Dementia Care 2013
Tim Gieseke MD, CMD
Assoc. Clinical Prof. UCSF
Multi-facility Medical Director
gieseke@sonic.net
Objectives
 Dementia Syndromes
 Stressors & Delirium Syndrome
 Mental Health Co-morbidities
 Pharmacologic Management
 Environmental Management
 Resources
DSM –IV Dementia Diagnosis
 An acquired impairment in areas of intellectual function:
 Memory + at least 1 of 4 other cognitive domains
 Language (Aphasia)
 Movement (Apraxia)
 Object/Situation Recognition (Agnosia)
 Executive Function (Initiative, Med Management, Problem solving)
 Interferes with either Occupational or Social functioning, or
Interpersonal relationships.
 Represents a Decline
 Progresses slowly over years with onset usually after 60 y/o
Importance
 Many NH residents have cognitive impairment (25-74%), but
commonly not recognized in early stages
 Over 75% of NH residents meet MDS-based criteria for dementia.
 Dependency is common
 73% dependent for toileting, transfers, & continence
 21% for feeding
 Behavior and Psychological problems are common and may be
difficult to manage
 Low stress tolerance with high risk for delirium
 Poor prognosis particularly after acute stressor like Pneumonia or
Hip fx
 4-5 times > 6 mo mortality compared to non-demented
Common Screening tests
 BIMS part of MDS 3.0
 http://dhmh.dfmc.org/longTermCare/documents/BIMS_Form_Ins
tructions.pdf
 Mini Mental Status Exam
 http://www.health.gov.bc.ca/pharmacare/adti/clinician/pdf/ADTI
%20SMMSE-GDS%20Reference%20Card.pdf
 Mini Cog
 http://www.alz.org/documents_custom/minicog.pdf
 SLUMS cognitive Assessment
 http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam
_05.pdf
If cognitive impairment detected, must
find a reliable historian.
 When did it begin?
 What is the time course of the cognitive decline?
 What was the pre-hospital function?
 ADLs – Bristol ADL Scale
http://www.health.fgov.be/internet2Prd/groups/public/%40public
/%40dg1/%40acutecare/documents/ie2divers/19073273_nl.pdf
 IADLS: http://www.abramsoncenter.org/pri/documents/iadl.pdf
 Are any medicines or medical conditions contributing to cognitive
impairment?
 Any current exacerbating factors?
 Hearing Aids, Eyeglasses, Death of spouse, dog, etc.
If Rapid Decline in Cognition, Consider
Delirium
 CAM = Confusion Assessment Method
 Below information apparent from interview of family and patient
 1. Acute onset and fluctuating course
 And
 2. Inattention
 And EITHER
 3. Disorganized thinking
 OR
 4. Altered level of consciousness
 http://consultgerirn.org/uploads/File/trythis/try_this_13.pdf
Dementia and Delirium
 Dementia is the strongest risk factor for the development of
delirium
 25-75% of patients with delirium have co-morbid dementia
 5-fold > risk
 Medications that Challenge Cognition
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Benzodiazepines
Tricyclic Antidepressants (Amitryptyline)
Anti-cholinergic meds: (Benedryl, Meclizine)
Narcotics
Withdrawal states (SSRIs, Alcohol, Benzos)
Digoxin toxicity
Evaluation of the Acutely Confused
Patient?
 Use INTERACT 3.0 Algorithm to support your SBAR
 Acute Mental Status Change Algorithm
 http://interact2.net/docs/INTERACT%20Version%203.0%20Tool
s/Decision%20Support%20Tools/Care%20Paths/INTERACT%20C
are_Path_%20Acute_MENTAL_STATUS_CHANGE%20Dec%2029
%202012%20revised.pdf
 Change in Behavior Algoithm
 http://interact2.net/docs/INTERACT%20Version%203.0%20Tool
s/Decision%20Support%20Tools/Care%20Paths/Care_Path_CHA
NGE_IN_BEHAVIOR%20Dec%2029%202012%20revised.pdf
Depression is Common in Dementia
Screen with PHQ-9 and OV for non-verbal patients on MDS 3.0
Is there a history (or family hx) of prior depression?
Is there a history of substance abuse disorder?
If depression is present, cognition may improve with effective
treatment of depression.
 Apathy is common in both depression and dementia, but folk with
depression usually:
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Complain of memory loss, but memory tests well.
Poor concentration
Gives up easily on testing
Orientation is generally intact
Aphasia and apraxia are absent
Dementia Syndromes ~ Prevalence
 Alzhiemers (DAT)
 Lewy Body (DLB)
 Vascular (VaD)
 Mixed (DAT + VaD)
 Parkinsons (PDD)
 Fronto-Temporal (FTD = Picks dz)
 Reversible:
50-60%
10-15%
10-15%
10-15%
5%
5%
5%
 Depression; B-12; Meds; etc.
