Lynn Etters, MSN, GNP-BC, ANP-C Angela Popoff , LMSW

1. Optimizing Treatment and Care for People with Behavioral and Psychological Symptoms of Dementia Lynn Etters, MSN, GNP-BC, ANP-C Angela Popoff, LMSW

2. Behavioral & Psychological Symptoms of Dementia (BPSD) “Symptoms of disturbed perception, thought content, mood or behavior that frequently occur in patients with dementia” (IPA consensus group 1999)

3. Introduction • Aging population = Significant increase in the absolute number of older people with Alzheimer’s disease (AD) & other dementias • Dementia is associated with progressive cognitive decline, a high prevalence of BPSD such as agitation, depression and psychosis, stress in caregivers, & costly care • BPSD are an integral part of the disease process & present severe problems to patients, their families, caregivers, & society at large • Treatment of BPSD offers the best chance to alleviate suffering, reduce family burden, & lower societal costs in patients with dementia

4. Prevalence of BPSD in Dementia • Up to 95% of persons with dementia develop BPSD • Over 80% of BPSD persist over an 18 month period -especially delusions, depression and aberrant motor behavior • BPSD predicts functional decline, cognitive decline & institutionalization • BPSD is not a unitary concept & should be divided into several or more groups of symptoms reflecting a different prevalence, course over time, biological correlate and psychosocial determinants

5. Prevalence of BPSD • Most intrusive & difficult BPSD to cope with are: • Delusions • Hallucinations • Misidentifications • Depression • Sleeplessness • Anxiety • Physical aggression • Wandering • Restlessness

6. using the Neuropsychiatric Inventory (NPI) • Delusions • Hallucinations • Agitation/aggression • Depression/dysphoria • Apathy/indifference • Elation/euphoria • Anxiety • Disinhibition • Irritability/lability • Aberrant motor behavior • Sleep • Appetitie/eating disorder

7. Why are BPSD Important?

8. Causes of BPSD • Biological Factors • Genetic • Neurotransmitters • Structural Changes • Clinical Factors • Psychological & Personality Factors • Social & Environmental Factors • Caregiver Factors

9. Clinical Risk Factors for BPSD • Increased Irritability in higher functioning groups • Executive impairment early in course of dementia associated with BPSD & carer stress 3-6 years later • Frontal symptoms are associated with increased severity & frequency of agitation & aggression as well as increased severity of psychosis & depression • Serious medical comorbidity – increased risk of agitation, irritability, disinhibition & aberrant motor behavior

10. BPSD are often Multi-Factorial in etiology • Few cases of BPSD are due to a single factor • Must consider a biopsychosocialapproach in the clinical context – medical, psychiatric, behavioral, cognitive, environmental, social – to identify treatable factors

11. Diagnosis and Assessment of BPSD • Phenomenology is the basis of diagnosis • Direct interview • Direct observation • Proxy report • Measurements and scales (NPI) • Need for accurate descriptions • Think of physical illness • Think of sensory impairment

12. Treatment Principles • When treating BPSD, success rates will be higher if the following principles are observed: • Identify what symptom(s) cause most concern • Describe each symptom in detail • Specify the Antecedents of Behaviors (the circumstances that spark them) & their Consequences (what makes them better or worse) • This approach is known as the ABC approach

13. Overview of Management of BPSD • Patients with BPSD should be evaluated for delirium • Consider changes in environment, medication, fecal impaction, pneumonia, urinary infection, etc. • Evaluate for needs that the dementia patient is unable to communicate normally e.g. pain • Behavioral management or situational manipulation are the initial strategies of choice for mild to moderate BPSD • Pharmacological interventions are useful if symptoms are severe or do not respond to non-pharmacologic strategies alone

14. Sleep deprivationWorsens dementia Sleep apnea Impaired memory processing High body mass, glucose intolerance

15. Key Messages • There is now a substantial body of evidence supporting the use of non-pharmacological treatments of BPSD • Even when BPSD are caused by physical discomfort, major depression, or psychosis, psychosocial interventions will prove helpful when offered in combination with analgesic, antidepressant, or antipsychotic medications • Psychosocial approaches are indicated as first-line approaches to all BPSD

16. Key Messages - II • Psychosocial interventions work best when they are tailored to people’s backgrounds, interests, & capacity • Family & professional caregivers are key collaborators. It is important to provide them with necessary information, education, & to support them as they test & refine their responses to challenging symptoms • The physical environment can help prevent or minimize BPSD by reducing distress, encouraging meaningful activity, maximizing independence, & promoting safety

17. Systematic Review of Psychosocial Treatments for BPSD • Only 25 of 118 relevant studies met every specification • Treatment proved more effective than an attention control condition in reducing behavioral symptoms in only 11 of the 25 studies • Effect sizes were mostly small or moderate • Treatments with moderate or large effect sizes included aromatherapy, ability-focused carer education, bed baths, preferred music, & muscle relaxation training • (O’Connor et al, 2009)

