Effective Clinical Management of
Difficult Behaviours Associated with
Dementia
Andrea Moser MD, MSc, CCFP, FCFP
Sid Feldman MD, CCFP, FCFP
Annual Scientific Assembly, 2013, Toronto, Ont
Based on a MAINPRO C program developed by :
Marie-France Rivard, Sid Feldman, John Feightner, Ken LeClair
for the Ontario Alzheimer Strategy Physician Education Program
Faculty/Presenter Disclosure
• Faculty: Andrea Moser
• Program: 51st Annual Scientific Assembly
• Relationships with commercial interests:
– Primary Care Advisory Board : Pfizer Canada
Disclosure of Commercial
Support
• None
• Potential for conflict(s) of interest:
– Andrea Moser has received payment from Pfizer
Canada whose product(s) are being discussed in this
program
Mitigating Potential Bias
Will identify all Pfizer products when discussed during
presentation
Faculty/Presenter Disclosure
• Faculty: Sid Feldman
• Program: 51st Annual Scientific Assembly
• Relationships with commercial interests:
– Speakers Bureau/Honoraria: Amgen.
Disclosure of Commercial
Support
• None
• Potential for conflict(s) of interest:
• None
Mitigating Potential Bias
• Not required
Objectives
• Have a framework for understanding BPSD
• Be able to use the PIECES framework to formulate
action plans for patients with BPSD
• Be able to use behavioural symptom clusters to help
guide treatment approaches
• Be familiar with risks, benefits and appropriate
dose range of medications that are recommended
for BPSD
What I would really
like to know is:
Overview
Behaviour problems in dementia
• Persons affected by dementia will react to the
symptoms of their illness through observable
behaviours.
• Some behaviours are adaptive, others cause
difficulties for the patient, the caregiver(s) or
other person(s) the patient may interact with.
Prevalence of BPSD
• 90% of patients affected by dementia will
experience Behavioural and Psychological
Symptoms of Dementia (BPSD) that are severe
enough to be labeled as a problem during the
course of their illness.
Impact of BPSD
• 50 – 90% of caregivers considered physical
aggression as the most serious problem they
encountered and a factor leading to
institutionalization (Rabins et al. 1982)
• Front-line staff working in LTC report that
physical assault contributes to significant work
related stress (Wimo et al. 1997)
Frequency of BPSD symptoms
*More common in later stages of dementia
Top Ten Behaviours not (usually)
responsive to medication
• Aimless wandering
• Inappropriate urination
/defecation
• Inappropriate dressing
/undressing
• Annoying perseverative
activities
• Vocally repetitious
behaviour
• Hiding/hoarding
• Pushing wheelchair
bound co-patient
• Eating in-edibles
• Inappropriate isolation
• Tugging at/ removal of
restraints
CCSMH National Guidelines 2006:
www.ccsmh.ca
• Assessment and treatment of mental health
issues in long term care homes
– Evaluate for medical conditions and diagnostic
tests as indicated
– Detailed interdisciplinary assessment for
antecedents/causes
– If BPSD does NOT pose imminent risk to patient or
others – non-pharmacologic Rx
Non-pharmacologic Approaches
• PIECES*
• Montessori methods
• Gentle persuasive approach (GPA)
*Focus today
P.I.E.C.E.S.
What is P.I.E.C.E.S.?
• Person-centered assessment and care
planning approach
– Develop hypotheses and test the implementation
of possible solutions.
