Behavioral Disturbances of DEMENTIA: Interventions to Reduce the Use of Psychotropic Medications - Drs. Michele Tomas and Andrew Heck (March 28, 2013)

1. Behavioral Disturbances of
DEMENTIA:
Interventions to Reduce the Use of
Psychotropic Medications
MICHELE THOMAS ANDREW HECK
Pharmacy Services Manager Clinical Director
Virginia Department of Piedmont Geriatric Hospital,
Behavioral Health, Virginia Department of
Developmental Services Behavioral Health,
Developmental Services
(c) 2013 by the authors, on behalf of the Virginia Geriatric Mental Health Partnership & made possible through a grant from the Virginia Center on Aging's Geriatric Training Education
Initiative and supported by the Riverside Center for Excellence in Aging and Lifelong Health, the Virginia Geriatric Mental Health Partnership, and the VCU's Department of Gerontology.

2. ABBREVIATION DETAIL
ADE Adverse Drug Effects
ADL Activities of Daily Living
ALF Assisted Living Facility
BPSD Behavioral and Psychological Symptoms of Dementia
CMS Centers for Medicare & Medicaid Services
GDR Gradual Dose Reduction
LTC Long Term Care
LTCF Long Term Care Facility
Sx Symptoms
ABBREVIATIONS

3. By the end of the
presentation,
participants will:
Learn about appropriate
use of antipsychotic
medications in individuals
diagnosed with problematic
Be able to more clearly
behaviors in dementia
describe Behavioral and
Psychological Symptoms of
Dementia, (problematic Become familiar with
behaviors, [BPSD or BPSD nonpharmacological strategies for
Sx’s]) and possible triggers; preventing and/or reducing
problematic behaviors;
Objectives

4. The patient is an 84 year old white female newly admitted to a LTC setting
exhibiting the following signs and symptoms:
• two to three year history of increasing forgetfulness
• Increased wandering and elopement attempts
• distractibility
• repetitive requests calling out for her husband
• intrusiveness
• resistance to personal care
• language deficits.
Ms. Take (MT)
Over the next few weeks at the LTCF, MT declined.
She:
• no longer recognized her husband
• exhibited repetitive behaviors
• verbalized suspicious statements about husband’s
whereabouts
• exhibited increased restlessness, and
Patient Intake & • began experiencing persistent nighttime
History wakefulness.
Case of Ms. Take (MT)

5. Common BPSD/Behaviors in Dementia
Aggression/Agitation Apathy Delusions Anxiety Psychomotor Disturbance
Up to 46%
72% 9-63% 48%
80%
Sleep/Wake
Hallucinations Physical Aggresion Irritability/Lability Depression/Dysphoria
Distburbance
4-41% 31-42% 42% 42% 38%
Disinhibition Sundowning Hypersexuality Obsessive/Compulsive
36% 18% 3% 2%
Jeste D, et al. Neuropsychopharmacology. 2008;33:957
Spalletta G, et al. Am J Geriatr Psychiatry. 2010;18:1026

6. Early(~0-3yrs) Mild-Mod(~3-5yrs) Severe(~6yrs)
Mood Cognition Behavior / Function
100 Agitation
80 Diurnal
rhythm
Depression
% patients
60
Irritability
Wandering Aggression
Social withdrawal
40 Anxiety Mood
Paranoia change Hallucinations
20 Socially unacceptable behavior
Suicidal ideation Accusatory Delusions
behavior Sexually inappropriate behavior
-40 -30 -20 10 0 10 20 30
months before dementia diagnosis / months after dementia diagnosis
Estimated Timeline of BPSD in Dementia
Jost BC, Grossberg GT. J Am Geriatr Soc. 1996;44:1078-1081
Brodaty et al. 2003. J. Clin Psychiatry 64:36.
http://www.ucc.ie/en/

7. POLL
Appropriate Antipsychotic Treatment targets include the
following:
(Check all that apply)
A. Distressing hallucinations
B. Physically aggressive behavior
C. Delusional jealousy
D. Anger over accepting assistance with ADL’s
POLL: CMS ―Approved‖ Indications for LTC Facilities

