Pain: Module 3 · 2014. 4. 24. · Pain: Module 3 Dr. Eileen Trigoboff & Dr. Daniel Trigoboff 6 16 No treatments are available specifically for cognitive deficiency Pharmacologic

Pain: Module 3

Dr. Eileen Trigoboff & Dr. Daniel Trigoboff 1

www.ResourcesForIntegratedCare.com

11

Dr. Eileen Trigoboff

RN, PMHCNS-BC, DNS, DABFN

Practical Considerations Related

to Pharmacology and

Developmental Disabilities


22

■ Common presentations of DD

■ Assessment strategies with individuals with DD

■ Typical medications for this population

■ Pharmacology options

■ Behavior changes and possible explanations

■ Communication barriers with clients

■ Communication tools for clients and caregivers

■ Coping with resistance to assessment and treatment

Outline


33

■ Originates during the developmental period

(conception through age 18 years)

■ Significantly sub-average general intellectual function

deficits in functional life skills

■ Diagnosis - intelligence quotient (IQ) score of at least

2 standard deviations (SD) below the mean IQ of 100

(i.e., IQ <70).

■ Equivalent deficits in at least 2 areas of functional life

skills or adaptive skills

Intellectual Disability (ID) or Mental

Retardation (MR)

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■ Self-direction

■ Functional academic skills

■ Work

■ Leisure

■ Health

■ Safety

■ Communication

■ Self-care

■ Home living

■ Social and interpersonal

skills

■ Use of community

resources

2 areas of deficits in the functional life skills of:

Adaptive Skills


55

CategoryIQ(SDs below mean)

IQ scoreEducational

Level

Intensity of

supports

required

Prevalence

in total

population

Mild 2-3 55 to 70 Educable Intermittent 0.9-2.7%

Moderate 3-4 40 to 54 Trainable Limited 0.3-0.4%

Severe 4-5 25 to 39 Non-trainable Extensive 0.3-0.4%

Profound >5 <25 Non-trainable Pervasive 0.3-0.4%

Mild 2-3 55 to 70 Educable Intermittent 0.9-2.7%

Needs Title


66

Ranges from 1.6-3% of the population

United States Frequency of

ID of All Degrees

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Health problems interfere with quality of life:

■ Epilepsy

■ Immobility

■ Significant Oral Motor Incoordination/

Dysphagia/Aspiration

■ Respiratory disease is the most prevalent cause of

death among individuals with profound ID

■ Mild cognitive impairment life expectancy is not

known to differ from that of the general population.

Health & ID


88

■ Diagnosed more frequently

■ Schizophrenia may have a prevalence of 3%

■ Bipolar illness has a 2- to 3-fold greater prevalence in the cognitively

impaired than in the general population

■ Attention deficit/hyperactivity disorder (ADHD) is diagnosed in 8-15% of

children and 17-52% of adults with ID

■ Self-injurious behaviors require treatment in 3-15%, particularly in the

severe range of ID

■ Major depression, autistic spectrum disorders, obsessive-compulsive

disorder, anxiety disorders, conduct disorder, tic disorders, and other

stereotypic behaviors are diagnosed more commonly

Comorbid Psychiatric Conditions


99

■ 5 times the rate of emotional or behavioral disorder

■ ID compounded by epilepsy can increase the risk of a

psychiatric problem to over 50%

■ Occult visual and auditory deficits occur in 50% of

those with ID

■ STDs, Hepatitis B, and Helicobacter pylori infection

(H. Pylori) are increased significantly

Emotional/Behavioral Problems

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■ 1 in 5 also has cerebral palsy (CP)

■ As many as 20% have seizures

■ GI complications: feeding dysfunction, excess

drooling, reflux esophagitis, and constipation

■ GU complications: urinary incontinence and poor

menstrual hygiene

■ Profound social morbidity: lost wages, dependence

on social services, impaired long-term relationships,

and emotional suffering.

