All Dementias are not Created Equal Monica Tegeler, MD Assistant professor of clinical medicine IU Geriatrics September 22, 2014 Objectives ◦ Identify “behaviors” as communication. ◦ Distinguish behaviors that suggest “come to me” (repetitive statements, yelling) vs. behaviors that suggest “get away” (hitting, biting, kicking). ◦ List three broad categories of dementia (Alzheimer’s,Vascular, other). Dementia: True or False ? T/F Memory problems is the only criteria for diagnosis of dementia.  T/F Dementia is a part of normal aging.  T/F Prevalence of dementia increases with age - >40% by age 85  T/F Dementia is a terminal illness like cancer.  Dementia ≠ Alzheimer’s Alzheimer’s Other: FTD, LBD, Vascular alcoholic, Parkinson’s, anoxic brain injury, Huntington’s, TBI “Behaviors” as communication  Must identify the unmet need  “Get Away from me!” ◦ Hitting, biting, kicking, screaming  “Come to me!” ◦ “help me” or other repetitive vocalizations, repetitive questions Case 1 72 y/o WF c/o bugs coming into the chimney and believes husband is having an affair, cries all the time  Clothes are on backwards and inside out  Gait is normal, wears glasses, no hearing aids  Gradual decline over the past 2 years per spouse  Cross-section Alzheimer’s brain Progression of Alzheimer’s Characteristic features DAT Memory problems – short term then long term (regression)  Imaging shows cerebral atrophy  Gradual progression over time  Course of disease 6 yrs. on average (less if onset < 65 y/o, large variability)  Treatment of Alzheimer’s  Acetyl cholinesterase inhibitors  Improve 2 points on 70 point research scale, does NOT translate to improved clinical function Significant side effects: diarrhea, weight loss, abnormal dreams Memantine/Namenda – not indicated w/o cholinesterase inhibitor   ◦ Donepezil ◦ Rivastigmine ◦ Galantamine Hallucinations, Paranoia, Delusions Hallucinations – usually visual or auditory ◦ Bugs crawling on skin (not seen by others) ◦ If not bothersome to pt, best ignored/accepted  Paranoia – unrealistic, blaming beliefs ◦ Pt believes someone stole her purse/his wallet (when in fact he/she hid it & can’t locate now)  Delusions – beliefs contrary to fact ◦ Pt states faithful spouse is having an affair ◦ Don’t confront person or play along; give a noncommittal answer  Suggestions for Hallucinations/paranoia/delusions Avoid denying the person’s experience or directly confronting him/her or arguing with the person.  Increase lighting, glasses on (hearing aids)  Respond to general feelings of loss  Distractions – music, exercise, cards, photos, pets, drawing, social activities  Paranoia: Management Understand that this is not behavior the patient can control.  Do not confront the patient or argue about the truthfulness of the complaint.  Distract the patient with other activities.  Consider medication intervention.  Antipsychotic for Case 1? “Approved” for delusions, visual hallucinations, paranoia IF  Presents danger to self/others – in this case crying all the time  AND behavior interventions tried and failed  (According to LTC pharmacy guidelines, not FDA approved, has “black box” warning)  Case 2 75 y/o AAF s/p CVA with Lt hemiparesis, HTN, CAD  Abrupt cognitive decline after CVA 6 mos. ago but short term memory relatively good  Repeatedly asks “Where is Jane?”(her daughter)  Vascular Dementia - MRI Severe Moderate Mild http://www.dementiacarecentral.com/aboutdementia/vasculardementia/symptoms Characteristics of VaD Stepwise progression  Cognitive impairment depends on area of brain affected  Imaging shows moderate-severe chronic small vessel ischemic disease OR multiple large vessel strokes  Course of disease 5 years on average  Treatment of Vascular Dementia  Similar to cardiovascular disease ◦ Aspirin ◦ Cholesterol lowering medications  Acetyl cholinesterase inhibitors are often prescribed but benefit is similar to DAT Repetitive Actions/Words Parts of bodies, other people, objects can represent significant people or events from past  May be trying to express a feeling  Body movements replace speech  Need to link the need to the behavior ◦ Former carpenter banging fist is hammering nails  Repetitive Actions/Words Avoid: ◦ Telling her to stop ◦ Asking why she is doing it  Suggestions: ◦ Occupy the person’s hand with an activity, doll, stuffed animal, ball ◦ Give her full attention and respond to emotional needs (affection, loneliness) ◦ Distract with food, music, exercise  Antipsychotic for Case 2?  Not indicated for repetitive actions/words when not causing danger to self or others Case 3 65 y/o WM disrobes in hallway, urinates on floor, difficulty following simple commands,  walks quickly with head down, doesn’t speak  Fronto-Temporal Dementia http://medlibes.com/entry/frontotemporal-dementia Characteristics of FTD (behavioral variant)  Impulsive (disinhibited) ◦ an increased interest in sex        Lack of social tact (loss of insight into the behaviors of oneself and others) Lack of empathy Distractibility Agitation or, conversely, blunted emotions Neglect of personal hygiene Repetitive or compulsive behavior Decreased energy and motivation (apathy) Treatment of FTD Acetyl cholinesterase inhibitors not indicated/effective  Behavior Modification +/- medications  Often need secure behavior unit with close supervision  Inappropriate Sexual Behavior Management Separate male & female residents during social interactions  Consider same gender staff for personal care  Educate family and encourage physical affection (hugging, hand holding, etc.)  