Treatment Modalities for the Management of Distressed Behaviors in Elderly

Revised by Tony Setiabudhi December 2010

Definitions
Behavior refers to an individuals observable actions. Cognition refers to any personal activities related to organizing memory, sensation, and thin ing !ental status refers to an individuals overall level of alertness, activation, and responsiveness to the outside "orld.
#!$# $ementia C%& 1''(

Incidence of Behaviors
#pathy *+2, #gitation *./, #n0iety *12, 3rritability *12, !otor restlessness *)(, $isinhibition *)., 4leep disturbance *21, $epression *2), $elusions *22, 5allucinations *1/,)

Distressed Behaviors in -ursing .omes

3ncreases stress bet"een patients and caregivers1 Create intensive and costly levels of treatment1 3ncrease morbidity and mortality 1 6ead to public health problems that contribute to the enormous cost of treating dementia1 3ncrease ris of overmedication and restraints
1 !in"el SI et al Int #sychogeriatr 1$$%&'()$*+,00
1

/0gitation1
70cessive motor or verbal activity that is 1 1. 8ne of the follo"ing Disru2tive OR 3nsafe OR Distressing to the 2atient 1. 3nterferes "ith care and 2. 3s not because of need &enerally, is a poor descriptor of behavior #ppears similar despite great variety of causes 9eed to ma e diagnosis, not focus only on symptoms :hen severe, may be the target for urgent intervention 1 4ohen+Mansfield et al5 1$$%& Tariot et al5 1$$)
4ohen+ Mansfield 0gitation Inventory 666 medafile com78y6eb74M0I htm

0gitation and 0ggression in Dementia

%hysical 5itting %acing =ic ing Biting %ushing 4pitting 4cratching ;erbal <hreats #ccusations 9ame>calling 8bscenities Complaining #ttention>see ing 4creaming
.

4ohen+Mansfield et al5 1$$%& Tariot et al5 1$$)

Behavior $iagnosis? %itfalls

!any etiologies can present "ith the same behaviors *70ample of fever Co>e0istence of multiple ris factors present in any one resident? disease, medications, changed environment, etc. <he ey is to have a process to evaluate the resident for the behavior

9eneral 022roach to Behaviors

Clearly characterize target symptoms 4tandard medical evaluation to identify possible medical disorder Differential diagnosis of behavior cause <he A,B,Cs of Behavior Intervention
@ Antecedent, Behavior, Consequences

Document, Document, Document Non-pharmacologic intervention

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9ood Target Sym2toms

#n0iety 3nsomnia $elusions *stressful 5allucinations *stressful $ysphoriaA$epression Compulsive behaviors #gitationA#ggressiveness !otor restlessness %ain
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#oor Target Sym2toms

70it>see ing %acing B :andering %erseverant vocalizations 5oardingA4tealing 3nappropriate se0ual touching 9on>stressful delusions $isrobing
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Medical Evaluation
!edicalA%sychiatric 5istory !edication? e0cess, "ithdra"al, #$C %hysical evaluation? urinary retention, fecal impaction *constipation-, pain, dental problems !ental 4tatus 70am 6ab studiesAo0imetry 3maging 4tudies
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!edical 3llness
3llnesses? &7C$, angina, 8#, etc. !edication side effects Chronic pain Constipation 5earing or vision impairment 4leep deprivation $ental problems
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Differential for Behavior 4auses

$ementing disorders Drontal 6obe impairment $elirium !edications <o0ic personality syndrome %ain
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Differential for Behaviors :cont ;

%rimary psychiatric illness > #ffective disorder *$epression> #n0iety disorder > %sychotic disorder > %ersonality disorder 7nvironmentA4tressors
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Definition( Dementia
# syndrome *a collection of signs B symptoms- of progressive decline in multiple areas of cognitive function "hich eventually produces significant deficits in self>care and social and occupational performance.

