients can result from multiple etiologies. Psychotic symptoms may be driven by a chronic psychotic mental disorder, the dementia process itself, delirium, medications and medication withdrawal, as well as psychotic depression or mania. It is critical to make the etiology clear so that the underlying cause can be treated and the antipsychotic can be titrated down and discontinued when appropriate. Before we examine the assessment and treatment options, for psychosis, we will first review the relevant regulations in the LTC setting.Psychosis in dementia patients can result from multiple etiologies. Psychotic symptoms may be driven by a chronic psychotic mental disorder, the dementia process itself, delirium, medications and medication withdrawal, as well as psychotic depression or mania. It is critical to make the etiology clear so that the underlying cause can be treated and the antipsychotic can be titrated down and discontinued when appropriate. Before we examine the assessment and treatment options, for psychosis, we will first review the relevant regulations in the LTC setting.

42. 42 Personality Disorders Easy to over-diagnose when elder patients decompensate due to dementia, depression, pain, etc. Consider empiric treatment with antidepressant Look for LIFELONG history of the personality disorder The diagnosis of a personality disorder often carries with it the assumption that complaints by the patient have less validity. This can result in less than ideal medical and/or medical and psychiatric care. In some cases, this takes the form of numerous medical tests and medications, in others, the symptoms may be disregarded without appropriate evaluation. For this reason, it is paramount that a patient be fully evaluated before we ascribe or believe such a diagnosis. If the personality disorder did not begin in childhood/adolescence, it does not meet criteria for a personality disorder. Not unusual is the presentation of an elder who has had impaired coping for years, even decades that has resulted from an untreated depression. As the use of antidepressants is so very safe now, an empiric trial may be elucidating in some cases. As with any treatment of depression, consider using a GDS or Cornell to help monitor treatment effects. The diagnosis of a personality disorder often carries with it the assumption that complaints by the patient have less validity. This can result in less than ideal medical and/or medical and psychiatric care. In some cases, this takes the form of numerous medical tests and medications, in others, the symptoms may be disregarded without appropriate evaluation. For this reason, it is paramount that a patient be fully evaluated before we ascribe or believe such a diagnosis. If the personality disorder did not begin in childhood/adolescence, it does not meet criteria for a personality disorder. Not unusual is the presentation of an elder who has had impaired coping for years, even decades that has resulted from an untreated depression. As the use of antidepressants is so very safe now, an empiric trial may be elucidating in some cases. As with any treatment of depression, consider using a GDS or Cornell to help monitor treatment effects.

43. 43 Toxic Personality Syndrome Not a disease, but a personality type This personality type is often hypercritical, angry, and accusatory in spite of every effort to give them comfort and optimal care. (Take care not to judge the care in a facility based solely on the behaviors or statements of this personality) Does not require (or respond to) any treatment

44. 44 The ABC�s of Behavior Intervention �A� = The Antecedent Events �B� = The Behavioral Event �C� = The Consequences

45. 45 The Antecedent Event(Behavior events are rarely unprovoked) Triggers that occurred before or even caused the behavioral event. Modifying triggers is best approach for cognitively impaired, because memory loss interferes with learning consequences.

46. 46 Five Categories of Triggers Physical Triggers:: pain, impaired sight or hearing, fecal impaction/constipation, needs changing or repositioning, etc. Emotional Triggers: worried, afraid, distressed, etc. Environmental Triggers: too much or too little lighting, noise, temperature, activity levels, etc. Task Triggers: difficulty when challenged by a specific task like bathing, dressing or eating, etc. Communication Triggers: difficulty understanding others or expressing self, etc.

47. 47 Environment/Stressors In the category of environment and stressors, many elements can be considered for improvement. This list is only a small example. Often the awareness of these factors increases over time and with additional input from staff and families. This area should be considered first in any hierarchical algorhythm. Often nonpharmalogic interventions will be appropriate no matter what is discovered throughout the remainder of the evaluation process. Frequently, LTC staff are conditioned, or become tolerant to environmental stimuli that needs to be changed. Our observations and suggestions as consultants are invaluable. This list is in no way complete but does give the speaker prompts to describe some of their experiences that have benefited patient care. Rather than view patients as appropriate for pharmacological or nonpharmacological interventions, we advocate nonpharmacological interventions for any patient in distress and then to consider pharmacological treatment if appropriate for a diagnosed illness or severe symptom. In the category of environment and stressors, many elements can be considered for improvement. This list is only a small example. Often the awareness of these factors increases over time and with additional input from staff and families. This area should be considered first in any hierarchical algorhythm. Often nonpharmalogic interventions will be appropriate no matter what is discovered throughout the remainder of the evaluation process. Frequently, LTC staff are conditioned, or become tolerant to environmental stimuli that needs to be changed. Our observations and suggestions as consultants are invaluable. This list is in no way complete but does give the speaker prompts to describe some of their experiences that have benefited patient care. Rather than view patients as appropriate for pharmacological or nonpharmacological interventions, we advocate nonpharmacological interventions for any patient in distress and then to consider pharmacological treatment if appropriate for a diagnosed illness or severe symptom.

48. 48

49. 49 Goals of Treating Behaviors in the NH Reduce the risk of injury Reduce patient distress Minimize adverse drug events Maintain resident in most desirable living setting Define for WHOM it is a problem

50. 50 Impact of Behavioral Symptoms 25% required no intervention. 0.8% resulted in injury to others. 0.9% resulted in physical damage to the environment. An average of 24 minutes of staff time was required per intervention.

51. 51 The Consequences Includes all actions or occurrences encountered after the episode or as an outcome of the event. A cognitively intact resident learns to repeat behaviors that are �rewarded�, for example, if they get attention from staff. Caregivers must consistently reward desired behavior. Cognitively impaired residents don�t remember the �rewards�, so it�s best to focus on changing the antecedents or triggers.

52. 52 Documentation Tips Document all diagnosis being actively treated in monthly orders & progress notes Document behavior in progress notes Summarize target symptoms Attempted nonpharmacologic interventions PRN�s used onset, duration, frequency, associated factors Document medication efficacy re: target symptoms Look at behavior monitoring for accuracy and completeness. Consider other ways to document GDS, Cornell, Behave AD, Cohen Mansfield This is an example of the common aspects of documentation that clinicians must keep in mind when prescribing antipsychotics in LTC. These guidelines may be helpful when prescribing any psychotropic to help with overall compliance and provide good documentation. This is an example of the common aspects of documentation that clinicians must keep in mind when prescribing antipsychotics in LTC. These guidelines may be helpful when prescribing any psychotropic to help with overall compliance and provide good documentation.

53. 53 Documentation Shortfalls 108 bed community nursing home. 44 (41%) residents were on antidepressant therapy. 14 residents were also on at least one antipsychotic medication for management of agitation. Indication for use was documented in 42 cases (95%). Outcome was documented in 25 cases (57%). Adverse drug reaction monitoring was documented in 9 cases (20%).

54. 54 Non-pharmacologic Interventions:Behavioral Strategies Behavioral Contracting Positive Reinforcers Written Communications One-on-One Intervention Redirection Distraction Traffic Controllers Signs/Symbols Wander Prevention Nets

55. 55 Urgent Action Issues

56. 56 The Prescribing Cascade Important in behaviors as it is in other areas of LTC issues The continuing use of medications to address the adverse drug effects of prior drugs On-call doctors and frequent staff changes in facilities can inadvertently accelerate the cascade