Treatment Modalities for the Management of Distressed Behaviors in Elderly Nursing Home Residents Je

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Treatment Modalities for the Management of
Distressed Behaviors in Elderly Nursing Home
ResidentsJeanne Jackson-Siegal, MDJames E.
Lett II, MD, CMDJanuary 9, 2004

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Definitions

• Behavior refers to an individuals observable
  actions.
• Cognition refers to any personal activities
  related to organizing memory, sensation, and
  thinking
• Mental status refers to an individuals overall
  level of alertness, activation, and
  responsiveness to the outside world.
• AMDA Dementia CPG 1998

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Incidence of Behaviors

• Apathy (72)
• Agitation (60)
• Anxiety (45)
• Irritability (42)
• Motor restlessness (38)
• Disinhibition (36)
• Sleep disturbance (24)
• Depression (23)
• Delusions (22)
• Hallucinations (10)

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Distressed Behaviors in Nursing Homes

• Increases stress between patients and caregivers1
• Create intensive and costly levels of treatment1
• Increase morbidity and mortality 1
• Lead to public health problems that contribute to
  the enormous cost of treating dementia1
• Increase risk of overmedication and restraints

1. Finkel SI et al. Int Psychogeriatr.
19968497-500
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Agitation

• Excessive motor or verbal activity that is 1
  
• One of the following
• Disruptive OR
• Unsafe OR
• Distressing to the patient
• Interferes with care and
• Is not because of need
• Generally, is a poor descriptor of behavior
• Appears similar despite great variety of causes
• Need to make diagnosis, not focus only on
  symptoms
• When severe, may be the target for urgent
  intervention

1. Cohen-Mansfield et al, 1996 Tariot et al,
1994 Cohen- Mansfield Agitation Inventory.
www.medafile.com/zyweb/CMAI.htm
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Agitation and Aggression in Dementia
Physical Verbal Hitting Threats Pacing Accusations
Kicking Name-calling Biting Obscenities Pushing C
omplaining Spitting Attention-seeking Scratching S
creaming
Cohen-Mansfield et al, 1996 Tariot et al, 1994
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Behavior Diagnosis Pitfalls

• Many etiologies can present with the same
  behaviors (Example of fever)
• Co-existence of multiple risk factors present in
  any one resident disease, medications, changed
  environment, etc.
• The key is to have a process to evaluate the
  resident for the behavior

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General Approach to Behaviors

• Clearly characterize target symptoms
• Standard medical evaluation to identify possible
  medical disorder
• Differential diagnosis of behavior cause
• The A,B,Cs of Behavior Intervention
• Antecedent, Behavior, Consequences
• Document, Document, Document
• Non-pharmacologic intervention

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Good Target Symptoms

• Anxiety
• Insomnia
• Delusions (stressful)
• Hallucinations (stressful)
• Dysphoria/Depression
• Compulsive behaviors
• Agitation/Aggressiveness
• Motor restlessness
• Pain

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Poor Target Symptoms

• Exit-seeking
• Pacing Wandering
• Perseverant vocalizations
• Hoarding/Stealing
• Inappropriate sexual touching
• Non-stressful delusions
• Disrobing

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Medical Evaluation

• Medical/Psychiatric History
• Medication excess, withdrawal, ADR
• Physical evaluation urinary retention, fecal
  impaction (constipation), pain, dental problems
• Mental Status Exam
• Lab studies/oximetry
• Imaging Studies

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Medical Illness

• Illnesses GERD, angina, OA, etc.
• Medication side effects
• Chronic pain
• Constipation
• Hearing or vision impairment
• Sleep deprivation
• Dental problems

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Differential for Behavior Causes

• Dementing disorders
• Frontal Lobe impairment
• Delirium
• Medications
• Toxic personality syndrome
• Pain

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Differential for Behaviors (cont.)

