tim gieseke md, cmd assoc. clinical prof. ucsf multi-facility medical director [email protected]...

Tim Gieseke MD, CMD Assoc. Clinical Prof. UCSF Multi-facility Medical Director [email protected] Dementia Care 2013

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 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 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 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 http://www.health.fgov.be/internet2Prd/groups/public/%40public /%40dg1/%40acutecare/documents/ie2divers/19073273_nl.pdf IADLS: http://www.abramsoncenter.org/pri/documents/iadl.pdfhttp://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 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 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 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: 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)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 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 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 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: Atrial Fibrillation consider anticoagulation HBP Diabetes Lipid Disorders Cigarettes

Parkinsons 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 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 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/bipolar- disorder/complete-index.shtml http://www.nimh.nih.gov/health/publications/bipolar- disorder/complete-index.shtml Autistic Spectrum Disorder http://www.nimh.nih.gov/health/topics/autism-spectrum-disorders- pervasive-developmental-disorders/index.shtml 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 dont benefit) ACEIs like Donepezil (Aricept), but falls & anorexia risk NMDA Antagonists like Memantine (Namenda) Not both: no increased efficacy in recent studies

Pharmacologic Management Meds for Palliative Care 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 Prazocin 1 small study showed some efficacy for agitation Antipsychotics 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 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 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 features) Distressing Psychosis and Atypical Psychosis Brief Psychotic Disorder Medical Illness with Psychotic symptoms (Delirium, Steroid Psychosis, etc.) Tourettes 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: 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: 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 Cultural & gender issues Tone of voice Simple Direct Speech Bathing without a battle New caregiver or nurse?

Behavior (avoid Agitation term) 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 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: Patient Family Staff Facility Specific Consequencess: Attention Isolation Abuse - reportable Injury Medication response Behavior reinforcement (Borderline Personalities)

Documentation By 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 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 languageNew language Agitation Rummaging/Shopping Wandering Egress or Elopement Refusing Personal Care Repetitive Crying Out Energetic/Assertive Seeking Exploring Showing initiative Cautious 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 Get their attention Listen Calm Tone Yes or no questions Orient to task Use touch Watch you language Dont argue Repeat, rephrase, and 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 Magnesium 250-500 mg Familiar or comfort foods Essential oils lavender, rose, rosemary tiny amounts Favorite cologne, aftershave, perfume Colored lights pink, blue, outside sunlight Pets Small children Acupressure / shiatsu/ swaddling Exercise Foot bath, shoulder, massage, hydro therapy Neutral temperature bath Music

AHCA Recommends 1 st 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 1 st 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 1 st 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 Associations Initiative to safely reduce antipyschotics. http://www.ahcancal.org/quality_improvement/qualityinitiati ve/Pages/Antipsychotics.aspx 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 =dementiaCarehttp://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 http://www.caltcm.org/assets/documents/forms/cdph_lc_a ntipsychotic_survey_tool_07_11_12.pdf

tim gieseke md, cmd assoc. clinical prof. ucsf multi-facility medical director [email protected]...

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