Approaches to behavioral and psychological symptoms of Dementia

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Approaches to behavioral and psychological
symptoms of Dementia

• Marie-France Rivard, MD, FRCPC
• Division of Geriatric Psychiatry
• University of Ottawa

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Objectives

• Describe the causes of common psychological and
  behavioral symptoms in dementia (BPSD)
• Introduce the purpose of the PIECES program
• Identify appropriate interventions
• Advise on the role of pharmacotherapy

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Disclosure slide

• Over last 28 years, received honoraria for
  Continuing education activities from most
  pharmaceutical companies and some grants for
  research.
• Over last 7 years, no direct funding for research
  or Continuing Education honoraria by organizing
  committees who may have, in turn, received
  un-restricted grants.
• Currently Chair, Seniors Advisory Co to MHCC,
  mostly volunteer work.

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Prevalence of BPSD

• 90 of patients affected by dementia will
  experience Behavioral and Psychological Symptoms
  of Dementia (BPSD) that are severe enough to be
  labeled as a problem during the course of their
  illness.
• Agitation (75) Wandering (60) Depression (50)
  Psychosis (30) Screaming and violence (20) are
  most common

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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)
• Agitation, depression, anxiety, paranoid ideation
  cause significant suffering.

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BPSD Symptom Clusters
Aggression
Agitation
Pacing Repetitive actions Dressing/undressing Rest
less/anxious
Physical aggression Verbal Aggression Aggressive
resistance to care
Apathy
Withdrawn Lacks interest Amotivation
Hallucinations Delusions Misidentification Suspici
ous
Euphoria Pressured speech Irritable
Sad Tearful Hopeless Guilty Anxious Irritable/scr
eaming Suicidal
Mania
Psychosis
Depression
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Causes of BPSDWhat is P.I.E.C.E.S.

• Person-centered assessment and care planning
  approach, using the care team to develop
  hypotheses and test the implementation of
  possible solutions.
• An acronym that conveys the individuality and
  importance of the various factors that contribute
  to BPSD in dementia.
• These factors are Physical, Intellectual,
  Emotional, Capabilities, Environment and Social

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P.I.E.C.E.S.

• Taught in Ontario since 1998 to LTC registered
  staff
• From 1999-2007 expanded to include administrators
  of LTC, unregistered staff, acute care hospitals,
  CCAC case managers
• 2007-08 PIECES program for physicians
• Soon available for distribution
• To be tested with family health teams and
  utilized by Peer Presenters and Preceptors of
  Ontarios Alzheimer strategy

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Why use the P.I.E.C.E.S. approach?

• Identification of target behaviors which present
  risk or urgency
• Flags possible delirium
• Framework for synthesis of non-pharmacologic
  approaches
• Nutrition, comfort, hydration, sleep, etc
• Environment, personhood, social, stimulation
• Guide the pharmacologic approach

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PIECES Template

• The Three Question Template
• 1. What has changed?
• 2. What are the RISKS and possible causes (using
  the PIECES framework)?
• 3. What is/are the action (s)?

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P - Physical

• Drugs
• Anticholinergics, benzos,
• Include OTC, alcohol
• Disease
• Atypical presentations, hypoxia, pain, infections
• Delirium 30 mortality if undetected
• Hypoactive and hyperactive
• Basics
• Hydration, bowels, bladder, fatigue, sleep

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Delirium

• I infectious
• W - withdrawal
• A acute metabolic, dehydration, renal, bowels
• T toxins, drugs
• C CNS pathology
• H hypoxia,

• D - deficiencies
• E - endocrine
• A acute vascular
• T - trauma
• H heavy metals

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Delirium work up and intervention

• History and physical
• Bowel/bladder/pain/mobility
• Caregivers re what has changed
• Review medications including prns
• Investigations to identify and correct underlying
  causes
• Vitals, O2 sat, glucose, chest X-ray
• CBC, Na, K, Creatinine, Albumin, Drug levels,
  Ca, Mg, TSH, B12, Folate, Urine, etc.
• CT head if warranted

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Intellectual/cognitive changes

• Memory loss, Amnesia
• Annoying repetitive questioning.
• Accusing others of not telling them about
  upcoming events.
• Being uncooperative with previous requests.
• Agnosia
• Accusing family member of being an imposter when
  cannot quite recognize face
• Failing to recognize ones image in the mirror.
• Utilizing objects inappropriately.