Emotional/Behavioral Problems


1111

■ Before psychopathology can be

identified, infants and toddlers with

ID are more likely to have

■ Difficult temperaments

■ Noncompliance

■ Hyperactivity

■ Disordered sleep

■ Colic

■ Poor social skills

■ Delays in play skills

■ Aggression

■ Self-injury

■ Defiance

■ Inattention

■ Hyperactivity

■ Anxiety

■ Depression

■ Sleep disturbances

■ Stereotypic behaviors

Psychopathology


1212

■ Language delay - Many infants are thought to be deaf

due to lack of expressive language & environmental

inattention.

■ Fine motor/adaptive delay - Significant delays in self-

feeding, toileting, and play skills are typical

■ Prolonged and messy finger feeding

■ Lack of interest in age-appropriate toys and delays in

imaginative play & reciprocal play with age-matched

peers.

Other Clinical Observations

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■ Odd, repetitive behaviors often replace imaginative

play with symbolic toys.

■ Clumsiness

■ Prevalence of ID is increased among children with

seizure disorders, microcephaly, macrocephaly,

history of intrauterine or postnatal growth

retardation, prematurity, and congenital anomalies.

Other Clinical Observations


1414

The Overlapping Symptoms

of Developmental Disabilities

and Other Psychiatric Disorders


1515

Overlapping Symptoms

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■ No treatments are available specifically for cognitive

deficiency

■ Pharmacologic enhancement of cognition is an area

of interest

� Research on such nootropic (i.e., knowledge-enhancing)

compounds is limited

Treatment


1717

■ Complex habilitation plan

■ Special educators

■ Language therapists

■ Behavioral therapists

■ Occupational therapists

■ Community services that provide social support and

respite care for families

Treatment


1818

■ Target psychiatric disease/behavioral disturbances

■ Vitamin/mineral therapies are popular, but efficacy has not

been established

■ Antioxidant supplements with Down Syndrome is of

theoretical benefit, but has not yet been tested vigorously

■ CNS stimulants (psychostimulants methylphenidate and

dextroamphetamine appear to enhance dopamine and

norepinephrine activity in the CNS) - The most common class

of drugs prescribed with as many as 50% ADHD/ADD

Medications

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■ To understand the basics of psychiatric medications

(psychopharmacology)

■ To recognize likely treatment options for a set of

symptoms or problems

■ To be able to plan for main effects and side effects

that are possible with psychiatric treatment

Why We’re Talking About Medications


2020

■ Help the client have

better control over

impulses

■ Help the client feel

better

■ Help keep functioning

from slipping away

■ Help minimize

depressive symptoms

■ Help clarify thinking

■ Help reduce anxiety

Examples of Why Psychiatric

Medications May be Necessary


2121

■ Inattention

■ Excitability

■ Focus

■ Aggression

■ Sleep problems

■ Depression

■ Psychosis

■ Disorganized thinking

Medicate the Symptom

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Assessment Strategies and Tools

for Behavioral Assessment


2323

■ Hallucinations, Delusions, Disorganization,

Depression, Mood Variations, and Anxiety all affect:

� Activities

� Interactions

� Sleep

� Eating

Behavioral Problems Accompany

All Symptoms


2424

■ Schizophrenia

■ Depression

■ Bipolar Disorder

■ Anxiety

Assess for Symptoms of Major Mental

Illness

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The reason so many people do not like to take their medications as prescribed

Side Effects


2626

Side Effects Seen Particularly with Psychiatric Medications

Extra Pyramidal Side Effects

(EPSE)


2727

■ Dystonia

■ Akathisia

■ Drug-induced Parkinsonism

ExtraPyramidal Side Effects (EPSE)

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The Clinical Impacts of EPSE are far reaching and

durable. Experiences with EPSE:

■ Contribute to lack of trust in the treatment provider

■ Contribute to lack of trust in the medication

■ Enhances a less collaborative attitude toward

treatment in general.

Extra Pyramidal Side Effects (EPSE)


2929

■ TD Late onset (after at least 3 months of treatment)

during the course of treatment with antipsychotics

■ TD Frequently associated with irreversible abnormal

movements, or a neurological syndrome.