#!$# $ementia C%& 1''(

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Dementia
3ncidence of 1>2, at .2>+/ years of age, increasing to E)/, after (2 Fp to (/, of 9D residents have some degree of dementia <he resultant decline in functional capacity is the chief cause of 9D admission

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Dementia 4ategories
#lzheimers disease *.2, 6e"y Body dementia *+, #$ "Avascular disease *1/, #$ "A6e"y bodies *2, ;ascular dementia *2, 8ther? 3nfectious, 7t85, etc. *(,1+

Definition( Dementia of the 0l8heimer Ty2e :D0T;

# degenerative neurologic disease that results in impaired memory, thin ing and behavior. 3t is characterized by a gradual onset of progressive symptoms that include memory loss, personality changes, and decline in ability to thin and function. $#< is by far the most common from of dementia in the F.4., 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 1(

D0T
./>(/, of dementia that occurs in those E.2 years old 4lo", insidious decline in multiple cognitive s ills Celatively "ell preserved motor function early in disease course C<A!C3 normal, or atrophy, perhaps "ith mild "hite matter changes 9o biological mar ers > diagnosed at autopsy 7tiology? genetics *#%8 e1- G H
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$ementia "ith 6e"y Bodies *$6B $6B more recently accounts for 12 > 2/, of all dementia 5allmar feature? "idespread 6e"y bodies throughout the neocorte0 "ith 6e"y bodies and cell loss in the subcortical nucleii "ith distinctive pattern of neuritic

degeneration on autopsy
!ore males than females #ge of onset? 2/ @ () 3nsidious onset progressing to profound dementia
Mc<eith I 9 Dementia 6ith =e6y Bodies British > of #sychiatry 20025 1'051))+1)*
4hioza i et al?I 9eurol 9eurosurg %sych? ;.+?1'''

$6B 4ore !eatures

CeJuired? Cognitive $ecline "ith decreased social or occupational functioning # diagnosis of %robable $6B reJuires 2 of the follo"ing *%ossible $6B reJuires only one of the follo"ing-?
@ Dluctuating cognition "ith pronounced variation in attention and alertness 1 @ Cecurrent visual hallucinations that are typically "ell formed and detailed @ 4pontaneous motor features of par insonism
1 2 ?uantification and 4haracteri8ation of !luctuating 4ognition in Dementia 6ith =e6y Bodies and 0l8heimer@s Disease M # Aal"er5 9 0 0yre5 E < #erry5 < Aesnes5 I 9 Mc<eith5 M Tovee5 > 0 Ed6ardson5 4 9 Ballard Dementia and Geriatric Cognitive Disorders 2///K11?)2+>))2 *$83? 1/.112'A////1+2.2 Mc<eith I 9 Dementia 6ith =e6y Bodies British > of #sychiatry 20025 1'051))+1)*

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$ementia "ith 6e"y Bodies

<reatment 3ssues @ Fp to (/, of $6B patients have hypersensitivity to neuroleptics. %rescribe antipsychotics only "hen absolutely necessary and under strict monitoring @ %rovisional evidence suggests that patients may respond more preferentially to #Ch3 therapy @ Concomitant depression )2, of $6B vs. 1., of #$
Mc<eith I 9 Dementia 6ith =e6y Bodies British > of #sychiatry 20025 1'051))+1)*

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Drontal 6obe 3mpairment? 40

!ood lability or inappropriate affect %oor impulse control ;erbally rude, caustic, bigoted, etc. 7pisodically physically aggressive %erseverative CestlessAgrabbingAreacts strongly to stimuli $ifficult to redirect 4e0ually inappropriateAaggressive
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Drontal 6obe 3mpairment

9ot psychotic behavior, but poor impulse control 4een in multiple types of disease processes > 4$#< > ;ascular dementia > !ultiple sclerosis > 7t85 disease
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!rontal =obe Im2airment( -on+#harmacologic Management

!aintain professional distance
@ 70aggerated manners, professional attire @ 7mphasize courtesy, avoid overly friendly

Communicate concretely, no open ended comments $efine the activity, give fe" and clear choices 4hape the behavior, ac no"ledge improvements Medication when needed:
@ 4afety concerns @ 9ot responsive to nonpharmacologic interventions
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Definition( Delirium
# state of acute confusion, inattention, and altered level of consciousness *68C-, usually abrupt in onset *over several hours to several days-.

2.

