Dementia Care 2013

Tim Gieseke MD, CMDAssoc. Clinical Prof. UCSFMulti-facility Medical Directorgieseke@sonic.netDementia Care 2013ObjectivesDementia SyndromesStressors & Delirium SyndromeMental Health Co-morbiditiesPharmacologic ManagementEnvironmental ManagementResourcesDSM IV Dementia DiagnosisAn acquired impairment in areas of intellectual function:Memory + at least 1 of 4 other cognitive domainsLanguage (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 DeclineProgresses slowly over years with onset usually after 60 y/oImportanceMany NH residents have cognitive impairment (25-74%), but commonly not recognized in early stagesOver 75% of NH residents meet MDS-based criteria for dementia.Dependency is common73% dependent for toileting, transfers, & continence21% for feedingBehavior and Psychological problems are common and may be difficult to manageLow stress tolerance with high risk for deliriumPoor 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 3.0http://dhmh.dfmc.org/longTermCare/documents/BIMS_Form_Instructions.pdf Mini Mental Status Examhttp://www.health.gov.bc.ca/pharmacare/adti/clinician/pdf/ADTI%20SMMSE-GDS%20Reference%20Card.pdf Mini Coghttp://www.alz.org/documents_custom/minicog.pdf SLUMS cognitive Assessmenthttp://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 DeliriumCAM = Confusion Assessment MethodBelow information apparent from interview of family and patient1. Acute onset and fluctuating courseAnd2. InattentionAnd EITHER3. Disorganized thinkingOR4. Altered level of consciousnesshttp://consultgerirn.org/uploads/File/trythis/try_this_13.pdf Dementia and DeliriumDementia is the strongest risk factor for the development of delirium 25-75% of patients with delirium have co-morbid dementia5-fold > riskMedications that Challenge CognitionBenzodiazepinesTricyclic Antidepressants (Amitryptyline)Anti-cholinergic meds: (Benedryl, Meclizine)NarcoticsWithdrawal states (SSRIs, Alcohol, Benzos)Digoxin toxicityEvaluation of the Acutely Confused Patient? Use INTERACT 3.0 Algorithm to support your SBARAcute Mental Status Change Algorithmhttp://interact2.net/docs/INTERACT%20Version%203.0%20Tools/Decision%20Support%20Tools/Care%20Paths/INTERACT%20Care_Path_%20Acute_MENTAL_STATUS_CHANGE%20Dec%2029%202012%20revised.pdf Change in Behavior Algoithmhttp://interact2.net/docs/INTERACT%20Version%203.0%20Tools/Decision%20Support%20Tools/Care%20Paths/Care_Path_CHANGE_IN_BEHAVIOR%20Dec%2029%202012%20revised.pdf Depression is Common in DementiaScreen with PHQ-9 and OV for non-verbal patients on MDS 3.0Is 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:Complain of memory loss, but memory tests well.Poor concentrationGives up easily on testingOrientation is generally intactAphasia and apraxia are absent

Dementia Syndromes ~ PrevalenceAlzhiemers (DAT)50-60%Lewy Body (DLB)10-15%Vascular (VaD)10-15%Mixed (DAT + VaD)10-15%Parkinsons (PDD) 5%Fronto-Temporal (FTD = Picks dz) 5%Reversible: 5%Depression; B-12; Meds; etc. Others: Supranuclear Palsey; Jacob Creutzfeld, and many others

