Elizabeth Galik, PhD, CRNP Associate Professor University of Maryland School of Nursing

 This presentation will include discussion of off-label uses of medications.

1. Discuss a framework for accurate assessment of older adults with dementia and behavioral symptoms 2. Apply evidence based practice principles to the non-pharmacologic and pharmacologic management of older adults with dementia and behavioral symptoms.

 85-90% of individuals with dementia at some point during the course of their illness exhibit challenging behavioral symptoms such as: ◦ Physical aggression ◦ Resistance to care ◦ Agitation

CLIENTS/RESIDENTSCAREGIVERS  Negatively impacts quality of life  Increases risk of injury  Leads to inappropriate use of psychotropic medications  Exacerbates functional decline  Increases time spent in care  Increases risk of injury  Decreases job satisfaction and leads to staff turnover

 We interpret behavior differently/different stakeholders  We give behavior meaning  Behavior is rarely random or unprovoked

 Client/Resident  Family  Staff  Peers  Facility  Regulatory Agencies

Psychiatric Cognitive Status Physical/Medical Environment Disorders Caregiver Approach

“I don’t understand you.” “I’m depressed.” “I’m in pain”. “You’re rushing me”. “It’s too noisy”.

 Amnesia (memory loss)  Aphasia (language impairment…receptive and/or expressive  Apraxia (impairment of learned motor skills)  Agnosia (perceptual impairment)

 Adjust expectations to abilities  Simplify communication  Cue and role model  Minimize objects that may be misperceived  Optimize sensory input  You almost always get a “do over”

 Temperature  Noise  Over and under stimulation  Too much or too little space  Familiarity, routine

 Adapt environmental stimuli (noise, temperature, lighting, peers, staff, etc.)  Consistent routines and caregivers  Provide opportunities for activity to prevent boredom  Redirection, distraction

 Individuals with dementia exhibit behavioral symptoms most commonly during care activities, such as: ◦ Bathing ◦ Oral care ◦ Dressing ◦ Transfers and mobility ◦ Toileting ◦ Mealtime

 Older adults with dementia and/or delirium ◦ Have difficulty understanding verbal directions ◦ Misinterpret touch that occurs during care activities ◦ Care becomes a perceived threat and results in fear, fight, flight response

 Listening and empathy (acknowledge the fear, worry, anger, etc.)  Validate and reassure  Then redirect, distract

 Use cueing, gesturing, pantomime  He washes one area and you another  Hand over hand  Minimize verbal speech  Use deeper voice if patient is hard of hearing  Remain calm  Limit the number of caregivers  Wait for the “best time” for the patient

 Pain  Constipation  Infection  Medication

 Give vigilant medical care  Recognize and treat delirium early  Consider the impact of pain…

 Depression  Psychotic symptoms

 Describe the behavior  Decode the influence of: ◦ Cognitive status, environment, caregiver approach, physical/medical, and psychiatric symptoms  Design a plan  Determine if it works (Rabins, Lyketsos, & Steele, 2006)

 Frequency  Duration  Setting  Who is involved?  Be specific…..agitation is not enough

 Cognitive Status  Environment  Caregiver Approach  Physical/Medical  Psychiatric Symptoms

 Nursing Home Toolkit ◦  Advancing Excellence ◦ ?controls=dementiaCare ?controls=dementiaCare  Function Focused Care ◦

 Community dwelling (1.7%-5.1%)  Nursing home residents (16%-40%) ◦ Conventional (1.75%) atypical (31.63%) ◦ CMS National 23.9% to 18.0% (2012- Quarter 2 of 2015) ◦ CMS Maryland 26.9% to 18.33% (2012-Quarter 2 of 2015)  Beck et al., 2005; Briesacher et al., 2005; Gruber-Baldini et al., 2007; Kamble et al., 2009)  Acute care ◦ 34% (Elie et al 2009) ◦ 10% on ACE units (Flaherty & Little, 2011) (

 Bipolar disorder  Schizophrenia  Adjunct to antidepressants for major depressive disorder (aripiprazole)