Tardive Dyskinesia (TD)


3030

Generally Drying in Physiologic Effect

Anticholinergic

Side Effects

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■ Neuroleptic Malignant Syndrome (NBS)

■ Sexual Dysfunction

■ Sleep Disturbances

■ Weight Gain – waist circumference, BMI,

metabolic syndrome, diabetes,

hypertension, hypercholesterolemia

Additional Side Effects


3232

■ A side effect called QT

Prolongation or QTc Prolongation

affects the length of time it takes

for the heart to go through its

electronic and mechanical cycle.

■ Most antipsychotics cause this

Mellaril is the most problematic

Side Effect


3333

■ Intensive case management

■ Atypical antipsychotic drugs

� Especially clozapine in high hospital utilizers

■ Rehabilitation therapy

■ Family treatment

■ Social skills training

Interventions that Improve Recovery from

Schizophrenia

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Break


3535

Mood Disorders


3636

Depression

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Depression is more common in those with DD than for the general population

CALLED THE COMMON COLD OF

MENTAL HEALTH ISSUES


3838

Manic Depression

Bipolar Illness


3939

■ An estimated: 5.7 million Americans have BPI.

■ Bipolar illness has a 2- to 3-fold greater prevalence in

the cognitively impaired than in the general

population

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D Distractibility

I Insomnia

G Grandiosity

F Flight of ideas

A Agitation

S Speech

T Thoughtlessness (Impulsivity)

Manic Symptoms


4141

■ Lithium (LiCO3)

■ Anticonvulsants

■ Atypical Antipsychotics

Mood Stabilizers


4242

Starting Maintenance

On a Mood Stabilizer

Earlier

Predicts Greater Improvement.

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■ Individuals who are taught coping skills to anticipate

potential problems are likely to do better at handling

stressful situations.

■ Education on self-monitoring can be an important

tool for the individual adjusting to a new

environment.

Stress & Relapse


4444

Anxiety and the Medications

to Address It


4545

■ At low to moderate levels, anxiety

can be motivating, instructive, and

provide cues to the environment.

■ When anxiety passes these stages

and proceeds to excess, high anxiety

and panic can occur.

■ Extreme feelings of anxiety are not

motivating—in fact they are

immobilizing and learning is not

possible.

Anxiety

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Anti-Anxiety medications include tranquilizers

■ Benzodiazepines such as Valium, Librium, Ativan,

Xanax, and Versed

■ Non-benzodiazepines such as Ambien and Sonata

Anxiolytics (Anti-Anxiety Meds)


4747

■ Medicating such that higher levels of anxiety are

prevented allows the individual to have enough anxiety in

a given situation to manage that anxiety with the coping

skills taught, and to gauge their effectiveness.

■ If antianxiety medications are given without regard to the

actual anxiety level and the learning of the individual, it is

possible to obliterate the need to learn to cope with

stress. The client learns instead to rely on the medication

to cope.

Anxiolytics (Anti-Anxiety Meds)


4848

Strategies to Overcome

Communication Barriers and

Resistance To Treatment

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■ Difficulty adjusting to new routines is a

feature of Developmental Disabilities

(DD). In the weeks prior to the

beginning of a change, gradually move

into the schedule that is necessary for

that change. This might mean shifting

bed time, meal times, chores,

interactions, TV, etc.

Establish Routines


5050

You can help make waking up earlier in the

morning easier. For many people with any DD, it

is important that they also have morning

routines. This may reduce some of the

challenging mornings. For example, if client

Joshua has been in the habit of eating breakfast

in his pajamas and watching his favorite

television show for an hour prior to getting

dressed in one setting, it would be advisable to

modify his routine several weeks prior to the

change in setting.

Routines


5151

■ Establish some quiet time routines by getting into the

habit of doing quiet activities at a specific time and

place every day. This could be time for reviewing

previously mastered skills, doing silent reading,

journal writing, crossword puzzles, and similar

activities.

Quieting the Storm

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■ Plan on using external motivational systems in order

to be able to implement these changes. People with

DD rarely see our agenda as necessary or important.