PIECES
Physical
Intellectual
Emotional
Capabilities
Environment
Social
Each health discipline tends
to be a bit “letter-centric”
e.g. Physicians tend to be“P”-centric
P
PIECES
Physical
Intellectual
Emotional
Capabilities
Environment
Social
P – Physical
– Pain, discomfort
– Bowels, bladder
– Hunger, thirst
– Delirium
•
•
•
•
•
Infectious
Cardiovascular, respiratory, renal, etc…
Metabolic
Traumatic
Toxins, Drugs
I - Intellectual/cognitive changes
•
•
•
•
•
•
•
•
•
•
Memory loss, Amnesia:
Agnosia (Recognition of people or things)
Apraxia
Aphasia (speech)
Anosognosia (Not knowing you don’t know)
Impaired executive functions (planning)
Return to a place back in time
Apathy
Perceptual difficulties
Primitive reflexes, perseveration
E - Emotions
• Depressive symptoms
– Withdrawal, crying, repetitive
• Anxiety
– Resistive behaviours
•
•
•
•
Sun-downing
Suspiciousness
Delusions
Psychosis
C – Capabilities
E - Environment
• Capability too low to meet demands of
environment
– catastrophic reactions
• or not utilized enough
– boredom
• Environment
– Too noisy, confusing
– Too quiet
– Familiar vs unfamiliar settings
S- Social interactions
• Social, Spiritual
–
–
–
–
–
–
Mountain Top Highs and Lows
acknowledge accomplishments
need to be useful
likes and dislikes of the person
cultural background
Lifelong coping strategies less effective
Mrs. Blake
Mrs. Blake has moderately advanced
Alzheimer type dementia. She requires
assistance with dressing and toileting.
• Each time she is taken to the bathroom, Mrs.
Blake helps lower her pants but refuses to sit on
the toilet. She resists and grabs her personal
care attendants with such force that they are
getting injured.
Pharmacologic Approaches
Top Ten Behaviors responsive
(perhaps!) to medication
•
•
•
•
Physical aggression
Verbal aggression
Anxious, restless
Sadness, crying,
anorexia
• Withdrawn, apathetic
• Sleep disturbance
• Wandering with
agitation/aggression
• Vocally repetitious
behavior due to
depression or pain
• Delusions and
hallucinations
• Sexually inappropriate
behavior with agitation
When to Consider Pharmacologic
Treatment of BPSD?
• Behavior is dangerous, distressing, disturbing,
damaging to social relationships, persistent and
may respond to treatment
AND
• Has not responded to comprehensive nonpharmacologic treatment plan including removal of
possibly offending drugs.
OR
• Requires emergency treatment to allow proper
investigation of underlying problems
Decision framework for
Pharmacological treatment
•
•
•
•
•
•
Clear indication, potential benefits
Expected time to response
Risks associated with and without Rx
Appropriate dose range
Monitoring for side effects and response
When to consider dose reduction,
discontinuation.
Clinical Assessment Tools
• Daily Observation Sheet (DOS)
 Shows frequency, patterns of behaviours, individualized
• Cohen Mansfield Agitation Inventory
 behaviours and severity over 7 day period
• Kingston Standardized Behavioural
Assessment (KSBA)
 Caregiver report of function, cognition and behaviour
• MMSE, MOCA, Clock - cognitive
• Confusion Assessment Method (CAM)
Pharmacological treatment:
Choosing best drug
• Correct underlying cause:
– Pain, acute illness, constipation, etc….
– Optimize treatment of dementia, CEIs, memantine
• Target appropriate symptom cluster
• Choose least likely to worsen dementia and
medical problems
– E.g. Least anticholinergic
• Choose drugs without problematic
interaction
• Use one drug at time, monitoring effect on
target symptoms
BPSD Symptom Clusters
Aggression
Apathy
Agitation
Physical aggression
Verbal Aggression
Aggressive resistance
to care; defensive
Withdrawn
Lacks interest
Amotivation
Pacing
Repetitive actions
Dressing/undressing
Restless/anxious
Euphoria
Pressured speech
Irritable
Sad
Tearful
Hopeless
Guilty
Anxious
Irritable/screaming
Suicidal
Depression
Mania
Hallucinations
Delusions
Misidentification
Suspicious
Psychosis
Adapted from McShane R.
Int Psychogeriatr 2000;12 (suppl 1):147
Pharmacologic Options
• Dementia
– Cognitive enhancers
• Depressive symptoms
– SSRI, SNRI
– Match side effect profile with symptoms
• Psychosis/distressing delusions
– Atypical antipsychotics
• Agitation
– Choice depends on symptom and degree of risk
Anxiety Symptoms
• “Anxiety is NOT a benzodiazepine deficiency”
Dr. Bill Dalziel, geriatrician
• Cholinesterase inhibitor
– particularly for anxiety of early dementia.
• SSRIs
– will take a few weeks to work
– first line treatment for anxiety disorders
– check drug interactions.
