Behavioral Disturbance and its Management in Dementia PatientsPRESE NTED BY KARL A BRENNSCHE IDT , PSY.D .OWNER, D IRECTO RCL IN ICAL NEURO PSYCHOLO GIST – CEDAR VALLEY NEU ROSYCHO LOY SERV ICES , CEDAR FALLS

Outline• Aging Society • Iowa Data• Defining Dementia• Dementia Types• Define Behavioral Disturbance• Causes• Comprehensive Assessment• Managing Agitation• Other Behavioral Approaches to Treatment • Case Studies

Aging Society

Supercentenarians

Mortality

http://www.alz.org/alzheimers_disease_facts_and_figures.asp#quickFacts

Iowa

http://www.alz.org/alzheimers_disease_facts_and_figures.asp

Iowa

What is Dementia? NINDS – National Institute of Neurological Disorders and Stroke

◦ Not a specific disease.◦ A descriptive term for a collection of symptoms. ◦ Caused by a number of disorders that affect the brain. ◦ Significantly impaired intellectual functioning that interferes with normal activities and relationships. ◦ Loss of problem-solving ability; loss of and inability to maintain emotional control. ◦ Personality changes and behavioral problems, such as agitation, delusions, and hallucinations. ◦ Memory loss a common symptom of dementia, but by itself not diagnostic of dementia.

◦ Multifactorial, including changes in thinking, memory, executive deficits, language, visual-perceptual skills, and BEHAVIORS.

Behavioral disturbance most common reason for nursing home admittance.

Dementia TypesALZHEIMER’S DISEASE

Most common type of dementia; accounts for an estimated 60 to 80 percent of cases.

Symptoms: Difficulty remembering names and recent events is often an early clinical symptom; apathy and depression are also often early symptoms. Later symptoms include impaired judgment, disorientation, confusion, behavior changes and difficulty speaking, swallowing and walking.New criteria and guidelines for diagnosing Alzheimer's were published in 2011 recommending that Alzheimer's disease be considered a disease with three stages, beginning well before the development of symptoms.

Brain changes: Hallmark abnormalities are deposits of the protein fragment beta-amyloid (plaques) and twisted strands of the protein tau (tangles) as well as evidence of nerve cell damage and death in the brain.

VASCULAR DEMENTIA

The second most common cause of dementia after Alzheimer's disease.

Symptoms: Impaired judgment or ability to plan steps needed to complete a task is more likely to be the initial symptom, as opposed to the memory loss often associated with the initial symptoms of Alzheimer's. Occurs because of brain injuries such as microscopic bleeding and blood vessel blockage. The location of the brain injury determines how the individual's thinking and physical functioning are affected.

Brain changes: Brain imaging can often detect blood vessel problems implicated in vascular dementia. In the past, evidence for vascular dementia was used to exclude a diagnosis of Alzheimer's disease (and vice versa). That practice is no longer considered consistent with pathologic evidence, which shows that the brain changes of several types of dementia can be present simultaneously.

Dementia TypesDEMENTIA WITH LEWY BODIES (DLB)

Symptoms: People with dementia with Lewy bodies often have memory loss and thinking problems common in Alzheimer's, but are more likely than people with Alzheimer's to have initial or early symptoms such as sleep disturbances, well-formed visual hallucinations, and muscle rigidity or other parkinsonian movement features.

Brain changes: Lewy bodies are abnormal aggregations (or clumps) of the protein alpha-synuclein. When they develop in a part of the brain called the cortex, dementia can result. Alpha-synuclein also aggregates in the brains of people with Parkinson's disease, but the aggregates may appear in a pattern that is different from dementia with Lewy bodies.

FRONTOTEMPORAL DEMENTIA

Includes dementias such as behavioral variant FTD (bvFTD), primary progressive aphasia, Pick's disease and progressive supranuclear palsy.

Symptoms: Typical symptoms include changes in personality and behavior and difficulty with language. Nerve cells in the front and side regions of the brain are especially affected.

Brain changes: No distinguishing microscopic abnormality is linked to all cases. People with FTD generally develop symptoms at a younger age (at about age 60) and survive for fewer years than those with Alzheimer's.

Behavioral Disturbance• Leading reason for admission into nursing homes.• Increases stress between patient and caregiver.• Increases morbidity and mortality of dementia patients.• Create more intensive and costly levels of treatments.

Finkel, S., et al., Int Psychogeriatrics, 1996, 8, 497-500

Definition of behavioral disturbance

• A behavior that puts the patient or others at risk.• A behavior that makes keeping the patient in the milieu difficult for either staff or other patients.

Behavioral (and psychological) Symptoms

◦ Agitation.◦ Aggression (e.g., during daily care; hitting, kicking). ◦ Attention seeking behaviors (e.g., perseveration on bathroom activities). ◦ Delusions. ◦ Hallucinations.◦ Mood disturbances. ◦ Repetitive vocalizations (screaming, incessant calling out). ◦ Sexual disinhibition (verbal or physical). ◦ Wandering.