Delirium( Sym2toms
Dluctuations in alertness B mental functioning manifested by inattention #n0iety 5allucinations $isorientation <remors $elusions 3ncoherence
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4ommon Delirium Triggers

#cute illness 5eart or lung disease 3nfections %oor nutrition 7ndocrine disorders !7$3C#<3894 #lcohol use
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Delirium
# syndrome, not a final diagnosis

Dluctuating level of alertness $ifficult to assess "ith dementia

!ust identify etiology to treat appropriately 3f psychotic, time-limit use of antipsychotics
2'

Delirium
1/, of all hospitalized patients 22>)(, of hospitalized patients E.2 ./, of hip fracture cases Fp to +2, of hospitalized patients from 49Ds #ssociated "ith a )2, increase in hospital mortality %hysicians correctly diagnose delirium in less than 2/, of cases
)/

Distinguishing Delirium from Dementia

Delirium
L0cute onset5 usually occurring over days or less

Dementia
L9radual onset that cannot be dated

L9lobal disorder of attention L 0ttention fairly normal B cognition initially L=evel Cf 4onsciousness( .y2oactive5 hy2er+active or both L9enerally lasts days to 6ee"s L3sually reversible L#rominent 2hysiologic changes L=evel Cf 4onsciousness( normal until final stages L4hronically 2rogressive over months or years LIrreversible LMinimal 2hysiologic changes
)1

De2ression( Diagnosis
$epressed mood for at least 2 "ee s lus #t least four of the follo"ing? > 3nsomnia or hypersomnia > 4ignificant "eight loss or malnutrition > Datigue or loss of energy > $ecreased ability to concentrate > %sychomotor agitation or retardation > 70cessive guilt or feelings of "orthlessness > <houghts of death, suicidal ideation, or a planned or attempted suicidal act > 6oss of interest or pleasure in nearly all activities

)2

De2ression( Diagnosis
&eriatric $epression 4cale *&$4 Cornell 4cale for $epression in $ementia Center for 7pidemiologic 4tudies of $epression *especially for #frican>#merican and 9ative #mericans 9o direct biologic mar er
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De2ression( Elder vs Dounger

L 7lders e0hibit different symptoms
L !ultiple somatic complaints L Datigue L 3nsomnia L Dunctional loss L 3rritability

L Mounger? tearfulness, sadness and suicidal indications

)1

De2ression
<he most common geriatric psychological disorder Fp to 1A) of 9D residents 7stimated that %C%s fail to diagnose depression up to half the time B fail to provide adeJuate treatment for half of those so diagnosed *=roen e, AI!" 1''+ Closely associated "ith functional decline B triggering Juality indicators
)2

De2ression
8ften co>morbid "ith dementia Common post>stro e @ up to )/, Be"are ageism as a barrier to diagnosisAt0 6oo for underlying medicalAmedication causes

).

De2ression
!ay be mimic edAcaused by #$C > CarbidopaAlevodopa > Beta>bloc ers > Clonidine > Benzodiazepines > Barbituates > #nticonvulsants > 52 bloc ers
)+

De2ressionE or DementiaE :or BothF;

De2ression
4lear5 recent onset Shorter duration Cften 2revious 2sychiatric history Memory com2laints !luctuating 2erformance Recent and remote memory eGually bad De2ressed mood 2recedes memory com2laints

Dementia
9radual onset #rogression over years May not have 2sychiatric history Minimi8es disabilities Tries hard to 2erform Memory loss greater for recent events Memory loss 2recedes de2ression
)(

0nHiety( Definition
#"areness of the physiologic reactions of the fight or flight responses !ay be triggered by internal or e0ternal factors !ay be triggered by issues considered irrelevant to others but are real to the sufferer #n0iety symptoms are far more common than an0iety disorder
)'

0nHiety Disorders
Thin" Differential Diagnosis(
@ %sychosisA$epressionA$eliriumA%ainA&#$

!odify environmental triggers if possible !edications? > Caffeine > Bronchodilators > %seudoephedrine !edical illness > 5yperthyroidism > Cardiac arrhythmias *#trial fibrillation, %;Cs, etc-

1/

#sychosis
$efinition
@ 3mpaired connection to reality @ #uditory or visual hallucinations or delusions

%sychosis is a symptom , not a final diagnosis $ifferential $iagnosis includes all types of $ementia, $elirium, $rugs *both into0ication and "ithdra"al-, 4chizophrenia, Bipolar !ania and %sychotic $epression <he diagnosis indicates duration of treatment
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#ersonality Disorders
7asy to over>diagnose "hen elder patients decompensate due to dementia, depression, pain, etc. Consider empiric treatment "ith antidepressant 6oo for 63D7689& history of the personality disorder
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ToHic #ersonality Syndrome