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Intellectual/cognitive changes

• Apraxia
• Dressing inappropriatelyupset with assistance
  provided/required
• Needing assistance to eat
• Aphasia
• Frustration/anxiety
• Inappropriate requests/comments
• Reacting concretely to abstract concept

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Intellectual/cognitive changes

• Anosognosia
• Not recognizing that one is no longer knows about
  or how to do some things, being unaware of
  deficits and need for help
• Impaired executive functions
• poor planning/initiation
• unable to appreciate consequences of things said
  or done before saying/doing them, impulsive
  behavior
• Return to a place back in time

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Intellectual/cognitive changes

• Perceptual difficulties (distances, depth, time
  elapsed, gaps)
• Resisting a bath or toileting, running over
  others.
• Apathy and perseveration
• May be confused with depression or ill-will.
• Return of primitive reflexes, perseverative
  behaviors
• Grabbing caregivers clothing or body part and
  being unable to let go.

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E - Emotions

• Delusions/Hallucinations/agitation
• Dopamine and cholinergic mediated
• Depression/irritability/anxiety
• Serotonergic, adrenergic, cholinergic mediated.
• Adjustment Disorder
• Reactivation of past psychiatric illness with
  stress of dementia, placement
• Emotional Memory, past trauma, losses

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C - Capabilities

• Balance of Physical Demands and Capabilities
• Capacities too low to do a task?
• Resistive behaviours, Frustration
• Catastrophic reactions
• Withdrawal
• Able to do more but assumed incapable
• Boredom, attention-seeking behaviors
• Be sensitive to changes in function
• Acute change rule out reversible component
• Gradual change Adapt care to progression of
  dementia

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E - Environment

• Environmental structure
• design, lighting (glare), physical space,
  temperature
• Ambience
• Sounds, smells, colour, noise
• Familiarity
• Noise excessive, distressing, confusing,
  unfamiliar
• Over/under stimulation
• Changing environment
• Relocation, routines, caregivers

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S - Social

• Life story, life accomplishments
• All about me, personhood
• Social network
• Relationships of family
• Lifelong coping strategies
• Interactions with caregivers who may not know you
  as a person
• Interaction with other residents, roommates,
  others with dementia

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P.I.E.C.E.S. tools

• Daily Observation Sheet (DOS), A-B-C charting
• Shows frequency, severity, patterns of
  behaviours, can be individualized
• Cohen Mansfield Agitation Inventory (CMAI)
• Identifies behaviours and severity over 7 day
  period
• Confusion Assessment Method (CAM)
• Delirium screen
• MMSE, MOCA, Clock
• Sig E Caps, Cornell Depression Scale

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DOS Behavior Map
Time MON TUE WED THU FRI SAT SUN
6am
7am
8am
9am
10a
11a
12p
1pm
2pm
3pm
4pm
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Other Common Tools
Scale Assessment
CMAI The Cohen-Mansfield Agitation Inventory 29 agitated behaviors rated by caregiver on 7 point frequency scale
NPI-NH Neuro-psychiatric Inventory-Nursing Home Version 12 items rated by caregiver on a 4 point frequency and a 3 point severity scale
BEHAVE-AD The Behavioral Pathology in Alzheimers Disease Rating Scale 25 symptoms rated by caregiver on a 4 point severity scale
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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
• ie - Kingston Behavioural Assessment

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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.

