Behavioral Approaches to Agitation in Dementia

1. Behavioral Approaches to Agitation in Dementia Erin L. Patel, Psy.D. Clinical Psychologist Alvin C. York VAMC Tennessee Valley Healthcare System March 19, 2013

2. What is dementia? • How does dementia impact communication and behavior? • What is agitation? How else can it be described? • What are the risks associated with pharmacological management of agitation in patients with dementia? • What are non-pharmacological interventions for agitation? • What is the ABC approach to behaviors? • What barriers exist in implementing non-pharmacological approaches? Goals and Objectives:

3. Dementia is brain failure

4. Dementia’s Impact Frontal Lobes Temporal Lobes The temporal lobes, above the ears, are involved in hearing, identifying objects, understanding language, and storing memories. They also play a role in emotions. The frontal lobes are located behind the forehead. This area of the brain is associated with higher-level thinking, such as problem solving, reasoning, and some aspects of speech. It also contains the motor cortex, which controls voluntary movement. The Limbic System Parietal Lobes The limbic system is a ring-shaped group of structures involved in emotions, instincts, and memory formation. Together with the brain stem, it manages essential survival functions such as temperature, blood pressure, heart rate, and blood sugar. The parietal lobes on the top of the head process senses like touch, pain, temperature, pressure, and spatial awareness. They are also associated with voluntary movement, attention, language, and some mathematical abilities. Occipital Lobes The occipital lobes at the back of the brain interpret visual information like color, light, shape, and movement.

5. Behavior as Communication • Communication is impaired in dementia • Expressive/ Receptive/ Global aphasia • Actions speak louder than words- but not as clearly • Behavior communicates needs and wants • Behavior as poorly communicated needs • How might a resident show… • Pain? • Being too cold or too hot? • Fear? • Boredom? • Need for control? • Being thirsty or hungry? • Being overtired?

6. What is Agitation? • Per the dictionary: • To excite and often trouble the mind and feelingsof: DISTURB • What about behavior? • Antonyms: • Calm • Quiet • Settle • Sooth • Tranquilize (uh, oh!) • Agitation in older adults can take many forms- what comes to mind?

7. How Common is Agitation and Other Behavioral Problems in Dementia? • It is estimated that roughly 90% of patients with dementia will exhibit agitation or other problematic behaviors during the course of their illness • Common complaints include hitting at others, yelling/cursing, wandering, disrobing, hoarding/stealing, anxiety, sexualized behaviors or comments, reversed sleep/wake cycles, resisting care • Distressing for patient and caregivers • May put patient or others at risk of harm • What should we do for behaviors that are seemingly harmless and just annoy? • Psychotic symptoms may also be present • Hallucinations • Delusions • Paranoia • Delirium also occurs frequently in older adults, especially in those who are cognitively and medically compromised

8. PTSD • Depression • Anxiety • Psychotic Disorders • Personality Disorders • Medical conditions/treatments: • COPD • Parkinson’s Disease • ALS • Delirium • Medical restraints The Impact of Co-Morbid Conditions

9. Sleep • Pain • Infection • Dehydration • Past experiences • Pre-morbid personality The Impact of Other Conditions

10. Medications are SECOND line treatment for behavioral and psychological symptoms associated with dementia • Classes of medications often used: • Antipsychotics • Hypnotics • Benzodiazepines • Mood Stabilizers • Antidepressants • Cholinesterase Inhibitors • What do medications treat? • How do medicines change/improve behaviors? Pharmacological Management of Agitation in Dementia

11. Risk versus Benefit Analysis of Pharmacotherapy (specifically antipsychotics) for Agitation in Dementia Risks Benefits Quick acting Mild/short term benefits for aggression and psychosis Sedation Requires less staff time Accelerated cognitive decline Reciprocal reactions Delirium Hospitalization Cerebrovascular impacts Metabolic effects Cardiovascular effects DEATH! Falls Sedation Extrapyramidal symptoms Restlessness Social withdrawal Reduced quality of life Pneumonia

12. Omnibus Budget Reconciliation Act (OBRA)- 1987- Guidelines: states that patients who reside in nursing homes must be free from excessive physical and chemical restraints • FDA- Public Health Advisory- 4/11/2005- http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/DrugSafetyInformationforHeathcareProfessionals/PublicHealthAdvisories/ucm053171.htm • National Institute of Mental Health- Press Release- 10/11/2006 • According to the Clinical Antipsychotic Trial of Intervention Effectiveness (CATIE-AD) study (n=421), antipsychotic medications (Zyprexa, Seroquel, and Risperdal) were no more effective than placebo when adverse side effects are considered • FDA Alert- 6/16/2008- Warning regarding Conventional Antipsychotics- http://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/ucm124830.htm • The New York Times- 1/11/2010, “Overmedication in the Nursing Home” • 71% of Medicaid NH residents in FL on psychoactive medications within 3 months of admission • “Beers consensus criteria for safe medication use in the elderly recommend avoiding antipsychotics to treat neuropsychiatric symptoms of dementia “unless nonpharmacological options have failed and [the] patient is [a] threat to self or others.”” (Steinberg & Lyketsos, 2012)

13. Risk versus Benefit Analysis of Use of Restraints Risks Benefits Keeps the resident in one location and unable to move extremities Staff may believe that this practice will keep the person safe Increased rate of falls and injuries Negative psychological outcomes Death: Asphyxiation Strangulation Cardiac Arrest Functional Decline Incontinence Pressure Ulcers Regressive Behaviors

14. Risks associated with antipsychotic medications • Falls • Death • Reduced quality of life • Initiatives to reduce the use of antipsychotic medications in nursing home patients • Cultural transformation efforts to make the environment “home-like” and reduce the use of medications • Promotion of quality of life • Shift away from the medical model of nursing home care • What would you want for your family member? For yourself? Why Use Non-Pharmacological Techniques? How is this related to the concepts of cultural transformation in long term care?