8. BPSD Clusters & Antipsychotic Medications
PSYCHOMOTOR
AGITATION
• Pacing
*AGGRESSION • Restlessness
• Physically aggressive • Repetitive actions
• Verbally aggressive • Dressing/undressing
• Aggressive resistance
MANIA • Sleep disturbance
to care • Euphoria
• Pressured Speech
• Irritable
*PSYCHOSIS
• Hallucinations
• Delusions
APATHY • Misidentifications
• Withdrawn DEPRESSION • Suspiciousness
• Lacks interest • Sad
• Amotivation • Tearful
• Hopeless
• Low self esteem
• Anxiety
• Guilt
Bugden. Antipsychotics and Dementia: Part of the Solution or Part of the Problem, Dementia Care Conf. 2012

9. Apathy
Calling out e.g., screaming
Most Hiding/hoarding
common Nocturnal restlessness
BPSD Repetitive activities e.g., pulling on locked doors, etc.
NOT Wandering
amenable to Unsociability
medication/ Poor self‐care
antipsychotic Uncooperativeness without aggressive behavior
medication Verbal expressions or behaviors that do not represent a danger
Nervousness / fidgeting / Mild anxiety
Impaired memory
Bugden. Antipsychotics and Dementia: Part of the Solution or Part of the Problem, Dementia Care Conf. 2012

10. • No FDA-approved medications to treat
dementia-related behavioral disturbances
• Medications utilized today, prescribed off-label:
• Typical & atypical antipsychotics
• Benzodiazepines
• Anticonvulsants
• Cholinesterase inhibitors
• NMDA receptor antagonist
• Selective serotonin reuptake inhibitors (SSRIs)
BPSD and Psychotropics
Lawrence RM et al, Psychiatric Bulletin. 2002;26:230

11. • 2005: FDA issued warning: 1.6 – 1.7 fold increase in mortality in
response to analysis of 17 placebo-controlled studies.
• 2010: Nearly 1/3 of elderly patients with dementia residing in nursing
homes are on atypical antipsychotics for BPSD even though..
Most episodes of BPSD appear as
single episode (~86%)
and
the average duration of each episode lasts
between ~9 to 19 months
BLACK BOX WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS
WITH DEMENTIA-RELATED PSYCHOSIS and SUICIDALITY …
*Antipsychotic drugs have increased risk of death…*
Jablow V. Trial. 2008;44:12
Recupero PR et al. J Psychiatric Pract. 2007;13:143

12. • HHS Initiative: National Partnership to Improve Dementia Care
• CMS’s initial goal to reduce unnecessary antipsychotic medication
use in all care settings.
• Goal:
Using person-
centered and
Unnecessary
By improving individualized
medication use
dementia care interventions for
will decrease.
behavioral health
in nursing homes
Antipsychotics are the initial focus of the partnership, however attention to other
potentially harmful medications is also part of this initiative.
§483.25(l) Unnecessary Drugs
Each resident’s drug regimen must be free from unnecessary drugs
(F329)

13. National prevalence Initiative: Reduce the
rate of antipsychotic national rate by 15%
medication use in
long-stay residents
23.9%
This number includes all residents .
2012 GOAL
in NH’s EXCEPT persons
diagnosed with Schizophrenia, 2013 GOALs?
Tourette’s Syndrome or
Huntington’s disease Reevaluate
. based on 2012
4th quarter
findings
First Year Goals

14. • Effective interventions follow thorough assessments
aimed at the problem’s specific cause
• Management of BPSD must be comprehensive and
systematic
• Successful BPSD management blends reactive and
proactive strategies
to experience
to feel safe
pleasure
Treatment of BPSD should begin with
nonpharmacological approaches keeping in to experience
minimal
mind five care goals for the patient with stress with
adequate
to feel
comfortable
dementia: positive
stimulation
to
experience a
sense of
control
BPSD: Need for Alternative Approaches in Treatment
Buhr GT, White HK. Difficult behaviors in long-term care patients with dementia. J Am Med Dir Assoc. 2006;7(3):181.
Ryden MB, Feldt KS. Goal-directed care: caring for aggressive nursing home residents with dementia. J Gerontol Nurs.
1992;18(11):35-42.