Behavioral DisturbancePossible Causes:• Inherent changes of disease process.• Medical comorbidities.• Environmental disruptions.• Lack of staff knowledge.• Lack of family education about disease process.

Requires Comprehensive Assessment:• Environment / stressors.• Delirium.• Medical Problems.• Psychotic Disorder.• Affective Disorder.• Anxiety Disorder.• Personality Disorder.

What do we do? – Multiple Goals• Make the behavior go away.• Treat the underlying cause.• Improve patient outcomes.• Restore calm and safety to the situation and the unit.

Detective Work • Identifying environmental stressors.• Identifying any trends.• Working on a “crisis plan” with family, patient, or significant others.• Enlist the help of specific staff members.• Use of adjunct therapies and specialized interventions (e.g., sensory room; aromatherapy).

• Call your neuropsychologist!!!

Environmental Stressors• Room location.• Excess noise (TV, overhead pagers).• Glare from windows, mirrors, floors.• Slamming doors.• Proximity to bathrooms.• Proximity to peers of opposite sex.

Delirium• Delirium is a syndrome.• Altered or fluctuating level of consciousness – attention deficits / alertness.• Not a final diagnosis.• Acute or subacute onset.• Caused by a variety of illnesses or medications.• Difficult to assess with dementia.• Must identify to treat appropriately.

Causes: • Acute illness – UTI, respiratory infection.• Chronic illness – CHF, COPF causing hypoxia, renal insufficiency, anemia.• Sensory impairment – cataract, hearing loss.• Iatrogenesis – recent medication change; drugs with anticholinergic effects; r/o withdrawal syndrome.

Medical Issues • Illnesses: GERD, angina, etc.• Medication side effects.• Pain.• Constipation.• Hearing or vision impairment.• Sleep deprivation.• Dental problems.

Managing AgitationAREAS TO CONSIDER

Pain

Over-sedation

Poor sleep

TREATMENT IDEAS

R/O under-medication; assess resting and procedural pain; pre-medicate for painful procedures; use standing, not PRN scheduling; remove or discontinue painful stimuli; consult pain service in difficult cases.

Reduce or d/c benzodiazepines or other sedative medications if not working.

Examine sleeping medications and sleep hygiene issues; help patient remain active during the day.

Managing Agitation cont’dENVIRONMENTAL FACTORS

Patient experiences frustration with therapies.

Over-stimulation

Confusion / disorientation

Therapy demands may be too high; increase success rate to approx. 90%; increase overall positive reinforcement.

Reduce auditory, visual, olfactory, and tactile stimulation; reduce interaction with others; restrict visitors in number and frequency.

Consistent nurses, therapists; frequent visits and calls from family. Photos and notes from family members; white boards with salient orientation information.

Sensory Stimulation Rooms Not many nursing homes or hospitals have those rooms, but certainly a good investment for those facilities that have memory or dementia units.

Interventions designed to stimulate one or more of the senses.

Promotes self-soothing in agitated or distressed individuals.

Is based on Dutch concept of Snoelezen ® rooms (to sniff, to doze).

Sensory equipment: sand tray, weighted blankets, aroma therapy, tactile objects, soft lighting, music, sensory tower.

Other activities: yarn rolling, folding towels, soft blankets.

Managing Other BehaviorsINTERPERSONAL FACTORS

Patient feels threatened / acts aggressively

Patient is paranoid

Lower self below patient’s eye-level, use quiet calm voice; open posture.

Give detailed information the patient requests; write it down; write in memory book and refer patient to what other staff have written; psychiatry evaluation for antipsychotic meds.

Managing Other Behaviors Patient needs restraints for safety

Population at risk: Older patients with dementia.

Use only as a last resort; associated with poor outcomes. Facilities are required to have rules and regulations in place (incl. patients rights and freedom from inappropriate restraints).

Use bed and chair alarms; frequent check-ins; 1:1 sitter; place near nurse’s station or common area, if possible.

Questions To Ask◦ What has worked before?◦ Simplify.◦ Work with the patient’s schedule, do not ask the patient to work with ours.◦ Be creative. Affect means more than words. Don’t push. Talk to other staff about patient’s responses to

treatment – do co-treat, if possible.◦ Take cues from patient.◦ If possible, ask patient.

Case Study 78 year-old widowed female Lived at home with family until 2 months prior to hospitalization Admitted to hospital from LTCF because of

◦ aggression with ADL’s◦ constant calling out◦ general irritability◦ refusal to take meds

What was the problem for nursing and therapists?

Case Study – Use of the Sensory Room

◦ Responded well to 1:1 activity◦ Yarn rolling◦ Sand tray◦ Compression vest

Sometimes, all we have to do is ask the patient – rehabilitation example – a fearful patient with intellectual disability and limited verbal means

References 1. http://www.ninds.nih.gov/disorders/dementias/dementia.htm 2. Finkel, S., et al., Int Psychogeriatrics, 1996, 8, 497-500 3. http://www.alz.org/alzheimers_disease_facts_and_figures.asp

Dr. Brent Forester’s original presentation on evaluation and management of behavioral disturbances and psychosis in dementia, was adapted – with his kind permission - and expanded.