• Consider trazodone (watch for hypotension)
Antipsychotics: indications
• Severe and persistent behavioral and
psychological symptoms which are distressing
to the patient or put the patient at risk and
do not respond to non-pharmacological
intervention
• Acute management of delirium
• Continuation of treatment of psychotic
disorders that preceded the dementia
Antipsychotic medications
• Benefits:
– Decrease suffering
– Decrease risk of injury or exhaustion
– May allow much needed medical investigations
or interventions in acute delirium
• Benefits of low dose atypical anti-psychotics
may take up to 2 months…
Antipsychotic medications
• Risks and side effects:
Hypotension - falls and fractures
Over-sedation
Anticholinergic side effects that can worsen cognition
Weight gain and increased vascular risk factors may increase
risk of CVA or worsen vascular or mixed dementia
Parkinsonism (extra-pyramidal side effects affecting gait and
posture, tremors, rigidity, excessive drooling) and tardive
dyskinesia
Increased mortality with all anti-psychotics (X2)
• NO ideal anti-psychotic available at this time
Antipsychotic medications
• Strategies that minimize the risks to the
patient.
▫ Baseline neuro, gait, BP assessment
▫ Use only if absolutely needed and only for as long as
needed (e.g. days in delirium, months in severe BPSD)
▫ Chose drug that will be least likely to worsen medical
problems of the patient
▫ Monitor closely for side effects
▫ Give it time to work before increasing the dose to toxic
range…
▫ As soon as the symptoms appear to be under control,
decrease the dose to avoid accumulation
▫ Review every 6 months if used for BPSD
Antipsychotic medications
• Strategies that minimize the medico-legal risks
with anti-psychotics:
▫ Document consent discussion and target symptom
▫ Discuss risk/benefit with capable patient or substitute
decision maker
▫ Review benefits and side effects you are watching for with
family or SDM
▫ Document that you are reviewing regularly to try to
decrease or discontinue. At minimum q 6 months
▫ Document non-pharmacological interventions used to
reduce use of anti-psychotic medications
Best choices: anti-psychotics
• For acute delirium– very short term (days)
– Haloperidol (0.5 mg that may be repeated)
– Risperidone (0.25 mg that may be repeated)
• For persistent psychosis/agitation
– Risperidone (Risperdal) start with 0.25-0.5 mg daily and
increase slowly as needed/tolerated over weeks to max. 2
mg per day
– Olanzapine (Zyprexa): start with 2.5 mg daily and increase
slowly as needed/tolerated over weeks, to max 10 mg daily
– Quetiapine (Seroquel): start with 12.5 mg daily or BID and
increase slowly over weeks to max 200 mg daily
Approach to the Acutely Agitated
Patient
• Safety - of the patient, other residents and
staff is number one concern
• Assess competency - Except in an emergency
the patient (if capable) or Substitute Decision
Maker must be involved in treatment plan.
• Treatment – of choice in urgent situations is
oral atypical antipsychotics
Urgent situations – Atypical
Antipsychotics
• M tab and Zydis are more quickly dissolved
but do not have a more rapid onset of action
• Time to peak plasma concentration:
– risperidone = 1.5 hrs
– olanzapine = 5 hrs
– quetiapine = 1.5 hrs
Summary Table: Meds for BPSD
Target
Symptoms
Medication
Starting Dose
(mg/day)
Average Target
Dose
(mg/day)
Delusions
Hallucination
Aggression
“Agitation”
Atypical
Antipsychotics:
risperidone
olanzapine
quetiapine
0.25-0.5
2.5-5
12.5-25
0.5-2.0
2.5-7.5
50-400
Sadness
Irritability
Anxiety
Insomnia
Antidepressants
citalopram
sertraline
venlafaxine
mirtazapine
trazodone
10
25
37.5
7.5
12.5-25
10-40
50-100
37.5-225
15-45
50-100
Summary Table: Meds for BPSD
Target
symptoms
Medication
Mood
swings
Euphoria
Impulsivity
Mood stabilizers:
valproic acid
carbamazepine
Agitation
Cholinesterase
Inhibitors.
Memantine
Apathy
Irritability
Anxiety
(short
term use in
predictable
situations)
Anxiolytics:
lorazepam
oxazepam
Starting Dose
(mg/day)
Average Target
Dose (mg/day)
250
50-100
500-1000
300-800
As directed
As directed
5 mg daily
10 mg BID
0.25-0.5
5-10
0.5-1.5
10-30
Case Vignettes
Case vignettes
• Using the PIECES framework, develop hypotheses
for why the behaviours are occurring and describe
appropriate investigations you would consider.