15. Is it:
Why is • only problematic for the
resident?
this • endangering/irritating/
upsetting to other
behavior a residents/family
members/visitors/staff?
• interfering with care?
problem?
• Focus resources towards behaviors that are dangerous or
cause marked distress to the resident or others
First Question in Identifying & Describing BPSD Behaviors

16. PRIORITY RISK AREAS
ROAMING?
IMMINENT PHYSICAL RISK (fire, falls, frailty?)
SUICIDE?
K INSHIP RELATIONSHIP ABUSE/NEGLECT?
SELF NEGLECT, SUBSTANCE ABUSE, SAFE DRIVING?
Risk Assessment: Taking Inventory

17. Static
Presence of delusions Depression
Impaired Low serotonin levels
communication
Psychosis; esp.
Frontotemporal command hallucinations
dementia and thought disorganization
Certain forms of Irritability
traumatic brain
damage
Dynamic
BPSD Example: Aggression Risk Factors
Heck, A. Aggressive behavior in the elderly: prevention and management.
Cross Country Education Seminar, 2006.

18. • Will want to know the following about the BPSD:
• Type
• Frequency
• Intensity
• Duration
• Functional analysis of behavior:
• an examination of what a behavior’s purpose (i.e., function) serves
for the individual
• Answers the ―what, where, when and how‖ questions
• Basic functional analyses can be performed by anyone clinically
familiar with the resident
Clarifying the BPSD

19. Behavior Behavior Behavior
Description Prediction Functions
did the behavior(s) What functions did the
what specific behavior(s) behavior(s) appear to
primarily occur during
occurred? serve for the person?
specific time periods?
What were the
were there periods when consequences that were
if >1 behavior, did any
the behavior(s) typically provided when
ever occur together?
consistently did not occur? the behavior(s) occurred?
when behavior(s) were occurring,
were there setting events or
stimuli which were consistently
related to their occurrence?
With answers to these questions, along with any baseline data gathered, clinicians may
begin to draw conclusions about the cause(s) and treatment of the problematic behavior
Clarifying the BPSD (cont.)

20. Health and medical conditions
E nvironment
Approach
Resident factors
• An ordered strategy for examining common sources of a behavior problem
The HEAR method

21. B12/Folic Acid Deficiency
dangerous causes of BPSD Sxs Infection (UTI/Pneumonia)
Hunger/Thirst
Most common and potentially
Nocturia
MEDICAL
Hypercalcemia
Pain
Hypothyroidism
Constipation
Digoxin
Anticholinergic agents Benzodiazepines
MEDICATIONS/DRUG INDUCED
DELIRIUM Opioids
Antihistamines
Health and Medical Conditions:
BPSD Common Causes and Trigger Factors
Bugden. Antipsychotics and Dementia: Part of the Solution or Part of the Problem, Dementia Care Conf. 2012

22. POLL
Delirium is a state of acute cognitive impairment caused by
a medical problem. Three primary cardinal features of
delirium are:
A. Acute/onset is days to weeks
B. Transient in severity often fluctuating throughout the
day for short periods of time
C. Reversible state of confusion
D. Most often irreversible state of confusion
POLL: Delirium

23. • The likelihood of developing delirium increases with age
• Three primary features to look for:
1. ACUTE
2. TRANSIENT (lasts only for a short time) and
3. REVERSIBLE state of confusion.
• Delirium diagnosis is often missed in up to 70% of cases
• This is especially concerning, since up to 60 % of elderly
individuals experience a delirium prior to or during a hospitalization
Delirium is Always an Acute Medical Emergency
Delirium
http://www.nlm.nih.gov/medlineplus/ency/article/000740.htm

24. DRUGS, DRUGS, DRUGS!
EYES, EARS –POOR HEARING AND VISION = RISK FACTORS
L OW O STATES (MI, CHF, COPD, acute respiratory distress syndrome)
2
I NFECTION, IMMOBILZATION
RETENTION (URINE/STOOL), RESTRAINTS
ICTAL—SEIZURES CAN CAUSE DELIRIUM
UNDERHYDRATION, UNDERNUTRITION
METABOLIC ABNORMALITIES
(s)UBDURAL, SLEEP DEPRIVATION
Common Causes of Delirium

