2014 Conference Presentation (C1) Dement[...]

All Dementias are not Created Equal
Monica Tegeler, MD
Assistant professor of clinical medicine
IU Geriatrics
September 22, 2014
◦ 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
Dementia ≠ Alzheimer’s
Other: FTD, LBD,
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
 Gradual decline over the past 2 years per
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
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
 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
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
 (According to LTC pharmacy guidelines,
not FDA approved, has “black box”
Case 2
75 y/o AAF s/p CVA with Lt hemiparesis,
 Abrupt cognitive decline after CVA 6 mos.
ago but short term memory relatively
 Repeatedly asks “Where is Jane?”(her
Vascular Dementia - MRI
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
Repetitive Actions/Words
◦ 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
 walks quickly with head down, doesn’t
Fronto-Temporal 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
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
 Behavior Modification +/- medications
 Often need secure behavior unit with
close supervision
Inappropriate Sexual Behavior Management
Separate male & female residents during social
 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
 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
Characteristics of Alcoholic
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
 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.
People with dementia can sense a
caregiver’s anger/frustration and react
 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
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
What do these people have in
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
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,
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
Nurse Calls
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
 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
 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
Rule out potential medical causes
Must be individualized (cognitive & physical
fn, personality, interests, preferred routines)
Consistently carried out
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
 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
Alzheimer’s Vascular
Lewy Body
< 60 y/o
Depends on
area affected
Apathy Behavior
Rare early
Depends on
area affected
Progression Gradual
8-10 yrs.
5 years
faster than DAT
Gradual, faster
than DAT
Small vessel
ischemic dz
Possible atrophy
Atrophy frontal
& temporal
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
Additional Resources
Hand in Hand
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 &
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
Ballard, Lana, Theodoulou, et al. A Randomised, Blinded,
Placebo-Controlled Trial in Dementia Patients Continuing or
Stopping Neuroleptics (The DART-AD Trial). PLoS Med.
Brackey J: Creating Moments of Joy. Purdue University Press,
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
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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.
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 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
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 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
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
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