9ot a disease, but a personality type <his personality type is often hypercritical, angry, and accusatory in spite of every effort to give them comfort and optimal care. *<a e care not to Nudge the care in a facility based solely on the behaviors or statements of this personality $oes not reJuire *or respond to- any treatment
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The 0B4Is of Behavior Intervention

/01 J The 0ntecedent Events /B1 J The Behavioral Event /41 J The 4onseGuences
Slattery et al, Annals of Long Term Care 1999; 7[10]:385-391

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The Antecedent Event

*Behavior events are rarely unprovo ed <riggers that occurred before or even caused the behavioral event. !odifying triggers is best approach for cognitively impaired, because memory loss interferes "ith learning conseJuences .

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!ive 4ategories of Triggers

#hysical Triggers(( pain, impaired sight or hearing, fecal impactionAconstipation, needs changing or repositioning, etc. Emotional Triggers( "orried, afraid, distressed, etc. Environmental Triggers( too much or too little lighting, noise, temperature, activity levels, etc. Tas" Triggers( difficulty "hen challenged by a specific tas li e bathing, dressing or eating, etc. 4ommunication Triggers( difficulty understanding others or e0pressing self, etc.
1.

7nvironmentA4tressors
0reas to 4onsider
4tressors 7nvironment %remorbid personality Caregiver issues

EHam2les
6osses $ecreased control Cro"ding 6evel of stimulation 3dentity #ctivities

Burnout, need for respite 7ducation B e0pectations

Concrete "ith fle0ibility Cespect, redirection

#pproach

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The Behavioral Event

Defined as any behavioral e2isode that is disru2tive or adverse5 or that jeopardizes the safety of the resident5 other 2ersons5 or obKects in the environment

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9oals of Treating Behaviors in the -.

Ceduce the ris of inNury Ceduce patient distress !inimize adverse drug events !aintain resident in most desirable living setting $efine for :58! it is a problem
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Im2act of Behavioral Sym2toms

2,L reGuired no intervention 0 'L resulted in inKury to others 0 $L resulted in 2hysical damage to the environment 0n average of 2) minutes of staff time 6as reGuired 2er intervention
So !er ", #e$t%off &, '(S ll$)an *S , et al, Ag$ng an! +ental #ealt%, 1999; 3:5,--8
2/

The onse!uences
Includes all actions or occurrences encountered after the e2isode or as an outcome of the event 0 cognitively intact resident learns to re2eat behaviors that are /re6arded15 for eHam2le5 if they get attention from staff 4aregivers must consistently re6ard desired behavior 4ognitively im2aired residents donIt remember the /re6ards15 so itIs best to focus on changing the antecedents or triggers
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Documentation Ti2s
Document all diagnosis being actively treated in monthly orders B 2rogress notes Document behavior in 2rogress notes
@ Summari8e target sym2toms @ 0ttem2ted non2harmacologic interventions @ #R-Is used @ onset5 duration5 freGuency5 associated factors

Document medication efficacy re( target sym2toms =oo" at behavior monitoring for accuracy and com2leteness 4onsider other 6ays to document @ 9DS5 4ornell5 Behave 0D5 4ohen Mansfield
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Documentation Shortfalls
10' bed community nursing home )) :)1L; residents 6ere on antide2ressant thera2y 1) residents 6ere also on at least one anti2sychotic medication for management of agitation Indication for use 6as documented in )2 cases :$,L; Cutcome 6as documented in 2, cases :,*L; 0dverse drug reaction monitoring 6as documented in $ cases :20L;
Annals of Long Term Care 1999, 7[10]:3-,-3-8
2)

-on+2harmacologic Interventions( Behavioral "trategies

Behavioral Contracting %ositive Ceinforcers :ritten Communications 8ne>on>8ne 3ntervention Cedirection $istraction <raffic Controllers 4ignsA4ymbols :ander %revention 9ets
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3rgent 0ction Issues

The immediacy and intensity of action ta"en should reflect the severity and safety of the situation
There may not be time to eH2lore antecedents in an eH2losive situation

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The #rescribing 4ascade

3mportant in behaviors as it is in other areas of 6<C issues <he continuing use of medications to address the adverse drug effects of prior drugs 8n>call doctors and freJuent staff changes in facilities can inadvertently accelerate the cascade
2.