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Top Ten Behaviors not (usually) responsive to
medication

• Hiding/hoarding
• Pushing wheelchair bound co-patient
• Eating in-edibles
• Inappropriate isolation
• Tugging at/ removal of restraints

• Aimless wandering
• Inappropriate urination /defecation
• Inappropriate dressing /undressing
• Annoying perseverative activities
• Vocally repetitious behavior

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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
• Delusions and hallucinations
• Sexually inappropriate behavior with agitation

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Pharmacological treatmentWhen (indications)

• Behaviors that have not responded to
  non-pharmacological treatment.
• Persistent despite P.I.E.C.E.S. approach
• Imminent and severe risk to self or others
• E.g. delirium needing to be investigated
• Behaviors that can respond to medication listed
  previously
• Target appropriate symptom cluster depression,
  anxiety (acute or chronic), difficulty falling
  asleep, psychosis

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Pharmacological treatmentChoosing best drug

• Correct underlying cause, deficiency
• Optimize treatment of dementia, CEIs, memantine
• Target appropriate symptom cluster
• Depression Antidepressant
• Anxiety (longer term) antidepressant
• Difficulty falling asleep Trazodone
• Psychosis antipsychotic
• Aggression antipsychotic
• Choose least likely to worsen dementia and
  medical problems
• E.g. Least anticholinergic
• Choose drugs without problematic interaction

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Best choices antidepressants

• SSRI for depression or anxiety
• Citalopram (Celexa) and Escitalopram (Cipralex)
• Sertraline (Zoloft)
• When noradrenergic properties may be wanted
  (pain, activation)
• Venlafaxine (Effexor XR) not if unstable BP
• Bupropion (not if unstable BP)
• When sedation may be needed urgently
• Trazodone watch for hypotension
• Mirtazapine (some anticholinergic properties)
• When important to have a drug well tolerated
• Moclobemide (Manerix) drug interactions

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Best Choices - anxiety

• Cholinesterase inhibitor
• particularly for anxiety of early dementia.
• SSRIs
• first line treatment for anxiety disorders
• will take a few weeks to work
• check drug interactions.
• Consider trazodone (watch for hypotension)

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Best choices anti-psychotics

• For acute delirium very short term (days)
• Haloperidol (0.5 mg that may be repeated)
• Loxapine (2.5 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

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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
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Meds for BPSD
Target symptoms Medication Starting Dose (mg/day) Average Target Dose (mg/day)
Mood swings Euphoria Impulsivity Mood stabilizers valproic acid carbamazepine 250 50-100 500-1000 300-800
Agitation Apathy Irritability Cholinesterase Inhibitors. Memantine As directed 5 mg daily As directed 10 mg BID
Anxiety (short term use in predictable situations) Anxiolytics lorazepam oxazepam 0.25-0.5 5-10 0.5-1.5 10-30
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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.

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Risks associated with pharmacological Rx

• Risks of antidepressants
• Hyponatremia
• Increased agitation/insomnia/suicide in first few
  weeks
• GI upset and bleed if previous ulcers
• Headaches
• Risks of anti-psychotics
• Increase risk of death (all antipsychotics),
  increased QT, cerebrovascular accident
• EPS and tardive dyskinesia
• Worsening of vascular risk factors (increased
  weight, lipids, diabetes)
• Risks of benzodiazepines
• Falls, ataxia, worsening dementia, memory,
  disinhibition

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Using minimal effective dose, only for the
duration required

• Consider dose reduction for antipsychotic as soon
  as there is clear therapeutic response to prevent
  development of side effects
• Review anti-psychotic medication for possible
  discontinuation Q 6 months
• Maintain full dose of antidepressant but review
  if still needed after 1-2 years? Only if no prior
  history of depression

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Family physicians are at the core of the
treatment team, working with

• Patients and substitute decision makers
• Other caregivers (home care, LTC staff)
• Community resources (Alzheimer Society, First
  Link programs)
• Consultants such as PRCs, Outreach teams,
  Specialized geriatric medicine and mental health
  services

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Questions and further readings

• Program for physicians should be available in the
  coming months distribution strategies?
• CCSMH guidelines on LTC issues, depression,
  delirium and suicide
• New Canadian Consensus guidelines on Dementia.