18. First Line The Acetylcholinesterases Tablet 5mg, 10mg 23mg Tablet 3mg, 4.5mg, 6mg Patch 4.6mg, 9.5mg Tablet 8mg, 16mg, 24mg

19. Great Expectations • For all AD stages • Mild • Moderate • Severe • Exelon approved for Parkinson’s/Lewy body • Those who took AchEI the earliest and continued the longest lived three years longer than those who • Never took AchEI • Stopped the drug • Started later • Benefits • Slows progression • Improve behavior (hallucinations, delusions, mood) • Safest and most specific treatment for the disease

20. Side Effects • Runny nose • Initial nausea, diarrhea • Abates without intervention • Upon first starting or increasing dose • If continues, check for other underlying cause • Avoid if: • COPD dependent on steroids • Active lung infection • Active stomach ulcer • Heart block

21. Second Line -Namenda • Moderate to severe AD • NMDA receptor antagonist • Slows neuron death • Add to Acetylcholinesterase inhibitors • Side effects: • insomnia, • constipation • headache • Drug interactions • dextromethorphan Titration pack 10mg twice daily

22. Potentially Inappropriate Medications for those with DementiaAnti-cholinergic Medications Possible Consequences Caution Minimize use if possible Cancels effects of acetyl cholinesterase inhibitors Benefits vs. disadvantages • Confusion and delirium • Blurred vision • Dry mouth • Urinary retention • Constipation • Increased risk for falls

23. AnticholinergicsIncrease risk for dementia • In a cross-sectional, prospective study of 1,380 elderly inpatients, researcher found, medication with anticholinergic properties are associated with worse cognitive & functional performance in elderly patients • There was a dose-response relationship for total burden score and cognitive impairment. • (Pasina et al., 2013)

24. If Pharmacological Therapy Is Needed: • Look for symptom complexes such as depression, psychosis or anxiety to guide initial choice of agent • In most situations, medications should be given in lower doses than are typically recommended for an adult population • Ideally, use agents with demonstrable efficacy as first line agents

26. Antidepressants in Dementia • Effectiveness in treating depression, anxiety and agitation in dementia is modest • Meta-analysis by Thompson et al (2007) of depression in dementia included five DB placebo controlled studies involving 165 patients and found antidepressants efficacious with the number needed to treat being five • Subsequently, one large RCT of 131 depressed patients treated with sertraline was found to be ineffective (Rosenberg et al, 2010) • SSRIs remain the first choice agents, if only due to their tolerability

27. Atypical Antipsychotics for BPSD • Meta-analysis of 13 studies concluded ‘effect sizes of atypical antipsychotics for behavioral problems are medium, and there are no statistically or clinically significant differences between atypical antipsychotics and placebo’ (Yury & Fisher, 2007) • Best quality evidence of effectiveness is with risperidone

28. Antipsychotics for BPSD • Antipsychotic medications are most effective in the treatment of psychotic symptoms (hallucinations, delusions), agitation, and aggression • Both atypical and typical antipsychotics appear to carry an increased risk for mortality and stroke in patients with dementia • Atypical antipsychotics are preferred over typical antipsychotics for BPSD • Side effects include sedation, weight gain, confusion, parkinsonism

29. Key Messages • In general, non-pharmacological approaches are first-line treatment for BPSD • Medication is indicated for BPSD that are moderate to severe that has impact on a patient’s or caregiver’s quality of life, functioning, or that pose a safety concern, often in conjunction with non-pharmacological interventions • In a person unable to provide informed consent, it should be obtained from the appropriate proxy & include the potential risks associated with pharmacological treatments • Develop a plan to monitor therapy – aim to cease medication within 3 months if possible

30. Conclusions • BPSD occurs in up to 95% persons with dementia • The course of BPSD is now better understood • Causes of BPSD are multifactorial including biological, social, psychological, and environmental factors • Non-pharmacological treatments should be first line for all BPSD • Pharmacological treatments have only modest efficacy & may have serious adverse effects & should be reserved for only moderate to severe BPSD