 Psychotic symptoms associated with dementia ◦ Delusions in AD patients 9-63% (median 36%) ◦ Hallucinations in AD patients 4-41% (median 18%) (Jeste & Finkle, 2000)  Agitated behavioral symptoms associated with dementia (occurs in 40-70% of hospitalized patients with dementia) (Fick & Mion, 2008)  Delirium (Hakim, Othman & Naoum, 2012)

 Some efficacy among those with psychotic symptoms and significant physical aggression in short term use only (Maglion, et al., 2011) though risks may outweigh benefits (Schneider et al., 2005; 2006)  Little evidence of efficacy with agitation, verbal outbursts, resistance to care

 May have increased risk of relapse for those with severe neuropsychiatric symptoms (2x compared to placebo) ◦ Devanand et al 2012 NEJM  Cochrane review: most can be tapered off successfully (7out of 9 studies) ◦ Declercq et al 2013

 Falls and Fracture  Sedation, Delirium  Extrapyramidal symptoms (Parkinsonism, Dyskinesias)  Anticholinergic side effects (orthostasis, constipation, blurry vision, etc)  Hyperglycemia

 Pneumonia  Cardiovascular risks ◦ QT prolongation, ventricular tachycardia (especially when given IV)  Death (Bronskill et al., 2004; FDA, 2005; Galik & Resnick, 2012; Gray et al., 2002; Gurwitz et al., 2005; Lanctot et al., 2000; Muzk et al., 2012; Schneider et al., 2005; 2006; Takkouche et al., 2007)

 Analysis of 17 placebo controlled trials  Modal duration 10 weeks  Risk of death in the drug treated patients between times that seen in placebo  Rate of death 4.5% in drug treated patients compared to 2.6% in the placebo group  Cardiovascular events or infection (pneumonia) Schneider et al., (2005) JAMA

 Clinical Antipsychotic Trials of Intervention and Effectiveness-Alzheimer’s Disease (CATIE-AD) ◦ No significant differences found among the atypical antipsychotics (risperidone, olanzapine, quetiapine) ◦ 26-32% in Rx group improved compared to 21% in control ◦ Adverse events may offset advantages in the efficacy of antipsychotic use for treatment of agitation, aggression (15-24% d/c med in Rx group, 5% in control) (Schneider et al., 2005; 2006)

 National Initiative to Improve Behavioral Health and Reduce Antipsychotic Use among Nursing Home Residents with Dementia ◦ Quality indicator, Ftag 329 will result in penalties ◦ Documentation to support use, non-pharm interventions, risk benefit discussion, monitoring for side effects, gradual dose reduction

1. Thoroughly assess behaviors 2. Attempt alternatives (non-pharm,pharm) 3. Clearly identify target symptom 4. Discussion and documentation of risks and benefits 5. Low dose, short term use 6. Monitor for adverse events

 Pain medications  Cholinesterase inhibitors  Antidepressants  Mood stabilizers/anticonvulsants  Benzodiazepines

 Efficacy is fair with good pain screening (challenges with patients who are not verbally reliable)  Renal and hepatic effects  Delirium  Falls, fractures  Tolerance for opioids

 Some mild improvement in behavior on these medications, (Reisberg et al, 2003) but takes awhile….they will be long gone from the hospital by then  GI side effects, syncope, vivid dreams

 Evidence mostly based on small trials only (Lyketsos et al., 2003; Pollock et al., 2007)  Recently some overprescribing of antidepressants  Side effect profile is typically more tolerable than antipsychotics, but associated with falls, hyponatremia, sedation, agitation, etc. in some patients

 Citalopram (CitAD study), N=186, mostly community dwelling, efficacy was not assessed at 20mg  Agitation, but no depression  Improved agitation in patients with AD  Reduced caregiver stress  Higher rates of cardiac adverse effects than placebo  Porsteinsson et al., 2014

 Efficacy is mixed (Sink, Holden, & Yaffe, 2005)  Sedation, ataxia, blood dyscrasias, routine CBC, AST, ALT, levels for valproic acid and carbamazepine

 Highly associated with falls, fractures and delirium among older adults with dementia  Try to avoid

 All of the previous mentioned classes are not risk free and are not FDA approved uses…so these medications are off label too.  Best to match symptoms with medication class (ie, tearful, poor appetite, self-deprecating, and agitated, maybe an antidepressant will work best)