• Primary psychiatric illness
• - Affective disorder (Depression)
• - Anxiety disorder
• - Psychotic disorder
• - Personality disorder
• Environment/Stressors

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Definition Dementia
A syndrome (a collection of signs symptoms) of
progressive decline in multiple areas of
cognitive function which eventually produces
significant deficits in self-care and social and
occupational performance. AMDA Dementia CPG
1998
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Dementia

• Incidence of 1-2 at 65-70 years of age,
  increasing to gt30 after 85
• Up to 80 of NF residents have some degree of
  dementia
• The resultant decline in functional capacity is
  the chief cause of NF admission

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Dementia Categories

• Alzheimers disease (65)
• Lewy Body dementia (7)
• AD w/vascular disease (10)
• AD w/Lewy bodies (5)
• Vascular dementia (5)
• Other Infectious, EtOH, etc. (8)

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Definition Dementia of the Alzheimer Type (DAT)
A degenerative neurologic disease that results in
impaired memory, thinking and behavior. It is
characterized by a gradual onset of progressive
symptoms that include memory loss, personality
changes, and decline in ability to think and
function. DAT is by far the most common from of
dementia in the U.S., so it is generally used as
the prototypical dementia in most guide to
diagnosis and treatment. All DAT is dementia,
but not all dementia is DAT
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DAT

• 60-80 of dementia that occurs in those gt65 years
  old
• Slow, insidious decline in multiple cognitive
  skills
• Relatively well preserved motor function early in
  disease course
• CT/MRI normal, or atrophy, perhaps with mild
  white matter changes
• No biological markers - diagnosed at autopsy
• Etiology genetics (APO e4) ?

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Dementia with Lewy Bodies (DLB)

• DLB more recently accounts for 15 - 20 of all
  dementia
• Hallmark feature widespread Lewy bodies
  throughout the neocortex with Lewy bodies and
  cell loss in the subcortical nucleii with
  distinctive pattern of neuritic degeneration on
  autopsy
• More males than females
• Age of onset 50 83
• Insidious onset progressing to profound dementia

McKeith. I.G. Dementia with Lewy Bodies. British
J of Psychiatry 2002, 180,144-147
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DLB Core Features

• Required Cognitive Decline with decreased social
  or occupational functioning
• A diagnosis of Probable DLB requires 2 of the
  following (Possible DLB requires only one of the
  following)
• Fluctuating cognition with pronounced variation
  in attention and alertness 1
• Recurrent visual hallucinations that are
  typically well formed and detailed 
• Spontaneous motor features of parkinsonism

• Quantification and Characterization of
  Fluctuating Cognition in Dementia with Lewy
  Bodies and Alzheimer's Disease M.P. Walker, G.A.
  Ayre, E.K. Perry, K. Wesnes, I.G. McKeith, M.
  Tovee, J.A. Edwardson, C.G. Ballard Dementia and
  Geriatric Cognitive Disorders 200011327-335
  (DOI 10.1159/000017262
• McKeith. I.G. Dementia with Lewy Bodies. British
  J of Psychiatry 2002, 180,144-147

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Dementia with Lewy Bodies

• Treatment Issues
• Up to 80 of DLB patients have hypersensitivity
  to neuroleptics. Prescribe antipsychotics only
  when absolutely necessary and under strict
  monitoring
• Provisional evidence suggests that patients may
  respond more preferentially to AChI therapy
• Concomitant depression
• 35 of DLB vs. 16 of AD

McKeith. I.G. Dementia with Lewy Bodies. British
J of Psychiatry 2002, 180,144-147
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Frontal Lobe Impairment Sx

• Mood lability or inappropriate affect
• Poor impulse control
• Verbally rude, caustic, bigoted, etc.
• Episodically physically aggressive
• Perseverative
• Restless/grabbing/reacts strongly to stimuli
• Difficult to redirect
• Sexually inappropriate/aggressive

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Frontal Lobe Impairment

• Not psychotic behavior, but poor impulse control
• Seen in multiple types of disease processes
• - SDAT
• - Vascular dementia
• - Multiple sclerosis
• - EtOH disease

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Frontal Lobe Impairment Non-Pharmacologic
Management

• Maintain professional distance
• Exaggerated manners, professional attire
• Emphasize courtesy, avoid overly friendly
• Communicate concretely, no open ended comments
• Define the activity, give few and clear choices
• Shape the behavior, acknowledge improvements
• Medication when needed
• Safety concerns
• Not responsive to nonpharmacologic interventions

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Definition Delirium
A state of acute confusion, inattention, and
altered level of consciousness (LOC), usually
abrupt in onset (over several hours to several
days).
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Delirium Symptoms

