Vanderbilt & Qsource Webinar Series disturbance, ... . ... Fluctuating cognition with pronounced variations in

Vanderbilt & Qsource Webinar Series

Vanderbilt University Medical Center

Vanderbilt University Center

for Quality Aging Qsource

Session #2: Dementia & Behavioral Disturbances

Session #3: Psychopharmacology in the Nursing Home

Session #4: Principles of Non-pharmacologic Management & the Formulation of Behavioral Care Plans

Session #5: The Implementation of Behavioral Strategies & the Management of Pharmacologic Interventions

Session #6: Addressing Barriers to Change: the Perspective of Psychiatry, Nursing, and Medical Directors

Chat Monitor: Britt Kuertz, RDN [email protected]

615-936-1499

Moderator: Emily Hollingsworth, MSW [email protected]

615-936-2718

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(Please answer in the chat pane, and be sure to include your full facility name)

Paul Newhouse, MD

Paul Newhouse, MD Director, Vanderbilt Center

for Cognitive Medicine,

Jim Turner Chair in Cognitive Disorders

Department of Psychiatry,

Vanderbilt University

Become familiar with common dementing disorders and their clinical symptoms.

Describe common behavioral problems in dementia

Understand the context in which behavioral disturbances occur in dementia patients

Auguste Deter

November, 1902

Her condition steadily deteriorates despite treatment with memory loss, speech difficulty, confusion, suspicion, agitation, wandering and screaming to becoming bedridden, incontinent, and unaware of her surroundings.

She dies and her brain is sent for

autopsy by… Dr Alois Alzheimer

Recently, her tissue was reexamined and found to show a rare familial Alzheimer’s Disease gene mutation (PS1).

Clinical Picture of Behavioral Problems in Dementia

A 51 year old , A.D. is admitted to the long-

term care facility for being unmanageable

at home..

Her husband reports that she has loss of

memory, delusions, and temporary

vegetative states. She will drag sheets

across the house, and scream for hours

in the middle of the night.

On examination, she has a cluster of

symptoms that include reduced

comprehension and memory, as well as

language disturbance, disorientation,

unpredictable behavior, paranoia,

auditory hallucinations, and severe

social impairment.

Alzheimer’s disease (AD) refers to the neurodegenerative brain disorder regardless of clinical status

AD can be conceptualized as

having two major stages

Preclinical (presymptomatic)

Symptomatic

Prodromal (MCI)

Dementia of the Alzheimer type

Dr Alois Alzheimer

More Recent Cases of Alzheimer’s Disease

Thursday, March 19, 15

16

A global impairment of higher cortical functions including memory, capacity to

solve problems of daily living, performance of learned perceptuomotor skills, correct use of social skills and control of emotional reactions.

Multiple Cognitive Deficits:

Memory dysfunction: especially new learning, a prominent early symptom

At least one additional cognitive deficit

aphasia, apraxia, agnosia, or executive dysfunction

Cognitive Disturbances must be sufficiently severe to cause impairment

of occupational or social functioning

Must represent a decline from a previous level of functioning

Symptom

Trouble remembering new information 46%

Difficulty with complicated tasks 27%

Trouble responding to problems 14%

Frequently getting lost or trouble staying oriented 18%

Trouble expressing thoughts, ideas, or following conversations

21%

Change in personality or behavior 25%

CHS Alzheimer’s Disease Caregiver Project: Wave 6, 2000

Co

gn

itiv

e f

un

ctio

n

•Forgetfulness

•Repetitive questions

•Daily function impaired

•Progression of cognitive deficits

•Short-term memory loss

•Word-finding difficulties

•Agitation

•Altered sleep patterns

•Total dependence: dressing, feeding, bathing

MCI

MMSE 24–30 Mild AD

MMSE 20–23

Moderate

AD

MMSE 10–19

Severe AD

MMSE 0–9

•Mild subjective/objective memory loss

•Normal function

10 y 0 y

Time (y)

Time?

MILD STAGE

Forgetfulness, difficulty learning new information

Difficulty planning meals, managing finances, taking medications on schedule

Symptoms sometimes mistaken for depression

Ability to perform activities of daily living (ADL) usually maintained

Sources: Galasko D. Eur J Neurol. 1998;5(suppl 4):S9-S17. Cefalu C, Grossberg GT. Diagnosis and Management of Dementia. Leawood, Kan: American Academy of Family Physicians; 2001.

MODERATE STAGE

Short- and Long- term memory impairment

Difficulty performing tasks (e.g., following written notes, using the shower or toilet)

Agitation, behavioral symptoms appear (e.g., restlessness, wandering, delusions, hallucinations)

Deficits in intellect and reasoning (e.g., poor judgment, forgets manners)

Sources: Galasko D. Eur J Neurol. 1998;5(suppl 4):S9-S17. National Institute on Aging Alzheimer’s Disease Education and Referral Center. Available at: http://www.alzheimers.org/unraveling/unraveling.pdf. Accessed April 6, 2005.

