LYNN ET T ERS , MSN , GNP-B C , A NP-CA NGELA POPOF F, LMS W

OPTIMIZING TREATMENT AND CARE FOR PEOPLE WITH

BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS OF

DEMENTIA

BEHAVIORAL & PSYCHOLOGICAL SYMPTOMS OF DEMENTIA (BPSD)

“Symptoms of disturbed perception, thought content, mood or behavior that frequently occur in patients with dementia”

(IPA consensus group 1999)

INTRODUCTION• Aging population = Significant increase in the

absolute number of older people with Alzheimer’s disease (AD) & other dementias• Dementia is associated with progressive

cognitive decline, a high prevalence of BPSD such as agitation, depression and psychosis, stress in caregivers, & costly care• BPSD are an integral part of the disease process

& present severe problems to patients, their families, caregivers, & society at large• Treatment of BPSD offers the best chance to

alleviate suffering, reduce family burden, & lower societal costs in patients with dementia

PREVALENCE OF BPSD IN DEMENTIA

• Up to 95% of persons with dementia develop BPSD

• Over 80% of BPSD persist over an 18 month period -especially delusions, depression and aberrant motor behavior

• BPSD predicts functional decline, cognitive decline & institutionalization

• BPSD is not a unitary concept & should be divided into several or more groups of symptoms reflecting a different prevalence, course over time, biological correlate and psychosocial determinants

PREVALENCE OF BPSD

• Delusions• Hallucinations• Misidentifications• Depression• Sleeplessness

• Anxiety• Physical aggression• Wandering• Restlessness

•Most intrusive & difficult BPSD to cope with are:

USING THE NEUROPSYCHIATRIC INVENTORY (NPI)

• Delusions• Hallucinations• Agitation/aggression• Depression/dysphoria• Apathy/indifference• Elation/euphoria

• Anxiety• Disinhibition• Irritability/lability• Aberrant motor behavior• Sleep• Appetitie/eating disorder

WHY ARE BPSD IMPORTANT?

CAUSES OF BPSD• Biological Factors• Genetic• Neurotransmitters• Structural Changes• Clinical Factors• Psychological & Personality Factors• Social & Environmental Factors• Caregiver Factors

CLINICAL RISK FACTORS FOR BPSD

• Increased Irritability in higher functioning groups

• Executive impairment early in course of dementia associated with BPSD & carer stress 3-6 years later

• Frontal symptoms are associated with increased severity & frequency of agitation & aggression as well as increased severity of psychosis & depression

• Serious medical comorbidity – increased risk of agitation, irritability, disinhibition & aberrant motor behavior

BPSD ARE OFTEN MULTI-FACTORIAL IN ETIOLOGY

• Few cases of BPSD are due to a single factor

• Must consider a biopsychosocial approach in the clinical context – medical, psychiatric, behavioral, cognitive, environmental, social – to identify treatable factors

DIAGNOSIS AND ASSESSMENT OF BPSD

• Phenomenology is the basis of diagnosis• Direct interview• Direct observation• Proxy report• Measurements and scales (NPI)• Need for accurate descriptions• Think of physical illness• Think of sensory impairment

TREATMENT PRINCIPLES

• When treating BPSD, success rates will be higher if the following principles are observed:

• Identify what symptom(s) cause most concern• Describe each symptom in detail• Specify the Antecedents of Behaviors (the

circumstances that spark them) & their Consequences (what makes them better or worse)• This approach is known as the ABC

approach

OVERVIEW OF MANAGEMENT OF BPSD

• Patients with BPSD should be evaluated for delirium• Consider changes in environment, medication,

fecal impaction, pneumonia, urinary infection, etc.• Evaluate for needs that the dementia patient is

unable to communicate normally e.g. pain• Behavioral management or situational

manipulation are the initial strategies of choice for mild to moderate BPSD• Pharmacological interventions are useful if

symptoms are severe or do not respond to non-pharmacologic strategies alone

Sleep deprivationWorsens dementia

Sleep apnea

Impaired memory processing

High body mass, glucose intolerance

KEY MESSAGES

• There is now a substantial body of evidence supporting the use of non-pharmacological treatments of BPSD• Even when BPSD are caused by physical

discomfort, major depression, or psychosis, psychosocial interventions will prove helpful when offered in combination with analgesic, antidepressant, or antipsychotic medications• Psychosocial approaches are indicated as

first-line approaches to all BPSD

KEY MESSAGES - II

• Psychosocial interventions work best when they are tailored to people’s backgrounds, interests, & capacity• Family & professional caregivers are key

collaborators. It is important to provide them with necessary information, education, & to support them as they test & refine their responses to challenging symptoms• The physical environment can help prevent

or minimize BPSD by reducing distress, encouraging meaningful activity, maximizing independence, & promoting safety