25. 84 year old white female newly admitted to LTC setting exhibiting signs &
symptoms of:
• wandering
• elopement attempts
• distractibility at mealtime
• repetitive requests for husband
• intrusiveness
• resistance to personal care, and
MT • language deficits.
MT’s Husband MT’s current medications Adherence
• Staff talked with MT’s • Docusate 100mg bid • Prior to admission, Mr. Take
husband. He noted she constipation. reported that his wife’s dose
appeared more worried, • Oxybutynin 10mg XL daily of oxybutynin had been
apprehensive, fearful and incontinence. increased from 5mg to 10mg
she no longer recognized him but, he also stated that his
during their daily visits wife rarely took her
medications, let alone on a
regular basis...
Case Update: Ms. Take

26. • MT became more and more challenging exhibiting
increasing exit seeking behaviors; daytime
restlessness and pacing increased to where it
became extremely difficult for staff to redirect her
• She had periods of feeling exhausted, appearing
Ms. Take overly sedated or subdued; this resulted in
frequent daytime napping.
• MT also began exhibiting increased distractibility
and began refusing to eat. As a result, MT had an
eight pound weight loss.
MT: 30 Day Update

27. Orthopedic issues /
arthritis: feet (e.g.,
poorly fitting shoes), Is there
shoulder, back, knee, Dehydration/
etc
Nutritional Constipation, urinary
issues? retention / incontinence?
Musculoskeletal:
Joint pain?
HPE,
Vital Signs, Is there
Infection/
Is there Pain?
Labs Illness?
Eyes: Corneal
abrasion? as warranted
Sensory deficits?
Is the resident
Skin: Bed sores/ skin experiencing
lesions?
ADEs?
Evaluation: Are there any Physical Causes or Medication
Adverse Effects (ADE)?

28. **DELIRIUM**
Delirium Assessment
Labs: CBC, performed:
PE
electrolytes & U/A
MT was Positive
U/A >> Acute onset Sxs,
VS: fluctuating in
+orthostatic BUN relative course, and
hypotension; to SCr >>
+restlessness, Sp. Gravity>>
+poor a change in
3+ leuks & cognition,
attention
WBCs in urine (increasing difficulty in
focusing attention).
Findings: ANTICHOLINERGIC TOXICITY
"Compliance Toxicity”…due to increase in oxybutynin dose with
resultant anticholinergic load/toxicity
oxybutynin dose > oral intake > urinary retention >> bladder infection.
MT: Evaluation/Findings

29. • Definition:
• ANY ASPECTS OF AN INDIVIDUAL’S
SURROUNDINGS THAT INFLUENCE BPSD
• Both cognitively impaired and cognitively intact
individuals can be very sensitive to even minor
environmental irritants or changes
• Irritant/change + behavioral dyscontrol = potentially
harmful reaction!
• Environmental changes are recommended in most
circumstances
• No adverse effects
• Easy to implement
HEAR: Environmental Factors

30. • Common examples:
• Physical elements
• Highly patterned wallpaper
• Mirrors
• Noise and activity level
• Loud call bells/paging systems
• Constant Television Programs (e.g., Soap Operas, CNN)
• Space issues
• Frequent room changes/redesign
• Relocation (within or between facilities)
• Lack of adequate physical space
Environmental Factors cont.

31. Liberally attempt different environmental changes
(being sensitive to the amount of change the residents
strategies: can tolerate)
General
Try using soothing sounds
(ocean waves, babbling brooks, even white noise)
Scheduled walking or exercise programs have
demonstrated effectiveness in preventing and addressing
BPSD
Exposure to bright light can also be effective
(avoid in patients with a history of Bipolar Disorder)
Environmental Factors cont.