Alzheimer's Clinical PictureAge is greatest risk factor 1% at 60 y/o and doubles q 5 yearsInsidious onset with slow decline over many yearsLife expectancy ~ 10 years from diagnosisInitial cognitive loss in memory and executive functionloss of initiative (apathy) is commonLanguage loss and agnosias with confusion occur laterPredisposes to behavioral problems, sleep disturbance, and poor hygieneApraxias and loss of music appreciation occur late in the disease. Lewy Body DementiaPresents typically with:Early Parkinson shuffle, tremor, imbalance < 1 year durationVivid frightening visual & auditory hallucinations with potential for sudden and unexpected physical aggressionParanoid delusions supported by hallucinationsFluctuating levels of consciousness and impairment Some days seem normalNot much memory loss early onVery sensitive to side effects of antipsychotics. Aricept (Donepezil) or other Acetylcholine Esterase Inhibitors (ACEIs) may dramatically reduce hallucinations and paranoia Antidepressants may help Vascular DementiaCVAs may result in sudden development of dementia in close 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 scansAge is a strong risk factor, so DAT and VaD commonly occur together as a Mixed DementiaOther risk factors to manage:Atrial Fibrillation consider anticoagulationHBPDiabetesLipid DisordersCigarettes Parkinsons DementiaDementia generally occurs > 7 years after diagnosis of PD when commonly seeSignificant 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 delusionsAricept (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 DementiaProgressive Atrophy of above lobes, but not memory centers, so memory tends to be preservedFail to recognize functional impairmentsReceptive & Expressive AphasiaSocial disinhibition with repetitive behaviorsPseudobulbar affectOccurs at younger age then other dementias35-70 y/o at onsetFamilial occurrence in 20-40% of casesShorter survival from dx ~ 8.7 yearsAnti-depressants occasionally helpful, but not ACEIs like Aricept (Donepezol)Is there a Mental Health History or Brain Injury?Substance Abuse DisorderAlcoholOpiods or BenzosBorderline Personalityhttp://en.wikipedia.org/wiki/Borderline_personality_disorder Brain injury?Trauma, anoxic, Multiple Sclerosis, or hypoglycemicEncephalopathyHepatic, HIV, Herpes Encephalitis http://www.nlm.nih.gov/medlineplus/encephalitis.html

Pre-dementia Mental Disorders?Anxiety DisorderGeneralized, PTSD, Panic Attacks, OCD, Phobiashttp://www.webmd.com/anxiety-panic/guide/mental-health-anxiety-disorders Bipolar DisorderAntidepressants if used without mood stabilizer may promote rapid cycling to maniahttp://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml Autistic Spectrum Disorderhttp://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-pervasive-developmental-disorders/index.shtml Schizophreniahttp://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml

Pharmacologic ManagementMeds appropriate for identified co-morbid mental health problemsAntidepressants in DementiaSertraline (Zoloft) SSRI of choice well tolerated and few drug interactionsCitalopram (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 & depressionMemory Enhancers (in DAT, most dont benefit)ACEIs like Donepezil (Aricept), but falls & anorexia riskNMDA Antagonists like Memantine (Namenda)Not both: no increased efficacy in recent studies

Pharmacologic ManagementMeds for Palliative CarePainGI symptoms: Constipation, Diarrhea, Nausea,SOB/OSA: CPAP, O2Skin: Pruritis Sleep: Trazodone?, TylenolBenzodiazepamsPredispose to delirium & increase risk of falls, sundowning, & malnutritionChemical Restraint issueUse lowest dose for shortest period of time with clearly defined goalPrazocin1 small study showed some efficacy for agitationAntipsychoticsMay reduce delirium associated agitationMay reduce dementia associated paranoia, delusions, and hallucinationsEvidence best for Aripiprazole (Abilify), Olanzepine (Zyprexia), and Risperidone (Risperdal)Evidence for Quetiapine (Seroquel) is equivocal

Antipsychotics are Risky and have Black Box WarningAntipsychotics 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 benefit1 will dieMost controlled studies dont 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 behaviorsDelirium, 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 DisorderDelusional DisorderMood Disorders (Bipolar, Depression with psychotic features)Distressing Psychosis and Atypical PsychosisBrief Psychotic DisorderMedical Illness with Psychotic symptoms (Delirium, Steroid Psychosis, etc.)Tourettes Disorder or Huntington diseaseHiccups 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:Medical ConditionEnvironmental stressorsPsychological stressorsFailure to identify and implement appropriate non-pharmacologic interventionsDose of antipyschotic should not exceed recommended safe dose criteria of F329 unless clinical rationale justified and documentedBehavioral 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 ExpectationsAppropriate IndicationsChronic or Acute useDose AppropriateMonitoring for EffectivenessMonitoring for Adverse ConsequencesGDRInformed ConsentQAAPreventing Problem BehaviorsLife long sleep & meal patternsExercise Activities & social programLife HistoryBirthplace and where has livedEducation, Career, & AwardsSocial Connections and familyAffinity groupsStrengths & WeaknessesHistoric Hot Buttons

Managing Problem Behaviors in DementiaABCDEs of Neurobehavioral CareAntecedentsBehaviorsConsequencesDocumentation 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 incidentsAntecedentsGoal is to view all behavior as an attempt at communicating something importantOur job is to decode the potential meaning of the behavior, its triggers, and factors that perpetuate it.Consider: 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 activityRelated to ADL care?Bad news?Sick?Triggering Staff ApproachesCultural & gender issuesTone of voiceSimple Direct SpeechBathing without a battle New caregiver or nurse?