Don’t overreact. Lead pt calmly out of the area or provide a robe & help put it on.  Inappropriate Sexual Behavior: cont. Clothing that opens/closes in the back and pants that pull on versus zipping in the front. These can often stop undressing or fidgeting with clothing.  For masturbation: provide patient privacy or attempt to distract the patient by giving him/her a different activity.  Antipsychotic for Case 3? Not first line treatment for FTD or sexual behaviors and in general not effective  Consider SSRIs (side effect is sexual dysfunction) or Depo Provera – both are off-label use – if behavior interventions ineffective and danger to others  Famous People w/ Dementia Case 4 65 y/o AAM frequently requests key to leave building and buy cigarettes and alcohol  intermittently agitated, CNA attempts to remove clothing protector while standing behind him and he hits her  Later – CNA finds pt w/ fecal INC in room, offer to assist is refused, CNA backing out when pt pulls plastic glove box holder off wall and throws it at her  Cross-section Alcoholic Dementia http://www.protect-and-boost-your-brain.com/Alcohol-Brain-Damage.html Characteristics of Alcoholic Dementia       A clinical diagnosis of dementia at least 60 days after the last exposure to alcohol Significant alcohol use - minimum average of 35 standard drinks/week for men (28 for women) for > 5 years With abstinence, the cognitive impairment stabilizes or improves (in younger patients) Associated liver, pancreas, stomach, heart, kidney problems Cerebellar atrophy Ataxia or polyneuropathy Suggestions for Anger/Agitation Scenario 1 was provoked agitation (preventable)  Speak with a reassuring and gentle voice to the patient.  Approach slowly & calmly from the front. Tell the person what you are going to do and try not to startle them.  Use non-threatening postures when dealing with an agitated patient, try to be at the patient’s eye level.  Angry/Agitated People with dementia can sense a caregiver’s anger/frustration and react accordingly  Often a sign that the person is feeling loss of control of his/her life  If during personal care, leave room and return in few minutes with different approach.  Antipsychotic for Case 4? Not indicated if agitation was provoked (startling patient).  Could be indicated if agitation not provoked (scenario 2) and danger to self or others and behavior interventions unsuccessful.  What do these people have in common? Case 5 82 y/o WM sees small animals like rabbits and snakes in his room (bothered by snakes, not rabbits)  Gradual cognitive decline per family  Propels self down hallway repeatedly during the day and sometimes at night  Cogwheeling of both arms  Parkinson’s features Wandering May be due to searching for a part of life lost to disease or for a person, place, object of past  May be coping mechanism to relieve stress and tension  Might reflect former schedule or routine  Suggestions for Wandering      Direct person to labeled rooms (bedroom, toilet) Decrease noise levels and number of people interacting at one time Exercise/walk daily Redirect with food, conversation, activity rather than directly confront. “Bob, where have you been? I have been looking all over for you.” Antipsychotic for Case 5? Visual hallucinations common with LBD/DLB and side effect of some Parkinson’s medications  Antipsychotics often make LBD worse  Not indicated for VH that don’t bother the patient  Not indicated for wandering – no danger to self or others  Using Antipsychotics for Dementia? Current Model Poor Caregiver approach Nurse Calls provider Antipsychotic medication Rx’d • Timing, context • Negative pt response, more staff respond • Responds to staff frustration • Lack of knowledge of behavior approaches • Side effects – confusion, falls, death, etc. • State tags, financial penalties, “poor care” Severity of Behavior Minimal Risk or rarely socially disruptive: anxiety, safe wandering  Slight risk or sometimes socially disruptive: throwing food, mild verbal abuse  Moderate risk or often socially disruptive: intrusive, wandering unsafely  Major risk or always socially disruptive: defecating in public, violent  Behavioral or Psychological Sxs of Dementia (BPSD)   Symptoms present danger to resident (fear, continuous yelling/screaming/crying, weight loss, skin breakdown) or others (violent, sexual aggression ) AND one or both: ◦ Sxs identified as being due to mania or psychosis (hallucinations, delusions, paranoia) ◦ Behavioral interventions attempted and included in plan of care (except emergencies) Inadequate indications Wandering  Restless/fidgeting  Apathy  Impaired memory  Mild anxiety/nervousness  Insomnia  Refusal of personal