 Others: Supranuclear Palsey; Jacob Creutzfeld, and many
others
Alzheimer's Clinical Picture
 Age is greatest risk factor
 1% at 60 y/o and doubles q 5 years
 Insidious onset with slow decline over many years
 Life expectancy ~ 10 years from diagnosis
 Initial cognitive loss in memory and executive function
 loss of initiative (apathy) is common
 Language loss and agnosias with confusion occur later
 Predisposes to behavioral problems, sleep disturbance, and poor
hygiene
 Apraxias and loss of music appreciation occur late in the disease.
Lewy Body Dementia
 Presents typically with:
 Early Parkinson shuffle, tremor, imbalance < 1 year duration
 Vivid frightening visual & auditory hallucinations with potential for sudden
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and unexpected physical aggression
Paranoid delusions supported by hallucinations
Fluctuating levels of consciousness and impairment
Some days seem normal
Not much memory loss early on
Very sensitive to side effects of antipsychotics.
 Aricept (Donepezil) or other Acetylcholine Esterase Inhibitors (ACEIs)
may dramatically reduce hallucinations and paranoia
 Antidepressants may help
Vascular Dementia
 CVAs may result in sudden development of dementia in close
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proximity to the CVA.
Presents with more defined onset and cognition tends to decline
with each new CVA.
CVAs may be “Silent” only seen on CT or MRI scans
Age is a strong risk factor, so DAT and VaD commonly occur
together as a Mixed Dementia
Other risk factors to manage:
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Atrial Fibrillation – consider anticoagulation
HBP
Diabetes
Lipid Disorders
Cigarettes
Parkinson’s Dementia
 Dementia generally occurs > 7 years after diagnosis of PD when
commonly see
 Significant mobility impairment, dystonia, dysphagias, and
dysautonomias
 Once dementia develops PD meds may increase nocturnal
hallucinations and impulsiveness (> fall risk)
 Dementia manifestations are similar to Lewy Body with significant
delusions
 Aricept (Donepezil) may be tried.
 Sometimes tapering off the PD meds helps the distressing
hallucinations, delusions and impulsiveness, but PD motor
symptoms may worsen off meds.
Fronto-Temporal Dementia
 Progressive Atrophy of above lobes, but not memory centers, so
memory tends to be preserved
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Fail to recognize functional impairments
Receptive & Expressive Aphasia
Social disinhibition with repetitive behaviors
Pseudobulbar affect
 Occurs at younger age then other dementias
 35-70 y/o at onset
 Familial occurrence in 20-40% of cases
 Shorter survival from dx ~ 8.7 years
 Anti-depressants occasionally helpful, but not ACEIs like Aricept
(Donepezol)
Is there a Mental Health History or
Brain Injury?
 Substance Abuse Disorder
 Alcohol
 Opiods or Benzos
 Borderline Personality
 http://en.wikipedia.org/wiki/Borderline_personality_disorder
 Brain injury?
 Trauma, anoxic, Multiple Sclerosis, or hypoglycemic
 Encephalopathy
 Hepatic, HIV, Herpes Encephalitis
 http://www.nlm.nih.gov/medlineplus/encephalitis.html
Pre-dementia Mental Disorders?
 Anxiety Disorder
 Generalized, PTSD, Panic Attacks, OCD, Phobias
 http://www.webmd.com/anxiety-panic/guide/mental-health-anxiety-
disorders
 Bipolar Disorder
 Antidepressants if used without mood stabilizer may promote rapid cycling
to mania
 http://www.nimh.nih.gov/health/publications/bipolardisorder/complete-index.shtml
 Autistic Spectrum Disorder
 http://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-
pervasive-developmental-disorders/index.shtml
 Schizophrenia
 http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml
Pharmacologic Management
 Meds appropriate for identified co-morbid mental health problems
 Antidepressants in Dementia
 Sertraline (Zoloft) SSRI of choice – well tolerated and few drug interactions
 Citalopram (Celexa) may prolong QT interval at higher doses and has many drug
interactions that worsen the QT interval.
 Mirtazepine (Remeron) consider if need hypnotic & appetite enhancer.
 Venlefaxine (Effexor) or Duloxetine (Cymbalta) if neuropathic pain &
depression
 Memory Enhancers (in DAT, most don’t benefit)
 ACEIs like Donepezil (Aricept), but falls & anorexia risk
 NMDA Antagonists like Memantine (Namenda)
 Not both: no increased efficacy in recent studies
Pharmacologic Management
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Meds for Palliative Care
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Pain
GI symptoms: Constipation, Diarrhea, Nausea,
SOB/OSA: CPAP, O2
Skin: Pruritis
Sleep: Trazodone?, Tylenol
Benzodiazepams
 Predispose to delirium & increase risk of falls, sundowning, & malnutrition
 Chemical Restraint issue
 Use lowest dose for shortest period of time with clearly defined goal
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Prazocin
 1 small study showed some efficacy for agitation
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Antipsychotics
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May reduce delirium associated agitation
May reduce dementia associated paranoia, delusions, and hallucinations
Evidence best for Aripiprazole (Abilify), Olanzepine (Zyprexia), and Risperidone (Risperdal)
Evidence for Quetiapine (Seroquel) is equivocal
Antipsychotics are Risky and have
“Black Box Warning”
 Antipsychotics increase the risk of dying within months of use by 1.6-1.7 times.
