Interreg-IPA Cross-border Cooperation Programme Romania-Serbia 10 noiembrie 2015 - Timșoara, România Interreg-IPA Cross-border Cooperation Programme Romania-Serbia Agitation assessment scales in Dementia Slavica Nikolic Lalic, MD November 2017 Employment promotion and basic services strengthening for an inclusive growth

Dementia Today Dementia is a global public health concern The prevalence of dementia increases. 2010 - nearly 35.6 million people with dementia worldwide expected - nearly 115 million by the year 2050 Dementia disease is best known as a memory disorder. The hallmark of dementia is progressive cognitive and functional decline

Dementia Today II However, behavioral and psychiatric symptoms may also occur Many individuals with dementia will develop them. over the course of the illness, nearly 97% of patients develop behavioral or psychiatric symptoms - “Behavioral and Psychological Symptoms of Dementia (BPSD).”

Behavioral and Psychological Symptoms behavioral symptoms are the most challenging and distressing aspects of the disease. These symptoms are often a determining factor in residential care placement. They also have an enormous impact on quality of life for individuals in long-term care.

Evaluation of Behavioral Symptoms International Psychogeriatric assotiation (IPA)-formulated a consensus definition about agitation in dementia Anyone experiencing behavioral symptoms should receive a thorough medical evaluation. With proper intervention, patients’ symptoms can often be reduced or stabilized.

Agitation in Dementia Contributing medical conditions may include: Infections, uncorrected problems with hearing or vision, pain, medication side effects or drug interactions Contributing environmental influences may include: Change in caregiving arrangements Admission to a hospital Presence of houseguests Being asked to bathe or change clothes Moving to a new home Difficulty with expressing needs and wishes Travel

Rating scales Essential tools for diagnosis, staging, assessment and careful monitoring of AD symptoms as well as for evaluation of treatment effects. For decades most AD assessments were predominantly focused on cognition, which is the lead symptom in AD the symptoms more relevant to a patient's quality of life, caregiver burden and institutionalization - are functional and behavioral symptoms

Neuropsychiatric Inventory - NPI The NPI is the behavior instrument most widely used in clinical trials of antidementia agents. The NPI/NPI-C can be used to rate the presence of neuropsychiatric symptoms (NPS) across many domains Measure for specific NPS domains (e.g., dysphoria, agitation), or a combination of both (presence of NPS across domains plus particular focus on one or more specific domains.)

Elements of the NPI NPI assesses 10 (10-item NPI) or 12 (2-item NPI) behavioral domains common in dementia. These include: Hallucinations Delusions Agitation/aggression Dysphoria/depression Anxiety Irritability Disinhibition Euphoria Apathy Aberrant motor behavior Sleep and night-time behavior change (12 item version only) Appetite and eating change (12 item version only)

Key Aspects of the NPI track record in clinical trials adds the behavioral dimension to outcomes in clinical trials assesses behavioral changes s based on a standardized caregiver interview integrated caregiver distress scale training CDs available outpatient, residential and brief clinical versions available application across many neurologic and psychiatric disorders with behavioral profiles translations available in many (more than 40) languages

NPI/NPI-C Unlike the NPI, the NPI-C allows the rater to obtain additional caregiver and patient information to inform the rating for each item within a domain. completing each of the three NPI-C sections: caregiver interview, patient interview, and clinician rating

CMAI-C The Cohen-Mansfiled agitation inventory (1986) Agitation is operationally defined as: inappropriate verbal, vocal, or motor activity that is not judged by an outside observer to result directly from the needs or confusion of the agitated individual. Agitated behavior is always socially inappropriate, and can be manifested in three ways: 1. It may be abusive or aggressive toward self or other. 2. It may be appropriate behavior performed with inappropriate frequency, such as constantly asking questions. 3. It may be inappropriate according to social standards for the specific situation, as in taking off clothes in the activity room.

SCORING THE CMAI The rating scale for the agitated behaviors follows: 1 – Never 2 - Less than once a week but still occurring 3 - Once or twice a week 4 - Several times a week 5 - Once or twice a day 6 - Several times a day 7 - Several times an hour

VERSIONS OF THE COHEN-MANSFIELD AGITATION INVENTORY Long form - This is the original assessment used with the nursing home population. Long form with expanded definitions - This form gives additional examples of each behavior. Short form - Only 14 agitated behavior categories are included, each rated on a 5-point frequency scale instead of a 7-point frequency scale. Community form (CMAI-C) - this 37-item questionnaire has been used with formal and informal caregivers of community-dwelling elderly persons in a longitudinal study of agitation. This instrument is available in two formats: CMAI-C and the CMAI-Relative Form. Disruptiveness form - The disruptiveness of each behavior is rated along with frequency.

Treatment Options for BPSD There are two major types of treatment for behavioral symptoms: Nondrug strategies 2. Prescription medications

The Non-Pharmacological Interventions For the treatment of BPSD • Cognitive Interventions • Stimulant Based Interventions • Social Activity/Social Interaction • Physical Activity/Exercise/Dance • Environmental Interventions • Interventions For Caregivers and Stuff of Nursing Homes Psychoeducation Caregiver Support Group Therapy Case Management/ Counselling • Multicomponent Interventions

Helpful hints when a person becomes agitated Things to do: Use calm, positive statements "Back off" and ask permission Reassure Slow down Add light Offer guided choices between two options Focus on pleasant events Offer simple exercise options Try to limit stimulation

Helpful hints when a person becomes agitated Things to say: May I help you? Do you have time to help me? You are safe here. Everything is under control. I apologize. I’m sorry that you are upset. I know it’s hard. I will stay with you until you feel better.

Helpful hints when a person becomes agitated Do not: Raise your voice Make sudden movements Show alarm or offense Corner, crowd or restrain Demand, force or confront Rush or criticize Ignore or argue Shame or condescend

10 noiembrie 2015 - Timșoara, România Thank you!