This can often involve the use of activities/items we

often give away freely (watching TV shows, playing

favorite games, errand to favorite store,

points/tokens exchangeable for something s/he

wants). Remember, the key to motivation is that the

reinforcer must be powerful and immediate!

Communicate & Motivate


5353

■ Give the person with DD time to get

used to wearing new clothes. In some

cases, it may be helpful to wash them

several times with fabric softener to

lesson the sensory challenges. Plan

wearing his/her new clothes for

gradually longer periods of time, over

the course of several days.

Address Issue of Clothes


5454

Consider how a flexible attitude on your part can

make all tasks and issues run a lot more smoothly.

Set the Stage for a Good Relationship

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■ The development of positive social relationships is

essential but requires planning. Prior to the start of

any new social situation, target one or two people

who will be involved in a social activity with the DD

person. Usually, successful social experiences are

easiest to structure with one person at a time, rather

than a group.

Orchestrate a Few Social Gatherings


5656

■ People with DDs need an advocate - which is a never-

ending job! There is always so much to teach and so

much to do. Usually, there are stressors - not only for

people with DDs, but their caretakers as well.

Remember to make some effort to take care of your

own needs in order to have the time and energy to

attend to the needs of others.

Plan a Relaxing Adult Day


5757

■ Common presentations

■ Assessment strategies

■ Typical medications

■ Communication tools

■ Coping with resistance to assessment and treatment

What We’ve Covered . . .

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Question 1: One of your recipients, who has always been self stimulating,

begins to significantly scratch and cut herself as well. This could mean which of

the following?

(a) The recipient is having emotional problems

(b) The recipient may have a new physical complaint

(c) The recipient’s blood pressure has changed

(d) The recipient’s medications need to have Gradual Dose Reduction (GDR)

Answers: 1. (a) + (b)

2. (c)

3. (d)

4. (b)

Correct Answer: 1. (a) + (b)

Poll Questions


5959

Question 2: Assessment of a newly admitted recipient with

developmental disabilities takes into consideration:

� (a) The recipient’s communication skills

� (b) The recipient’s functional level

� (c) The recipient’s living environment

� (d) The recipient’s physical status

Answers: 1. (b) + (c)

2. (c)

3. (a)

4. All of the above

Correct Answer: 4. All of the above

Poll Questions


6060

Question 3: You are conducting a group with five recipients who

have developmental disabilities and one recipient suddenly and

for the first time is screaming, acting out, and aggressive. The

most likely explanation could be:

(a) Dementia

(b) Infection

(c) Environment

(d) Allergy

Answers: 1. (b) + (c)

2 (c)

3. (a)

4. All of the above

Correct Answer: 2. (c)

Poll Questions

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Question 4: When giving directions to recipients with

developmental disabilities and they are resisting assistance:

� (a) Repeat what they should be doing until they comply.

� (b) Distract with something they like to do then slowly reintroduce

assistance.

� (c) Express approval verbally and with appropriate facial expressions.

� (d) Carefully explain three problems with what they are doing.

Answers: 1. (a)

2. (b)

3. (c)

4. (d)

Correct Answer: 2. (b)

Poll Questions


6262

Question 5: Regarding medications commonly used with people

with developmental disabilities:

� (a) There are a variety of medications specifically indicated for treatment of

developmental disabilities.

� (b) Medications treat the various symptoms but are not indicated for the

disability.

� (c) Indications are not relevant when discussing medications.

� (d) No medications are commonly used exclusively for those with

developmental disabilities.

Answers: 1. (a)

2. (b)

3. (c) + (d)

4. (d)

Correct Answer: 2

Poll Questions


6363

At the conclusion of the webinar, please fill out the

survey that will pop up in your internet browser.

If you don’t see the survey, please follow the link in the

follow-up email that you will receive tomorrow.

Evaluation Survey

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6464

Lisa Zimmerman

[email protected]

(518) 449-2976

Questions / Comments?

Pain: Module 3 · 2014. 4. 24. · Pain: Module 3 Dr. Eileen Trigoboff & Dr. Daniel Trigoboff 6 16 No treatments are available specifically for cognitive deficiency Pharmacologic

Documents