 For atypical antipsychotics after 12 weeks of use in 100 demented patients with
psychosis:
 9-25 will have some objective benefit
 1 will die
 Most controlled studies don’t show efficacy beyond 3-4 months in patients with
dementia.
 Risperidal may have long term benefits (NEJM Nov 2012)
 For typical first generation antipsychotics, the risk of death is probably higher
(e.g. Haloperidol)
 OIG has found that these meds are commonly used in nursing homes without
an appropriate indication, at excessive dose, and longer then is necessary.
 Other risks include: Cognitive decline accelerated, falls, CVA, Diabetes, High
Lipids, Wt gain, Pneumonia, and reduced ADLs.
Antipsychotic Use Requires:
 Documented informed consent by the attending physician or referring
physician prior to administration, except in a serious emergency and
then only for the shortest of times.
 An NP is not allowed to do this.
 Because use of more then 1 antipsychotic has very little evidence for
added efficacy or safety, this practice should be rare, apart from
geropsychiatrist order.
 Clearly identified acceptable indication and measureable target behaviors
 Delirium, Hallucinations, Delusions, Paranoid ideation that are distressful to
the patient.
 Documented evidence of efficacy over time and with efficacy achieved at
the lowest possible dose.
Approved Indication of CDPH Survey
Tool (July 2012)
 Schizophrenia & Schizoaffective Disorder
 Delusional Disorder
 Mood Disorders (Bipolar, Depression with psychotic
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features)
Distressing Psychosis and Atypical Psychosis’
Brief Psychotic Disorder
Medical Illness with Psychotic symptoms (Delirium, Steroid
Psychosis, etc.)
Tourette’s Disorder or Huntington disease
Hiccups or nausea associated with Ca or Chemotherapy.
Surveyor Tool Expects:
 Those receiving antipsychotics have a documented comprehensive
evaluation and care plan indicating symptoms are not due to:
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Medical Condition
Environmental stressors
Psychological stressors
Failure to identify and implement appropriate non-pharmacologic
interventions
 Dose of antipyschotic should not exceed recommended safe dose
criteria of F329 unless clinical rationale justified and documented
 Behavioral data made available to prescriber at least monthly along with
adverse consequences data.
 Reasons for dose escalation are clearly documented and medically
necessary with informed consent.
Tool Expectations
 Appropriate Indications
 Chronic or Acute use
 Dose Appropriate
 Monitoring for Effectiveness
 Monitoring for Adverse Consequences
 GDR
 Informed Consent
 QAA
Preventing Problem Behaviors
 Life long sleep & meal patterns
 Exercise
 Activities & social program
 Life History
 Birthplace and where has lived
 Education, Career, & Awards
 Social Connections and family
 Affinity groups
 Strengths & Weaknesses
 Historic “Hot Buttons”
Managing Problem Behaviors in
Dementia
 ABCDEs of Neurobehavioral Care
 Antecedents
 Behaviors
 Consequences
 Documentation
 Emotional – recognize the fears, anger and distress of patient,
family, and staff. These emotions may impede critical thinking.
 Systematic – adjust the overall system on the basis of what you
find from these incidents
Antecedents
Goal is to view all behavior as an attempt at communicating something important
 Our job is to decode the potential meaning of the behavior, its triggers, and factors that
perpetuate it.
 Consider:
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What is the cause of the dementia?
What are the co-morbid illnesses?
Level of Stimulation (too much or too little?)
Hunger, Fatigue or Pain?
Lack of exercise or relevant activity
Related to ADL care?
Bad news?
Sick?
Triggering Staff Approaches
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Cultural & gender issues
Tone of voice
Simple Direct Speech
Bathing without a battle
New caregiver or nurse?
Behavior (avoid “Agitation” term)
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A detailed report by those who observed the behavior
Exact setting, time of day, who was involved, etc.
Was there any warning or were there any triggering factors?
What was tried to diffuse the situation (distraction, redirection)?
Potential Specific Distressful Behaviors
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Crying
Yelling / Calling out
Biting, Hitting, or Grabbing (Rubber duck intervention)
Fecal Play
Rejection of Care
Hoarding
Wandering / Pacing / Irritability
Consequences of the Behavior
 Focus on Perspective of:
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Patient
Family
Staff
Facility
 Specific Consequencess:
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Attention
Isolation
Abuse - reportable
Injury
Medication response
Behavior reinforcement (Borderline Personalities)
Documentation
 By patient’s individual licensed nurse(s)
 By IDT which meets on a weekly and prn basis and optimally includes activities director
and possibly a facility clinical psychologist.