SEVERE STAGE May lose language function and

mumble or speech may be unintelligible

Behavioral symptoms common (e.g., refuses to eat, cries out inappropriately)

Failure to recognize family or faces

Difficulty with all essential ADL (e.g., eating, toileting, walking)

Source: Gwyther LP. Caring for People With Alzheimer’s Disease: A Manual for Facility Staff. 2nd ed.

Washington, DC and Chicago, Ill: American Health Care Association and the Alzheimer’s Association; 2001.

Act

ivit

ies

of

Da

ily

Liv

ing

Progressive Loss of Function MMSE Score

Keep Appointments

Use the Telephone

Obtain Meal/Snack

Travel Alone

Use Home Appliances

Find Belongings

Select Clothes

Dress

Groom

25 20 15 10 5 0

0 2 4 6 8 10 Years

Maintain Hobby

Dispose of Litter

Clear Table

Walk

Eat

Mild Moderate Severe

Adapted from Galasko D, et al. Eur J Neurol. 1998;5(suppl 4):S9-S17.

Safety (driving, compliance, cooking, etc.)

Family stress and misunderstanding (blame, denial)

Early education of caregivers of how to handle patient (choices, getting started)

Advance planning while patient is competent (will, proxy, power of attorney, advance directives)

Specific treatments: May slow underlying disease process, (disease-modifying

treatments now under study) Standard treatment may delay nursing home placement longer if

started earlier May slow conversion from Mild Cognitive Impairment to AD

Patient initially diagnosed with AD

Patient’s first diagnosis other than AD

Yes 28%

No 72%

21%

7%

9%

14%

14%

35%

Normal aging

Depression No diagnosis

Dementia (not AD) Stroke

Other Source: Consumer Health Sciences, LLC. Alzheimer’s Caregiver Project. 1999.

Clinical features of FTD include

decline in personal hygiene and grooming,

mental rigidity and inflexibility, distractibility and impersistence,

hyperorality and dietary changes,

perseverative and stereotyped behavior, and utilization behavior

Common cause of early onset dementia 1:1 with AD 45-64 years More common than AD below

60 years

Lack of concern for loved one’s illness Cruelty to children, animals, elderly Lack of concern when others are sad Rude comments to others Lose respect for intrapersonal space “Disgusting” behaviors Diminished response to pain

Presence of dementia, gait/balance disorder, prominent hallucinations and delusions, sensitivity to traditional antipsychotics, and fluctuations in alertness

Neuropsychological tests do not reliably differentiate DLB from AD

Brain shows cortical Lewy bodies (alpha synuclein)

Fluctuating cognition with pronounced variations in attention and alertness Occurs in 80-90% of DLB, only 20% of AD

Recurrent visual hallucinations that are typically well

formed and detailed ▪ can involve scenes and bizarre situations

▪ can start with misinterpretations and are usually short

▪ often occur at night

Spontaneous motor features of parkinsonism: slow

gait, increased muscle tone, tremor

1. Preserve cognition and reduce decline

2. Maintain quality of life

3. Maximize function and maintain dignity

4. Treat mood and behavior problems

5. Refer, educate, and counsel

Source: Cefalu C, Grossberg GT. Diagnosis and Management of Dementia. Leawood, Kan: American Academy of Family Physicians; 2001.

Management Goals

Cholinesterase inhibitors are the mainstay of therapy

3 oral drugs currently on the market

Though some patients experience immediate improvement, most prominent effect is cognitive stabilization

Functional improvement may follow cognitive enhancement or stabilization

Positive effects of these agents appear to be sustained but fade over long periods

(Secondary Prevention)

Feldman et al. Poster presented at the 8th International Montreal/Springfield Symposium on Advances in Alzheimer Therapy, 2004

. Neuropsychiatric Inventory total

score (NPI) (n ~ 96) Holmes et al, 2004

.Randomization to donepezil

continuation or placebo

Significant differences were observed for the domains of depression, anxiety, and apathy (P.0166).

Adapted with permission from Feldman et al. Neurology. 2001;57:613-620. Gauthier et al. Int Psychogeriatr. 2002;14:389-404.

0

Endpoint

4

12

18

8

24

P=.0303

P=.0083 P=.0005

Clinical improvement

Clinical decline

-8

-6

-4

-2

0

2

4

Study week

To

tal N

PI c

ha

ng

e f

rom

ba

seli

ne

Aricept (n=144)

Placebo (n=146)

Most common reason for institutional placement

Agitation is the most common reason for

psychiatric consultation

In study by Cummings, only 12% of patients did

not have a behavioral problem.

Most common reason for caregiver distress

Jots, B. C. and Grossberg, G. T. (1996) The evolution of psychiatric symptoms in Alzheimer’s disease: a natural history study. J. Am. Geriatr. Soc. 44, 1078–1081

Apathy: Decreased motivation, indifference

Disrupted Mood: Depression, mania-like.