SYSTEMATIC REVIEW OF PSYCHOSOCIAL TREATMENTS FOR BPSD

• Only 25 of 118 relevant studies met every specification• Treatment proved more effective than an

attention control condition in reducing behavioral symptoms in only 11 of the 25 studies• Effect sizes were mostly small or moderate• Treatments with moderate or large effect sizes

included aromatherapy, ability-focused carer education, bed baths, preferred music, & muscle relaxation training

• (O’Connor et al, 2009)

Tablet5mg, 10mg23mg

Tablet3mg, 4.5mg, 6mgPatch4.6mg, 9.5mg

Tablet8mg, 16mg, 24mg

First Line The Acetylcholinesterases

Great Expectations• For all AD stages

– Mild– Moderate– Severe

• Exelon approved for Parkinson’s/Lewy body

• Those who took AchEI the earliest and continued the longest lived three years longer than those who – Never took AchEI– Stopped the drug– Started later

• Benefits– Slows progression– Improve behavior (hallucinations,

delusions, mood)• Safest and most specific treatment

for the disease

Side Effects• Runny nose• Initial nausea, diarrhea

– Abates without intervention– Upon first starting or

increasing dose– If continues, check for other

underlying cause• Avoid if:

– COPD dependent on steroids– Active lung infection– Active stomach ulcer– Heart block

Second Line -Namenda• Moderate to severe AD• NMDA receptor antagonist

– Slows neuron death• Add to Acetylcholinesterase

inhibitors• Side effects:

– insomnia, – constipation– headache

• Drug interactions– dextromethorphan

Titration pack10mg twice daily

Potentially Inappropriate Medications for those with Dementia

Anti-cholinergic MedicationsPossible Consequences

• Confusion and delirium• Blurred vision• Dry mouth• Urinary retention• Constipation• Increased risk for falls

Caution

• Minimize use if possible• Cancels effects of acetyl

cholinesterase inhibitors• Benefits vs. disadvantages

ANTICHOLINERGICSINCREASE RISK FOR DEMENTIA

• In a cross-sectional, prospective study of 1,380 elderly inpatients, researcher found, medication with anticholinergic properties are associated with worse cognitive & functional performance in elderly patients• There was a dose-response relationship for

total burden score and cognitive impairment.

• (Pasina et al., 2013)

IF PHARMACOLOGICAL THERAPY IS NEEDED:

• Look for symptom complexes such as depression, psychosis or anxiety to guide initial choice of agent

• In most situations, medications should be given in lower doses than are typically recommended for an adult population

• Ideally, use agents with demonstrable efficacy as first line agents

ANTIDEPRESSANTS IN DEMENTIA

• Effectiveness in treating depression, anxiety and agitation in dementia is modest

• Meta-analysis by Thompson et al (2007) of depression in dementia included five DB placebo controlled studies involving 165 patients and found antidepressants efficacious with the number needed to treat being five

• Subsequently, one large RCT of 131 depressed patients treated with sertraline was found to be ineffective (Rosenberg et al, 2010)

• SSRIs remain the first choice agents, if only due to their tolerability

ATYPICAL ANTIPSYCHOTICS FOR BPSD

• Meta-analysis of 13 studies concluded ‘effect sizes of atypical antipsychotics for behavioral problems are medium, and there are no statistically or clinically significant differences between atypical antipsychotics and placebo’ (Yury & Fisher, 2007)

• Best quality evidence of effectiveness is with risperidone

ANTIPSYCHOTICS FOR BPSD

• Antipsychotic medications are most effective in the treatment of psychotic symptoms (hallucinations, delusions), agitation, and aggression

• Both atypical and typical antipsychotics appear to carry an increased risk for mortality and stroke in patients with dementia

• Atypical antipsychotics are preferred over typical antipsychotics for BPSD

• Side effects include sedation, weight gain, confusion, parkinsonism

KEY MESSAGES

• In general, non-pharmacological approaches are first-line treatment for BPSD• Medication is indicated for BPSD that are

moderate to severe that has impact on a patient’s or caregiver’s quality of life, functioning, or that pose a safety concern, often in conjunction with non-pharmacological interventions• In a person unable to provide informed consent,

it should be obtained from the appropriate proxy & include the potential risks associated with pharmacological treatments• Develop a plan to monitor therapy – aim to cease

medication within 3 months if possible

CONCLUSIONS

• BPSD occurs in up to 95% persons with dementia• The course of BPSD is now better understood• Causes of BPSD are multifactorial including

biological, social, psychological, and environmental factors• Non-pharmacological treatments should be

first line for all BPSD• Pharmacological treatments have only

modest efficacy & may have serious adverse effects & should be reserved for only moderate to severe BPSD

RESOURCES• Ames, D., Burns, A., & O’Brian (Eds.), (2010). Dementia (4th Ed.), UK: Hodder Arnold.• International Psychogeriatric Association (IPA). (2013). The IPA complete guides to

behavioral and psychological symptoms of dementia. Retrieved from http://www.ipa-online.org

• Pasina, L., Djade, C. D., Lucca, U. Nobili, A., Tettamanti, M., Franchi, C.,…Mannucci, P. M. (2013). Association of anticholinergic burden with cognitive and functional status in a cohort of hospitalized elderly: Comparison of the anticholinergic cognitive burden scale and anticholinergic risk scale: Results from the REPOSI study. Drugs & Aging, 30(2), 103-112.