• Fluctuations in alertness mental functioning
  manifested by inattention
• Anxiety
• Hallucinations
• Disorientation
• Tremors
• Delusions
• Incoherence

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Common Delirium Triggers

• Acute illness
• Heart or lung disease
• Infections
• Poor nutrition
• Endocrine disorders
• MEDICATIONS
• Alcohol use

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Delirium

• A syndrome, not a final diagnosis
• Fluctuating level of alertness
• Difficult to assess with dementia
• Must identify etiology to treat appropriately
• If psychotic, time-limit use of antipsychotics

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Delirium

• 10 of all hospitalized patients
• 22-38 of hospitalized patients gt65
• 60 of hip fracture cases
• Up to 75 of hospitalized patients from SNFs
• Associated with a 35 increase in hospital
  mortality
• Physicians correctly diagnose delirium in less
  than 20 of cases

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Distinguishing Delirium from Dementia

• Delirium
• Acute onset, usually occurring over days or less
• Global disorder of attention cognition
• Level Of Consciousness Hypoactive, hyper-active
  or both
• Generally lasts days to weeks
• Usually reversible
• Prominent physiologic changes

• Dementia
• Gradual onset that cannot be dated
• Attention fairly normal initially
• Level Of Consciousness normal until final stages
• Chronically progressive over months or years
• Irreversible
• Minimal physiologic
  changes

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Depression Diagnosis

• Depressed mood for at least 2 weeks
• Plus
• At least four of the following
• - Insomnia or hypersomnia
• - Significant weight loss or malnutrition
• - Fatigue or loss of energy
• - Decreased ability to concentrate
• - Psychomotor agitation or retardation
• - Excessive guilt or feelings of worthlessness
• - Thoughts of death, suicidal ideation, or a
  planned or
• attempted suicidal act
• - Loss of interest or pleasure in nearly all
  activities

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Depression Diagnosis

• Geriatric Depression Scale (GDS)
• Cornell Scale for Depression in Dementia
• Center for Epidemiologic Studies of Depression
  (especially for African-American and Native
  Americans)
• No direct biologic marker

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Depression Elder vs Younger

• Elders exhibit different symptoms
• Multiple somatic complaints
• Fatigue
• Insomnia
• Functional loss
• Irritability
• Younger tearfulness, sadness and suicidal
  indications

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Depression

• The most common geriatric psychological disorder
• Up to 1/3 of NF residents
• Estimated that PCPs fail to diagnose depression
  up to half the time fail to provide adequate
  treatment for half of those so diagnosed
  (Kroenke, AIM. 1997)
• Closely associated with functional decline
  triggering quality indicators

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Depression

• Often co-morbid with dementia
• Common post-stroke up to 30
• Beware ageism as a barrier to diagnosis/tx
• Look for underlying medical/medication causes

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Depression

• May be mimicked/caused by ADR
• - Carbidopa/levodopa
• - Beta-blockers
• - Clonidine
• - Benzodiazepines
• - Barbituates
• - Anticonvulsants
• - H2 blockers

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Depression or Dementia (or Both?)

• Depression
• Clear, recent onset
• Shorter duration
• Often previous psychiatric history
• Memory complaints
• Fluctuating performance
• Recent and remote memory equally bad
• Depressed mood precedes memory complaints

• Dementia
• Gradual onset
• Progression over years
• May not have psychiatric history
• Minimizes disabilities
• Tries hard to perform
• Memory loss greater for recent events
• Memory loss precedes depression

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Anxiety Definition

• Awareness of the physiologic reactions of the
  fight or flight responses
• May be triggered by internal or external factors
• May be triggered by issues considered
  irrelevant to others but are real to the
  sufferer
• Anxiety symptoms are far more common than anxiety
  disorder

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Anxiety Disorders

• Think Differential Diagnosis
• Psychosis/Depression/Delirium/Pain/GAD
• Modify environmental triggers if possible
• Medications
• - Caffeine
• - Bronchodilators
• - Pseudoephedrine
• Medical illness
• - Hyperthyroidism
• - Cardiac arrhythmias (Atrial fibrillation,
  PVCs, etc)

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Psychosis

• Definition
• Impaired connection to reality
• Auditory or visual hallucinations or delusions
• Psychosis is a symptom, not a final diagnosis
• Differential Diagnosis includes all types of
  Dementia, Delirium, Drugs (both intoxication and
  withdrawal), Schizophrenia, Bipolar Mania and
  Psychotic Depression
• The diagnosis indicates duration of treatment