 Task(s):
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Define Triggers and decode the behavior
Defuse counter-productive emotional responses
Develop “Behavior Map” with measureable, well defined Monitors
Initiate at least 2 environmental interventions before resorting to medication, unless and
absolute emergency
Decide when an intervention is ineffective, partially effective, or no longer necessary.
If antipsychotics are used, monitor for common potential side effects and have system to
consider d/c med if s/e too great.
Adjust care plan including GDRs of meds
Regularly communicate with front line workers and the attending physician what is known
and the current care plan
Adjust facilities neurobehavioral policies and procedures on the basis of what has been
learned from individual cases
Common Reasons for Difficult
Behaviors
 Response to a Trigger
 Fear/Boredom/Anxiety
 Psychosis / Delirium
 Discomfort
 Personality / enjoys behavior
 Sleep deficit
 Exercise deficiency
 New Medication with adverse effect
 New Medical Problem
 Change in caregivers
 Apathy for perceived ADL care needs
Change in Perspective about Behaviors
“Old” language
“New” language
 Agitation
 Energetic/Assertive
 Rummaging/Shopping
 Seeking
 Wandering
 Exploring
 Egress or Elopement
 Showing initiative
 Refusing Personal Care
 Cautious
 Repetitive Crying Out
 Assertive
Strategies to Manage Behaviors
 Start with Consistent Assignment
 Sooth the anxiety – determine the cause (noise, constipation,
dehydration, pain, or hungry)
 Leave if they are escalating
 Let the patient make a call to a family or friend – short list
for day or night
 Switch TV or radio to a calming show
Communication Techniques
 Talk slow
 Don’t argue
 Get their attention
 Repeat, rephrase, and
 Listen
 Calm Tone
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 Yes or no questions
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 Orient to task
 Use touch
 Watch you language
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repair
Smile and laugh
Reinforce positive
moments
Affirmations
Use humor
Tell simple stories about
life or events
Environmental Care
 Optimal level of exercise and activity
 Individualized Activity program
 Music / recordings / Art
 Comfortable seating
 Appropriate lighting and color contrasts
 Personalized care plan
 Ambient temperature
 Background Noise or voices
Alternative Medicine Approaches
 Chamomile tea or milk
 Pets
 Magnesium 250-500 mg
 Small children
 Familiar or comfort foods
 Acupressure / shiatsu/
 Essential oils – lavender, rose,
rosemary – tiny amounts
 Favorite cologne, aftershave,
perfume
 Colored lights – pink, blue,
outside sunlight
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swaddling
Exercise
Foot bath, shoulder, massage,
hydro therapy
Neutral temperature bath
Music
AHCA Recommends “1st Steps”
(American Health Care Association)
 Identify and review everyone on antipsychotics
 Identify new admits with antipsychotics started in the
hospital with goal of d/c or rapid taper if no longer medically
necessary
 DC prns
 GDR for everyone q 3 months
 Implement a process to ensure that all antipsychotics Rx
initiated during the evening/night shift or on weekends are
critically evaluated ASAP by Lead Clinical or Behavioral IDT
AHCA Recommends Track Quarterly
 % new admissions w/o psychiatric diagnoses admitted to
facility on antipsychotic drugs that have those drugs
discontinued w/in 1st 30, 60, & 90 days of their admission
 % new admissions w/o psychiatric diagnoses admitted w/o
antipsychotic usage who are started on one or more of these
drugs w/in 1st 90 days.
 % of residents in your facility > 90 days on antipsychotics
but lack a psychiatric diagnosis.
 Track weekly the number of days since the last new
antipsychotic was prescribed in your facility
Resources
 Improving Antipsychotic Appropriateness in Dementia
patients
 https://www.healthcare.uiowa.edu/igec/iaadapt/
 Dementia Problem Behaviors app for android tablets and smart
phones
 Hand in Hand Training Videos from CMS for CNA training
 http://www.cms-handinhandtoolkit.info/
 American Health Care Association’s Initiative to safely reduce
antipyschotics.
 http://www.ahcancal.org/quality_improvement/qualityinitiati
ve/Pages/Antipsychotics.aspx
Resources
 Partnership to Improve Dementia Care in Nursing Homes in
conjunction with Advancing Excellence
 .http://www.nhqualitycampaign.org/star_index.aspx?controls
=dementiaCare
 CDPH L&C SNF Antipsychotic Use Survey Tool
 http://www.caltcm.org/assets/documents/forms/cdph_lc_a
ntipsychotic_survey_tool_07_11_12.pdf