• How will you help the patient’s caregivers (at
home or in the LTC)? Describe strategies that
could be used to care for this person & minimize
impact of the behaviours targeted.
• If alterations are needed in medication, what
should be done?
Mr. Rose
• Every day Mr. Rose remains in the same
chair all morning until someone comes to
get him for lunch. After lunch, he lingers
in the dining area even after everyone has
left.
• His wife is annoyed that “he just sits
there like a log” and never does anything!
Mrs. Easy
• Mrs. Easy was admitted to your ward 5
days ago. She looks upset and tells you
that she finds that “the service is
terrible”.
• She wants to leave immediately.
Mr. Klein
• Mr. Klein comes out of his room
inappropriately dressed. He has no shirt or
undershirt. He has put his sweater on rather
than a shirt and put his pajama top over his
sweater. You can also see his pajama bottom
sticking out of the bottom of his pants. He has
just walked past one of other residents who
shouted that he looked stupid and an
altercation followed.
Mr. Borden
• Mr. Borden was admitted to hospital
because he physically assaulted another
resident of the Long Term Care home,
where he resides. The dispute was over a
toothbrush.
• This morning, he is very upset because
his glasses and wallet have been stolen
and he demands that you call the police.
Mr. Smith
• Mr. Smith is admitted from the Nursing
Home because he has tried to climb into
bed with a female co-resident, while she
was asleep. By the time the woman woke
up, he had removed his pants and was
caressing her inappropriately. She
screamed and the nursing staff
intervened.
Mr. Noisy
• Mr. Noisy has yet again got into trouble
because he makes inappropriate
comments to other residents and staff. He
is insulting and provocative. This leads to
verbal shouting matches and sometimes
physical aggressive behavior.
Unanswered Questions???
Contact information
• Dr. Andrea Moser:
– amoser@baycrest.org
• Dr. Sid Feldman
– sfeldman@baycrest.org
P.I.E.C.E.S. tools
• Daily Observation Sheet (DOS),
• A-B-C charting
– Shows frequency, severity, patterns of behaviors, can be
individualized
• Cohen Mansfield Agitation Inventory (CMAI)
– Identifies behaviors and severity over 7 day period
• Confusion Assessment Method (CAM)
– Delirium screen
• MMSE, MOCA, Clock
• Sig: E Caps, Cornell Depression Scale
DOS Behavior Map
Time
6am
7am
8am
9am
10a
11a
12p
1pm
2pm
3pm
4pm
MON
TUE
WED
THU
FRI
SAT
SUN
Other Common Tools
Scale
Assessment
CMAI
29 agitated behaviors rated
by caregiver on 7 point
frequency scale
The Cohen-Mansfield
Agitation Inventory
12 items rated by caregiver
Neuro-psychiatric Inventory- on a 4 point frequency and
a 3 point severity scale
Nursing Home Version
25 symptoms rated by
BEHAVE-AD
The Behavioral Pathology in caregiver on a 4 point
Alzheimer’s Disease Rating severity scale
NPI-NH
Scale
Confusion Assessment Method for
Delirium (CAM)
Sensitivity 94-100%, Specificity 90-95%
1,2 AND 3 or 4 = Delirium
1. Acute onset and fluctuating course
2. Inattention
AND
3. Disorganized thinking
OR
4. Altered level of consciousness
Inouye SK. Ann Int Med 1990
SIG: E CAPS (Rx for energy caps)
•
•
•
•
•
•
•
•
•
Sleep
Interest
Guilt
: (colon...somatic complaints)
Energy
Concentration/Cognitive losses
Appetite
Psychomotor agitation/ retardation
Suicide
Caregiver Scales
• Useful for patients in the community
• Self report can be used in office setting or
home visit
• Allow caregivers to identify behaviours they
may not be comfortable talking about in front
of their loved one
• i.e. - Kingston Behavioural Assessment
Depression vs Dementia
Features that Distinguish Depression from Dementia
Primary Depression
Primary Dementia
Onset more acute and dated.
Insidious onset, vaguely dated.
Patient complains of cognitive deficits
and seeks help.