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Personality Disorders

• Easy to over-diagnose when elder patients
  decompensate due to dementia, depression, pain,
  etc.
• Consider empiric treatment with antidepressant
• Look for LIFELONG history of the personality
  disorder

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Toxic Personality Syndrome

• Not a disease, but a personality type
• This personality type is often hypercritical,
  angry, and accusatory in spite of every effort to
  give them comfort and optimal care. (Take care
  not to judge the care in a facility based solely
  on the behaviors or statements of this
  personality)
• Does not require (or respond to) any treatment

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The ABCs of Behavior Intervention

• A The Antecedent Events
• B The Behavioral Event
• C The Consequences

Slattery et al, Annals of Long Term Care 1999
710385-391
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The Antecedent Event(Behavior events are rarely
unprovoked)
A

• Triggers that occurred before or even caused the
  behavioral event.
• Modifying triggers is best approach for
  cognitively impaired, because memory loss
  interferes with learning consequences.

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Five Categories of Triggers

• Physical Triggers pain, impaired sight or
  hearing, fecal impaction/constipation, needs
  changing or repositioning, etc.
• Emotional Triggers worried, afraid, distressed,
  etc.
• Environmental Triggers too much or too little
  lighting, noise, temperature, activity levels,
  etc.
• Task Triggers difficulty when challenged by a
  specific task like bathing, dressing or eating,
  etc.
• Communication Triggers difficulty understanding
  others or expressing self, etc.

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Environment/Stressors
Areas to Consider Examples
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B
The Behavioral Event
Defined as any behavioral episode that is
disruptive or adverse, or that jeopardizes the
safety of the resident, other persons, or objects
in the environment.
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Goals of Treating Behaviors in the NH

• Reduce the risk of injury
• Reduce patient distress
• Minimize adverse drug events
• Maintain resident in most desirable living
  setting
• Define for WHOM it is a problem

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Impact of Behavioral Symptoms

• 25 required no intervention.
• 0.8 resulted in injury to others.
• 0.9 resulted in physical damage to the
  environment.
• An average of 24 minutes of staff time was
  required per intervention.

Souder E, Heithoff K, OSullivan PS , et al,
Aging and Mental Health, 1999 354-68
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The Consequences
C

• Includes all actions or occurrences encountered
  after the episode or as an outcome of the event.
• A cognitively intact resident learns to repeat
  behaviors that are rewarded, for example, if
  they get attention from staff. Caregivers must
  consistently reward desired behavior.
• Cognitively impaired residents dont remember the
  rewards, so its best to focus on changing the
  antecedents or triggers.

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Documentation Tips

• Document all diagnosis being actively treated in
  monthly orders progress notes
• Document behavior in progress notes
• Summarize target symptoms
• Attempted nonpharmacologic interventions
• PRNs used
• onset, duration, frequency, associated factors
• Document medication efficacy re target symptoms
• Look at behavior monitoring for accuracy and
  completeness. Consider other ways to document
• GDS, Cornell, Behave AD, Cohen Mansfield

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Documentation Shortfalls

• 108 bed community nursing home.
• 44 (41) residents were on antidepressant
  therapy.
• 14 residents were also on at least one
  antipsychotic medication for management of
  agitation.
• Indication for use was documented in 42 cases
  (95).
• Outcome was documented in 25 cases (57).
• Adverse drug reaction monitoring was documented
  in 9 cases (20).

Annals of Long Term Care 1999, 710364-368
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Non-pharmacologic InterventionsBehavioral
Strategies

• Behavioral Contracting
• Positive Reinforcers
• Written Communications
• One-on-One Intervention
• Redirection
• Distraction
• Traffic Controllers
• Signs/Symbols
• Wander Prevention Nets

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Urgent Action Issues
The immediacy and intensity of action taken
should reflect the severity
and safety of the situation. There may not be
time to explore antecedents in an explosive
situation
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The Prescribing Cascade

• Important in behaviors as it is in other areas of
  LTC issues
• The continuing use of medications to address the
  adverse drug effects of prior drugs
• On-call doctors and frequent staff changes in
  facilities can inadvertently accelerate the
  cascade