32. Providing
space to
freely wander
Brief gentle
Individualized
hand
music
massages Empirically
supported
interventions
to prevent/
manage
agitation
Use of
“gliding” Aromatherapy
rockers
Environmental Factors cont.
Landreville P et al. Intl Psychogeriatrics 2006;18
Rayner A et al. Am Fam Physician 2006; 73
Camp C et al. In Lichtenberg D et al., Handbook of dementia 2003; NY: Wiley & Sons

33. • 69 year old male with Alzheimer’s disease
• Has refused to leave room in past month; swings out at
staff who try to get him to come out for meals, activities
• Often observed to walk up to doorway, look at floor
beyond threshold, and retreat into room
• Staff discovered janitorial staff had recently changed to
Mr. a shinier wax for the hallway floors (looks slick?)
Faller
• Timing of change coincided with the emergence of
Mr. Faller’s behaviors
• Less shiny wax used, Mr. Faller was able to leave the
room with minimal difficulty soon afterward
Case Example: Mr. Faller

34. • Definition:
• THE METHOD(S) BY WHICH INDIVIDUALS ARE ADDRESSED
BY THEIR CAREGIVERS THAT CAN INFLUENCE BPSD
• Can include physical, verbal, nonverbal, schedule/routine
issues, etc.
Common
examples
Stance and Physical touch Erratic or
Violations of Caregiver Verbal
positioning (esp. during unpredictable
personal space attitude/reactions approaches
issues ADLs) daily structure
HEAR: Approach Factors

35. Emphasize lack of intentionality of resident behaviors
Educate about signs and symptoms of dementia
Staff training
Teach communication skills (below)
Train on proper physical approach to physical contact-based tasks
(e.g., ADLs)
Use short phrases that express one major idea at a time
Use closed-ended rather than open-ended questions
PREVENTION/
Communication Focus on the emotion rather than the content of what is being said
MANAGEMENT (validation)
STRATEGIES:
Give directions one step at a time
Use distraction rather than logic/reason to calm resident behavior
(most often in later dementia stages)
Keep predictable schedule (esp. mealtimes and sleep)
Structure
Use familiar staff whenever possible
Approach Factors cont.

36. • Resident with 6-year diagnosis of Alzheimer’s disease
• Memory unit in ALF: For the past three weeks, every morning
Ms. Hurley has been observed to throw her toast from her tray
across the room
• Resident had not previously expressed a dislike for toast, and
family said she used to like it
Ms. • After starting to observe Ms. Hurley from beginning of meal
Hurley forward, staff noticed that she struggled to apply the sealed
butter and jelly packets (sequencing problems)
• Staff started serving the toast with butter and jelly already
spread on it, behavior ceased directly.
• Example of catastrophic reaction
Case Example: Ms. Hurley

37. • Definition:
• THE NEEDS, WANTS, DESIRES, OR HABITS OF AN
INDIVIDUAL THAT INFLUENCE BEHAVIORAL PROBLEMS
• Can also be considered ―psychological‖ factors
• These constitute a broad array of potential contributing
causes for BPSD
• Learned patterns of behavior • Lack of socialization
and/or thinking • Boredom
• History of trauma • Lack of autonomy/privacy/intimacy
• Mood states • Distress/feeling abandoned
• Emotional discomfort • Fear of danger
• Misinterpretation paranoia
HEAR: Resident Factors

38. PSYCHOTHERAPY (for some residents)
• Individuals with early-state dementia may benefit from
some forms of psychotherapy
• Gather collateral information—family and others
• “Has your loved one ever shown behavior like this
before?”
• “Is there anything about these circumstances that may be
bringing up bad memories for your loved one?”
• Pass along information and observations to therapist
HEAR: Resident Factors (cont.)

39. BEHAVIOR PLANNING
• Some residents may benefit from more involved
contingency management plans (AKA behavior plans)
• Works across different levels of cognitive ability
• Typically developed by a MH consultant, implemented
by facility staff (with staff training)
• Aimed at bringing about desirable behaviors while
discouraging or eliminating harmful behaviors
HEAR: Resident Factors (cont.)