Unaware or no complaints of cognitive
deficits.
Patient complains in detail of memory.
Vague complaints.
Deficits are emphasized.
Deficits are concealed.
Patient makes little effort at task.
Patient struggles with tasks.
Attention is preserved.
Faulty attention and concentration.
“I don’t know” answers are typical.
Frequent “near miss” answers.
Variable performance.
Consistently poor performance.
Depression is often superimposed on dementia.
Dementia assessment Nov
18,2010
Delirium vs Dementia
CLINICAL FEATURES vs DEMENTIA
CLINICAL
DELIRIUM
DEMENTIA
Onset
Course
Consciousness
Attention
Hallucinations
Sudden
Fluctuating
Reduced
Disordered
Often Present
Insidious
Stable
Clear
Normal
Often Absent until
Late in Course
Often normal may
see agitation
late in course
Psychomotor Activity Increased,
Reduced
or Shifting
unpredictably
**WITH A NEW BEHAVIOUR PROBLEM, FIRST RULE OUT DELIRIUM**
Dementia assessment Nov
18,2010
Cognitive enhancers
• Acetylcholinesterase inhibitors
– Improving cognitive function or maintaining
functional abilities
– Improving socialization
– Prevent decline in ADLs, decreasing amount of
care needed
– Postponing institutional care
– Reducing behavioral and psychological symptoms
(esp. in Lewy Body dementia)
– Instilling hope and encouraging best use of
remaining abilities?
Cognitive enhancers
• Side effects of donepezil, rivastigmine,
galantamine:
• Worsening of heart block leading to syncope,
falls and fractures
▫
▫
▫
▫
Asthma, COPD
Peptic ulcers (esp. if taking other drugs)
Seizures
Drug interactions with Paroxetine, Fluoxetine,
Fluvoxamine
• Risks to monitor with use:
▫
▫
▫
▫
▫
Muscle cramps
Insomnia and agitation
Nausea and vomiting
Diarrhea and
Weight loss.
Glutaminergic agent for moderate dementia
• Memantine (Ebixa)
• Indications: moderate to severe AD and
vascular (or mixed) dementia
• Benefits: cognition, socialization, ADLs and
BPSD
• Risks: confusion, headaches, agitation,
insomnia, dizziness, urinary incontinence and
UTIs. Hallucinations if dose too high. Do not
use if severe renal impairment.
Antidepressants: indications
• Depression pre-existing or complicating
dementia: Sig: E Caps, Cornell depression
scale for depression in Dementia
• Depressive and anxiety symptoms of frontaltemporal lobe dementia
• Persistent anxiety symptoms leading to
catastrophic reactions (e.g. vascular dementia)
• Prevention of recurrent depressive episodes
and anxiety disorders
• Trazodone used for short-term sedation
Best choices: antidepressants
• SSRI for depression or anxiety
– Citalopram (Celexa) and Escitalopram (Cipralex)
– Sertraline (Zoloft)
• Noradrenergic properties (pain, activation)
–
–
–
–
Venlafaxine (Effexor XR) *not if unstable BP
Desvenlafaxine (Pristiq)
Duloxetine (Cymbalta)
Bupropion (not if unstable BP)
• Sedation may be needed
– Trazodone *watch for hypotension
– Mirtazapine (Remeron) * some anticholinergic
properties and noradrenergic at higher doses
Antidepressants: risks
•
•
•
•
•
•
•
Agitation and suicidal risk
Headaches
GI upset, diarrhea and bleeding ulcers
Hyponatremia
Over-sedation or insomnia
QT prolongation
Falls
Pharmacological treatment:
Expected time to response
• Antidepressants for anxiety or depression: usually
weeks
• Trazodone used for sedation: short-lived but rapid
response (repeat dose rather than increase HS
dose)
• Benzodiazepines: rapid response but multiple
problems with chronic use
• Antipsychotic Rx:
– major tranquilizing effect within 2 hours with IM
Haloperidol
– Usually weeks with low dose oral atypical antipsychotic
meds. Acute use unclear…
Risks present when there is no
pharmacological Rx
• Risks of injury (self and others), exhaustion,
severe and prolonged suffering, increased
risk of death with depression, etc.
• Need to present the risks of not treating with
medications to pt or SDM when obtaining
informed consent.