Behavior (avoid Agitation term) A detailed report by those who observed the behaviorExact 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 BehaviorsCryingYelling / Calling outBiting, Hitting, or Grabbing (Rubber duck intervention)Fecal PlayRejection of CareHoardingWandering / Pacing / IrritabilityConsequences of the BehaviorFocus on Perspective of:PatientFamilyStaffFacility Specific Consequencess:AttentionIsolationAbuse - reportableInjuryMedication responseBehavior reinforcement (Borderline Personalities)DocumentationBy patients 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):Define Triggers and decode the behaviorDefuse counter-productive emotional responsesDevelop Behavior Map with measureable, well defined MonitorsInitiate at least 2 environmental interventions before resorting to medication, unless and absolute emergencyDecide 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 medsRegularly communicate with front line workers and the attending physician what is known and the current care planAdjust facilities neurobehavioral policies and procedures on the basis of what has been learned from individual casesCommon Reasons for Difficult BehaviorsResponse to a TriggerFear/Boredom/AnxietyPsychosis / DeliriumDiscomfortPersonality / enjoys behaviorSleep deficitExercise deficiencyNew Medication with adverse effectNew Medical ProblemChange in caregiversApathy for perceived ADL care needs

Change in Perspective about BehaviorsOld languageNew languageAgitationRummaging/ShoppingWanderingEgress or ElopementRefusing Personal CareRepetitive Crying OutEnergetic/AssertiveSeekingExploringShowing initiativeCautious

AssertiveStrategies to Manage BehaviorsStart with Consistent AssignmentSooth the anxiety determine the cause (noise, constipation, dehydration, pain, or hungry)Leave if they are escalatingLet the patient make a call to a family or friend short list for day or nightSwitch TV or radio to a calming showCommunication TechniquesTalk slowGet their attentionListenCalm ToneYes or no questionsOrient to taskUse touchWatch you languageDont argueRepeat, rephrase, and repairSmile and laughReinforce positive momentsAffirmationsUse humorTell simple stories about life or events

Environmental CareOptimal level of exercise and activityIndividualized Activity programMusic / recordings / ArtComfortable seatingAppropriate lighting and color contrastsPersonalized care planAmbient temperatureBackground Noise or voices

Alternative Medicine ApproachesChamomile tea or milkMagnesium 250-500 mgFamiliar or comfort foodsEssential oils lavender, rose, rosemary tiny amountsFavorite cologne, aftershave, perfumeColored lights pink, blue, outside sunlightPetsSmall childrenAcupressure / shiatsu/ swaddlingExerciseFoot bath, shoulder, massage, hydro therapyNeutral temperature bathMusic AHCA Recommends 1st Steps(American Health Care Association)Identify and review everyone on antipsychoticsIdentify new admits with antipsychotics started in the hospital with goal of d/c or rapid taper if no longer medically necessaryDC prnsGDR for everyone q 3 monthsImplement 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 IDTAHCA 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 facilityResourcesImproving Antipsychotic Appropriateness in Dementia patientshttps://www.healthcare.uiowa.edu/igec/iaadapt/ Dementia Problem Behaviors app for android tablets and smart phonesHand in Hand Training Videos from CMS for CNA traininghttp://www.cms-handinhandtoolkit.info/ American Health Care Associations Initiative to safely reduce antipyschotics.http://www.ahcancal.org/quality_improvement/qualityinitiative/Pages/Antipsychotics.aspx

ResourcesPartnership 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 Toolhttp://www.caltcm.org/assets/documents/forms/cdph_lc_antipsychotic_survey_tool_07_11_12.pdf