40. • 81 year old woman in psychiatric hospital
• Cursing and swinging arms
• Personality disorder and early dementia
• Plan: could earn “treats” (coffee, strolls, etc.)
every 2 hours if no cursing or striking out
Mrs. Sweet • Needed frequent reminders of treat opportunities
• Problematic behavior dropped 66% in 2 months
• After thinning reinforcement schedule, behavior
stopped completely
Case Example: Mrs. Sweet

41. Identification and attribution of behaviors
• Prevalence of BPSD has been found to vary across cultures
• Is behavior culturally normative? (e.g., loudly and constantly praying,
high hostility in interpersonal interactions)
• Is environment or approach having a disproportionate impact due to
cultural factors? (e.g., physical touch during ADL care)
Diagnosis
• Were instruments geared toward individual’s [national or ethnic]
culture? (e.g., normative data, language)
• Was level of education accounted for?
BPSD: Cultural Considerations for Clinicians
Shah et al Int Psychogeriatr 2004; 16
Herbert P Can J Neurol Sci 2001; 28 Suppl 1

42. Communication
difficulties
“Taboo” topics
Stigma attached to
Cultural factors mental illness
that may
complicate the Bias and prejudice of
clinicians
diagnosis of
dementia Institutional racism
Unfamiliarity with sxs
of dementia by
relatives
Sxs of dementia being
viewed as a function
of old age
CULTURAL CONSIDERATIONS: Diagnosis
Shah, AS. CROSS-CULTURAL ISSUES AND COGNITIVE IMPAIRMENT
http://www.rcpsych.ac.uk/pdf/Dementia%20%20Culture.pdf

43. When is an antipsychotic justified?
Schizophrenia
Schizoaffective disorder
Delusional disorder
Mood disorders (e.g. mania, bipolar disorder, depression with
psychotic features, and treatment refractory major depression)
Antipsychotic Schizophreniform disorder
medication can be
used for the following
conditions/diagnoses: Psychosis NOS
Atypical psychosis
Brief psychotic disorder
Dementing illnesses with associated behavioral symptoms
Medical illnesses or delirium with manic or psychotic
Antipsychotic treatment goal[s]: to stabilize and or improve a resident’s
outcome, quality of life and functional capacity

44. JUSTIFY
BPSD Sxs must present a
DANGER to the person or others
“H” or, cause the patient to
experience one of the following:
After
“E”
- inconsolable or persistent
HEALTH
After
“A” distress;
and medical causes - a significant decline in
have been ruled out ENVIRON-
After
“R” function;
MENTAL - substantial difficulty
treatment strategies APPROACH
have been tried/ FACTORS After receiving needed care
implemented have been evaluated, RESIDENT
(training, FACTORS
communication & have been evaluated
structure)
SELECT
1. Individualize
2. Initiate monotherapy
Start low, go slow
3. Titrate dose to effect,
Rule of Thumb: 5-10% dose
increases q 4-6 wks
4. If effective, continue few
weeks – few months
5. STOP drug if INEFFECTIVE
(appropriately tapering)
Antipsychotic justification in BPSD
Maixner, et al. J Clin Psychiatry. 1999;60(suppl 8):29. Jibson and Tandon. J Psychiatry Res. 1998;32:215.

45. GDR attempts can be omitted if they are
―clinically contraindicated.”
For behavioral symptoms related to dementia,
“clinically contraindicated” is defined when:
 Resident’s target symptom[s] return or worsen after most recent
GDR attempt
AND
 Physician has documented rationale for why additional GDR
attempts would likely impair the resident’s function
Gradual Dose Reduction : Antipsychotics
Hardesty, JL. Presentation to VHCA, Under the Microscope: The Ever-Increasing
Scrutiny of Antipsychotics in LTC, 2012

46. In clinical record:
Clear documentation of treatment targets / symptoms
Non-pharmacological interventions tried and/or in use
Pharmacological intervention is prescribed:
• Lowest effective dose is utilized
• Time limited duration, (as warranted)
Ongoing monitoring / reporting of efficacy and response
• ADEs clearly being monitored for and supported in documentation
• Tolerability & efficacy assessed every 3 to 7 days
GDR attempts are documented
• Reassess for tapering / discontinuation per CMS guidelines
If the drug doesn’t help, stop it!

47. Explore, identify and
address the
following potential
contributors:
•Health/medical factors Clearly
•Environmental factors document
Conduct risk •Approach factors every step of
analysis •Resident factors the way…
Immediately Prescribe
address medications
imminent judiciously
safety issues •Start low and go slow!
Conclusions: Managing BPSD

48. • Michele Thomas, R.Ph., Pharm.D., BCPP
michele.thomas@dbhds.virginia.gov
• Andrew Heck, Psy.D., ABPP
andrew.heck@dbhds.virginia.gov
Contact