15. What are “Non-Pharmacological” Techniques? “Non-pharmacological” techniques consist of individualized behavioral interventions, as well as good care practices to prevent or reduce problematic behaviors Behavioral Interventions: Redirection Distraction Offering snack or activity Validation Respond to emotions Soothing or comfort Orient Explain procedures Incorporate history, occupation, interests, etc. Others (be specific and individualized)

16. How about environmental modifications and care practices? • Use active listening skills • Be mindful of non-verbal cues • Offer choices • Set appropriate boundaries • Provide praise, compliments, and acknowledgment • Offer positive social attention on a daily basis • Engage the resident in cooperative problem solving • Actively involve the resident in MEANINGFUL instrumental, leisure, productive, and social activities • Environmental Modifications: reduce noise, good lighting, clean and clutter free, pleasant sights and smells • Interprofessional care

17. Other non-pharmacological approaches*: • Light therapy • Animal therapy • Exercise • Music therapy • Aromatherapy • Sensory stimulation • Snoezelen • Validation • TENS • Acupuncture • Simulated Presence therapy • Reminiscence • Massage * These techniques have few studies supporting their efficacy, but may prove beneficial and can be used as part of an individualized approach

18. Non-pharmacological Interventions for Delirium, Depression, Anxiety, Sleep Problems, etc.

19. Meet a person’s needs before they are needs.

20. Behavioral Management in Practice • Eden Alternative • Dr. William Thomas • http://www.edenalt.org/ • http://www.youtube.com/watch?v=ZKRMd-r2dN8 • Teepa Snow, Occupational Therapist • http://www.teepasnow.com/teepa_snow_resources.html • Use of time • Hand over hand • Becoming a detective • Bathing without a Battle • http://www.bathingwithoutabattle.unc.edu/index.html

21. THE ABC APPROACH TO MANAGING BEHAVIORS Clinical Application of Learning Theory: Functional Analysis

22. A= Antecedents • Begin looking for any ANTECEDENTS to the behavior. Antecedents can be viewed as predictors of the behavior- if we know when the behavior will occur, then we can prevent it from even happening! • What preceded the behavior? • People- Who? • Places- Where? • Time of day- When? • Activities taking place

23. B= Behaviors • Determining the BEHAVIOR that needs to be assessed. Answers the “what?” • Describe the behavior: • What does it look like? Provide details so that others would be able to recognize the behavior. • How long does it happen? (Duration) • How often does it happen? (Frequency) • How severe is this behavior? (Intensity)

24. C= Consequences • CONSEQUENCES are not always negative; instead, they are what lead to learning and maintain a problematic behavior. • Reinforcement- anything given or taken away that INCREASES a behavior. Person specific! • Punishers- anything given or taken away that DECREASES a behavior. Person specific! • A consequence that starts a behavior may not be the consequence that maintains it. Situation specific!

25. ABCs of Difficult or Challenging Behaviors

26. Evidence for Non-Pharmacological Techniques • Department of Veterans Affairs- HSR&D- March 2011- systematic review of non-pharmacological interventions for behavioral sx of dementia: • Best evidence for systematic individualized interventions • Cohen-Mansfield has demonstrated positive effects of behavioral interventions (2001) • 2012- Cohen-Mansfield et al. demonstrated that Treatment Routes for Exploring Agitation (TREA) interventions for unmet needs led to statistically significant declines in total agitation and significant increases in pleasure and interest. • Behavioral management, cognitive stimulation, and physical activities improved quality of life in persons with dementia (Vernooij-Dassen et al., 2010) • Livingston et al. (2005) • Grade A evidence- caregiver education and support; Grade B evidence- music therapy, cognitive stimulation therapy, Snoezelen, behavioral management, staff training/education • “Only behavior management therapies, specific types of caregiver and residential care staff education, and possibly cognitive stimulation appear to have lasting effectiveness for the management of dementia-associated neuropsychiatric symptoms”

27. Barriers Associated with the Use of Non-pharmacological Techniques • MDs had more favorable attitudes towards pharmacological interventions (PIs) and less knowledge of non-pharmacological interventions (NPHIs) as compared to PhDs and NPs (Cohen-Mansfield, Jensen, Resnick, & Norris, 2012)- but still a strong desire to utilize NPHIs before PIs • Staff barriers (time, attitudes, education) • System barriers (need for interprofessional care) • Patient barriers (unwillingness to participate, sleeping) • Fewer barriers associated with socialization versus games/crafts (Cohen-Mansfield, Thein, Marx, & Dakheel-Ali, 2012)

28. Questions?