32. Resources • Ames, D., Burns, A., & O’Brian (Eds.), (2010). Dementia (4th Ed.), UK: Hodder Arnold. • International Psychogeriatric Association (IPA). (2013). The IPA complete guides to behavioral and psychological symptoms of dementia. Retrieved from http://www.ipa-online.org • Pasina, L., Djade, C. D., Lucca, U. Nobili, A., Tettamanti, M., Franchi, C.,…Mannucci, P. M. (2013). Association of anticholinergic burden with cognitive and functional status in a cohort of hospitalized elderly: Comparison of the anticholinergic cognitive burden scale and anticholinergic risk scale: Results from the REPOSI study. Drugs & Aging, 30(2), 103-112. • O’Connor, D. W., Ames, D., Gardner, B., & King, M. (2009). Psychosocial treatments of psychological symptoms in dementia: A systematic review of reports meeting quality standards. International Psychogeriatrics, 21, 225-251. • Selkoe, D. J., Mandelkow, E., & Holtzman, D. M. (Eds.), (2012). The Biology of Alzheimer’s Disease. Cold Spring Harbor, NY: Cold Spring Harbor Laboratory Press. • Thompson, C. A., Spilsbury, K., Hall, J., Birks, Y., Barnes, C., & Adamson, J. (2007). Systematic review of information and support interventions for caregivers of people with dementia. BMC Geriatrics, 27(7), 18. • Yury, C. A., & Fisher, J. E. (2007). Meta-analysis of the effectiveness of atypical antipsychotics for the treatment of behavioral problems in persons with dementia. Psychotherapy & Psychosomatics, 76(4), 213-218.

33. Greater Michigan Chapter 25200 Telegraph Road Southfield, MI 48033 (800) 272-3900 www.alz.org/gmc

34. Service Territory • Greater Michigan Chapter Office Locations • Southfield, MI • Wayne, Oakland, Macomb, St. Clair, Huron, and Sanilac Counties • Midland, MI • Traverse City, MI • Marquette, MI • Grand Rapids, MI • Alpena, MI • Great Lakes Chapter • http://www.alz.org/mglc/

35. HARRY L. NELSON HELPLINEOverview 1-800-272-3900 • Who is Harry L. Nelson? • What is the Harry L. Nelson Helpline? • The Harry L. Nelson Helpline Provides: • Confidentiality • Empathetic listening • Accurate information and referral • Accessibility (24/7)

36. Types of Helpline Calls • Information regarding our agency • Basic information on dementia • Program and service referrals • Guidance and support

37. What does this program provide? • 24/7/365 accessibility • Efficient and safe reunions • Information to emergency responders • Training for emergency responders • Incident follow up support

38. GPS tracking device • Portable device, device for car • Track location on a secured and protected website • Allows alerts to assist care partner in knowing where loved one • Allows a “safe zone” to be set • Pricing may vary, fees include: • Device, activation fee, and monthly fee

39. CARE CONSULTATION • Services Include: - Assessments - Assistance with planning & problem solving - Supportive listening • Fee for service is reimbursed through some insurances, or a sliding scale is utilized. NO ONE IS TURNED AWAY DUE TO INABILITY TO PAY

40. Types of Care Consultation Programs • General Care Consultation • The Wraparound Program • Henry Ford Health System Collaborative • West Bloomfield • Detroit • Taylor

41. SUPPORT GROUPS • Kinds of Support Groups • Caregiver Support Groups • Dial-in Support Group • Younger Onset Support Group • Early Stage Support Groups FOR INFORMATION ON THESE GROUPS, VISIT www.alz.org/gmc

42. Early Stage Programming • Ongoing support group • Early Stage Lecture Series • Early Stage Social Club • Living With Alzheimer’s Pre-assessment required for registration!

43. Minds on Art Minds on Art is a FREE 6 week program, as well as providing Saturday drop in sessions. For people living with Alzheimer’s disease and other dementias and their care-partners. Provides unique opportunity for individuals in the early and mid stages of the disease to create meaningful memories through art. Hosted at the Detroit Institute of Arts (DIA) PRE-REGISTRATION REQUIRED

44. EDUCATION PROGRAMS • Provided by instructors or moderators with appropriate expertise. • Provided for both the community and staff in the field of dementia care • Types of Education Programs • Foundations of Dementia Care • The Basics • Know the Ten Signs • Creating Confident Caregivers

45. Creating Confident Caregivers • Improving caregiver skill, knowledge, and outlook • Developing skills for self-care • Strengthening family resources • Strengthening decision making skills • Improving confidence reduces sense of distress

46. RESPITE SERVICES • What is Respite? • Respite Services Include: - Adult Day Programs • Rebecca & Gary Sawka Day Program- Southfield, MI • Robert & RoseAnn Comstock Day Program- Detroit, MI - Respite Care Assistance Program • Check with regional office for availability

47. Get Involved • Hosting a Third Party Event • Attending or assisting at a fundraiser: • Walk to End Alzheimer’s • Chocolate Jubilee • Writing letters, emails, making phone calls to local legislatures • Be a support group facilitator • Be a Harry L. Nelson Helpline Representative • Represent our agency at community health fairs • Be a speaker on our Speaker’s Bureau • Sign up for a clinical trial in your area using Trial Match • Visit our message boards at www.alz.org

48. CONTACT US! For more information on our services or to get more involved: Call our 24/7 Harry L. Nelson Helpline 1-800-272-3900 Visit our chapter website www.alz.org/gmc Visit our National website www.alz.org