Psychosis: 50-70% of patients; paranoia, visual hallucinations

Agitation: Caused by anxiety or psychosis

Aggression: Loss of impulse control

Wandering: Searching, disorientation

APATHY

Most common behavioral change

Decreased motivation, indifference

Associated with frontal hypoperfusion

(medial frontal, supraorbital, anterior

frontal areas)

Not related to depression

Cummings 1998

PSYCHOTIC SYMPTOMS

Cross sectional studies: 20-50% Longitudinal studies: 50-70% Common Delusions: theft,

infidelity, pseudo-Capgras-type delusion (thinking spouse or family member is someone else), phantom boarder.

Hallucinations tend to be visual

rather than auditory Cummings 1998

Patients with dementia experience both hallucinations and delusions

Usually less complex than the delusions seen in schizophrenia or mood disorder

Common delusions in dementia:

Belief that one’s belongings have been stolen

Conviction that one is being persecuted

Belief that one’s spouse is unfaithful

MOOD CHANGES

Mood symptoms are frequent and

may be secondary to impairment of

mood regulatory systems in the

brain (e.g. emotional incontinence)

Major depressive disorder (MDD) is uncommon

MDD may precede diagnosis of Alzheimer’s disease or vascular dementia

Cummings 1998

AGITATION Excessive motor or verbal activity that is:

Disruptive OR

Unsafe OR

Distressing to the patient

Interferes with care and

Is not because of need

Appears similar despite great variety of causes

Cohen-Mansfield et al., 1996; Tariot et al., 1994

AGITATION ▪ Correlates with anxiety in mildly demented

patients

Correlates with psychosis in moderately

demented patients

Correlation to breakdown of mood and/or behavioral regulation in severely demented patients

Modified from Cummings 1998

SUNDOWNING

Agitation associated with late

afternoon or evening

Causes:

Fatigue

Circadian factors

Lack of sensory stimulation

Need for security, protection

Modified from Reichman et al

WANDERING

Disorientation

Restlessness

Searching

Sundowning

Fear

Medication-induced akathisia

Modified from Reichman et al

AGGRESSIVITY Can be in response to environment or spontaneous

Verbal and physical

Can occur without delusions or hallucinations

May be resistant to conventional pharmacotherapy

Which of the following is not a common behavioral symptom in Alzheimer's disease?

A. Apathy

B. Psychosis

C. Aggression

D. Shaking

E. Fear

F. Anxiety

Fear - disorientation,

abandonment,

confusion

Over-stimulation

Lowered frustration

tolerance

Loss of impulse control

Inability to recognize

family, caregivers

Disorientation to time

or place

Disrupted routine

Forgetting of appropriate behaviors

Modified from Reichman et al

Personal Pain Sensory Loss Infection Psychosis

Environmental

Transfers Personal Care/Bathing Family Visits Medications

Chronological Awakening Late Afternoon Meal Times Bedtime Middle of the Night

Modified from Reichman et al

Unmet physical needs?

Pain?

Infection/illness?

Thirsty? Hungry? Tired?

Sleep disturbance?

Medication side effects?

Sensory impairment?

Constipation?

Incontinence?

Unmet psychological needs?

Loneliness, boredom?

Apprehension, fear, worry?

Emotional discomfort?

Lack of enjoyable activities?

Lack of socialization?

Loss of intimacy?

Cause related to social environmental?

Too many people, too much noise?

Too little to do?

Expectations for performance

are too high?

Communication is unclear?

Caregiver approaches aren’t adjusted to level of ability?

Cause related to physical environment?

Physical surroundings are not

“understandable”?

TV, radio, PA systems confusing?

Pictures, photographs,

reflections misunderstood?

Lacks appropriate signage or

cues to way-find, be independent?

Lacks meaningful activities?

Lacks natural walking paths, daily exercise?

Cause related to other Psychiatric illness?

Depression?

Anxiety?

Delirium?

Psychosis?

Other mental illness?

Overlapping syndromes are common!!

Altered or fluctuating level of alertness

Sudden change in behavior suggests delirium

Acute or subacute onset

Look for infection, new medications, and any anticholinergic medications

Dementia patient is VERY susceptible to delirium

Abrupt changes in behavior in a previously stable patient with dementia may indicate:

A. Delirium

B. Infection

C. Metabolic disturbance

D. Drug interaction

E. All of the above

Agitation should be assessed for causative factors

A. TRUE

B. FALSE

Dementia is a syndrome: Most common cause is Alzheimer’s Disease

Other dementias with behavioral disturbances include Fronto-temporal dementia, Lewy-Body dementia, vascular dementia

Behavioral disturbances are a core feature of dementia and can be expected in most patients

The context (environmental, personal, physical, psychological) will often determine whether and how behavioral disturbances are expressed

There will be a second presentation of Session #2 on Wednesday,

November 18th at 10AM CST (11AM EST)

Two options for attending Session #3:

• December 15th (Tuesday) 1pm CST • December 16th (Wednesday) 10am CST

Emily Hollingsworth [email protected]

Britt Kuertz [email protected] Project Website: www.VanderbiltAntipsychoticReduction.org Vanderbilt Center for Quality Aging 615-936-1499

www.vanderbiltcqa.org for other resources