care  Verbal expressions/behaviors not a danger to self or others  Care Plan Documentation       Indication/rationale for use – specific target behaviors & expected outcomes Dosage, duration, plans for GDR Monitoring for efficacy and/or adverse reactions Rule out potential medical causes Must be individualized (cognitive & physical fn, personality, interests, preferred routines) Consistently carried out Example      Bob is a former mechanic who loves working with his hands Being in large crowds causes him to become anxious and tear his shirt He likes chocolate chip cookies, apple juice, and Snickers. He prefers to sleep in until 0800 and go to bed at 2200. He prefers female caregivers and showers not baths. Suggested interventions for Bob Avoid large crowds – place near door for activities  Offer chocolate chip cookies when upset  Distract with hands on activities – removing bolts from board, tabletop pool table, etc.  Ongoing documentation Document (checklist by shift) presence or absence of specific behavior  If none documented for 3-6 mos., consider GDR or clearly document why not doing a GDR (multiple failed attempts, required inpt psych stay, etc.)  If no improvement in specific behavior with addition of medication, medication should be d/c’d  Antipsychotics - suggestions      Determine what the pt is trying to communicate Ask family/caregivers for more info. Prescribe environmental modifications as 1st, 2nd, 3rd line management (redirect, remove from situation, change staff member, offer alternative, offer treat) If antipsychotics prescribed, use monitoring tools for benefits, side effects, and GDRs Use Tylenol approach (use when needed, then d/c when need is over) Comparing Different Types of Dementia Alzheimer’s Vascular Lewy Body FTD Onset Gradual Sudden, stepwise Gradual Gradual < 60 y/o Cognitive Symptoms Primarily memory Depends on area affected Hallucinations Fluctuations Visual-spatial Disinhibition Apathy Behavior changes Motor Symptoms Rare early Depends on area affected Parkinsonism None Progression Gradual 8-10 yrs. Stepwise 5 years Gradual, faster than DAT Gradual, faster than DAT Imaging Small vessel ischemic dz Possible atrophy Atrophy frontal & temporal Global atrophy Algorithm for treating behaviors Step 1: identify, assess, treat antecedents and triggers  Step 2: apply non-drug interventions  Step 3: monitor outcomes & adjust as needed, consider antipsychotic for persistent and severe cases that meet criteria  Additional Resources Hand in Hand        http://www.cms-handinhandtoolkit.info/ 1. Understanding the World of Dementia: The Person & the Disease 2. What is Abuse 3. Being with a person w/ Dementia: Listening & Speaking 4. Being w/ a Person w/ Dementia: Actions & Reactions 5. Preventing Abuse 6. Being with a person with Dementia: Making a difference Teepa Snow Teepa Snow  www.teepasnow.com  Its All in Your Approach (DVD)  Progression of Dementia - Seeing Gems - Not Just Loss (DVD)  References       Ballard, Lana, Theodoulou, et al. A Randomised, Blinded, Placebo-Controlled Trial in Dementia Patients Continuing or Stopping Neuroleptics (The DART-AD Trial). PLoS Med. 2008;5(4):e76. Brackey J: Creating Moments of Joy. Purdue University Press, 2007. Feil N: The Validation Breakthrough: Simple Techniques for Communicating with People with “Alzheimer’s-Type Dementia.” Health Professions Press, 2002. Fitzpatrick AL. Survival following dementia onset: Alzheimer's disease and vascular dementia. J Neurol Sci. 2005 Mar 15;229-230:43-9. Geriatric Review Syllabus Jeste, Blazer, Casey, et al. ACNP White Paper: Update on Use of Antipsychotic Drugs in Elderly Persons with Dementia. Neuropsychopharmacology. 2008; 33(5): 957–970. References, cont. Maher, Maglione, Bagley, et al. Efficacy and Comparative Effectiveness of Atypical Antipsychotic Medications for OffLabel Uses in Adults: A Systematic Review and Meta-analysis. JAMA. 2011; 306 (12): 1359-1369.  McKhann GM, Knopman DS. The diagnosis of dementia due to Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimers Dement. 2011; 7(3): 263–269.  Oslin, D, Atkinson RM. Alcohol Related Dementia: Proposed Clinical Criteria. International Journal of Geriatric Psychiatry. 1998; 13: 203-212.  Revised S.O.M. Interpretive guidelines/Surveyor Guidance (2013)  References, cont.     Robinson A, Spencer B, White L: Understanding Difficult Behaviors: some practical suggestions for coping with Alzheimer’s Disease and related illnesses. Eastern Michigan University, 1989. Salzman, Jeste, Meyer, et al. Elderly Patients with Dementia-Related Symptoms of Severe Agitation and Aggression: Consensus Statement on Treatment Options, Clinical Trials Methodology, and Policy. J Clin Psychiatry. 2008; 69(6): 889–898. Schneider, Dagerman, Insel. Risk of Death With Atypical Antipsychotic Drug Treatment for Dementia Meta-analysis of Randomized PlaceboControlled Trials. JAMA. 2005; 294(15): 1934-1943. Schneider, Dagerman, Insel. Efficacy and Adverse Effects of Atypical Antipsychotics for Dementia: Meta-analysis of Randomized, PlaceboControlled Trials. Am J Geriatr Psychiatry. 2006; 14(3): 191-210