• O’Connor, D. W., Ames, D., Gardner, B., & King, M. (2009). Psychosocial treatments of psychological symptoms in dementia: A systematic review of reports meeting quality standards. International Psychogeriatrics, 21, 225-251.

• Selkoe, D. J., Mandelkow, E., & Holtzman, D. M. (Eds.), (2012). The Biology of Alzheimer’s Disease. Cold Spring Harbor, NY: Cold Spring Harbor Laboratory Press.

• Thompson, C. A., Spilsbury, K., Hall, J., Birks, Y., Barnes, C., & Adamson, J. (2007). Systematic review of information and support interventions for caregivers of people with dementia. BMC Geriatrics, 27(7), 18.

• Yury, C. A., & Fisher, J. E. (2007). Meta-analysis of the effectiveness of atypical antipsychotics for the treatment of behavioral problems in persons with dementia. Psychotherapy & Psychosomatics, 76(4), 213-218.

Greater Michigan Chapter25200 Telegraph RoadSouthfield, MI 48033

(800) 272-3900www.alz.org/gmc

Service Territory Greater Michigan Chapter Office

Locations Southfield, MI

Wayne, Oakland, Macomb, St. Clair, Huron, and Sanilac Counties

Midland, MI Traverse City, MI Marquette, MI Grand Rapids, MI Alpena, MI

Great Lakes Chapter http://www.alz.org/mglc/

HARRY L. NELSON HELPLINEOverview

1-800-272-3900 Who is Harry L. Nelson? What is the Harry L. Nelson

Helpline? The Harry L. Nelson Helpline

Provides: Confidentiality Empathetic listening Accurate information and referral Accessibility (24/7)

Types of Helpline Calls Information

regarding our agency

Basic information on dementia

Program and service referrals

Guidance and support

What does this program provide? 24/7/365 accessibility Efficient and safe reunions Information to emergency

responders Training for emergency

responders Incident follow up support

GPS tracking device Portable device, device for car

Track location on a secured and protected website

Allows alerts to assist care partner in knowing where loved one

Allows a “safe zone” to be set

Pricing may vary, fees include: Device, activation fee, and

monthly fee

CARE CONSULTATION Services Include:

- Assessments - Assistance with planning &

problem solving - Supportive listening

Fee for service is reimbursed through some insurances, or a sliding scale is utilized.

NO ONE IS TURNED AWAY DUE TO INABILITY TO PAY

Types of Care Consultation Programs

General Care ConsultationThe Wraparound ProgramHenry Ford Health System CollaborativeWest BloomfieldDetroitTaylor

SUPPORT GROUPS

Kinds of Support Groups Caregiver Support Groups Dial-in Support Group Younger Onset Support Group Early Stage Support Groups FOR INFORMATION ON THESE GROUPS, VISIT www.alz.org/gmc

Early Stage Programming

Ongoing support group

Early Stage Lecture Series

Early Stage Social Club

Living With Alzheimer’s

Pre-assessment required for registration!

Minds on Art Minds on Art is a FREE 6 week

program, as well as providing Saturday drop in sessions.

For people living with Alzheimer’s disease and other dementias and their care-partners.

Provides unique opportunity for individuals in the early and mid stages of the disease to create meaningful memories through art.

Hosted at the Detroit Institute of Arts (DIA)PRE-REGISTRATION REQUIRED

EDUCATION PROGRAMS

Provided by instructors or moderators with appropriate expertise.

Provided for both the community and staff in the field of dementia care

Types of Education Programs Foundations of Dementia Care The Basics Know the Ten Signs Creating Confident Caregivers

Creating Confident Caregivers

Improving caregiver skill, knowledge, and outlook

Developing skills for self-care

Strengthening family resources

Strengthening decision making skills

Improving confidence reduces sense of distress

RESPITE SERVICES

What is Respite? Respite Services Include:

- Adult Day Programs Rebecca & Gary Sawka Day Program- Southfield,

MI Robert & RoseAnn Comstock Day Program-

Detroit, MI

- Respite Care Assistance Program

Check with regional office for availability

Get Involved Hosting a Third Party Event Attending or assisting at a fundraiser:

Walk to End Alzheimer’sChocolate Jubilee

Writing letters, emails, making phone calls to local legislatures

Be a support group facilitator Be a Harry L. Nelson Helpline

Representative Represent our agency at community

health fairs Be a speaker on our Speaker’s Bureau Sign up for a clinical trial in your area

using Trial Match Visit our message boards at www.alz.org

CONTACT US!For more information on our services or to

get more involved:

Call our 24/7 Harry L. Nelson Helpline1-800-272-3900

Visit our chapter websitewww.alz.org/gmc

Visit our National websitewww.alz.org