1. Althea Lloyd, Ph.D. HBPC Psychologist VA Pittsburgh Healthcare System No Disclosures to Report ©AAHCM

2.  Identify benefits of non-pharmacological approaches for managing Neuropsychiatric Symptoms (NPS) of Dementia  Summarize the Describe-Investigate-Create- Evaluate (DICE) approach for assessing and managing NPS ©AAHCM2

3. NPS affects up to 90% of dementia patients ( Nowrangi et al, 2015 ) Use of psychotropic medications for NPS is associated with numerous safety and efficacy concerns Left untreated NPS can lead to: (Gitlin, Kales, & Lyketsos, 2012) ◦ Rapid disease progression ◦ Premature nursing home placement ◦ Poor quality of life ◦ Accelerated functional decline ◦ Caregiver burden ◦ Excessive hospitalization ◦ Higher health care costs ◦ Increased mortality Concerns regarding psychotropic medications use: Not FDA-approved for NPS Significant associated risks and side effects:  Increased risk of cerebrovascular events  Somnolence  Abnormal Gait  Increased cognitive decline  Death ©AAHCM3

4.  Recommended as first line of care for NPS  Address unmet needs, environment, or interactions between the patient, caregiver, and the environment  Prevent and/or reduce behavioral symptoms, increase patient and caregiver satisfaction, and improve quality of life  Consistent with the Center for Medicare and Medicaid Services’ National Partnership to Improve Dementia Care in Nursing Homes by reducing unnecessary use of antipsychotics (cms.gov)  Can be implemented by any trained professional or caregiver ©AAHCM4

5. Describe Investigate Create Evaluate ©AAHCM5

6.  Developed by a multidisciplinary panel of experts  Evidence Informed ◦ Utilized non-pharmacological strategies with the strongest evidence base  Can be implemented in various settings, including home care  Steps focus on Patient, Caregiver, and Environmental Factors  Allows for integration of medical, pharmacological, and non-pharmacological treatment ©AAHCM6

7.  77-year-old man with moderate dementia  Wife reports that he refuses to go to bed at night and becomes verbally aggressive when she tries to reason with him ©AAHCM7

8.  PATIENT CONSIDERATIONS  Patient becomes verbally aggressive (yells, screams, curses); refuses to get in bed or gets out of bed shortly after caregiver falls asleep; safety concerns (i.e. patient has wandered away from the home twice before, falls); patient describes caregiver as “mean”  CAREGIVER CONSIDERATIONS  Caregiver reports feeling stressed and frustrated, denies feeling threatened by patient; she admits to yelling at patient when he does not listen; she reports that she believes patient is intentionally producing these behaviors and states that “he is just stubborn”  ENVIRONMENTAL CONSIDERATIONS  Patient spends all day in the living room recliner watching TV and sleeping; limited interaction with family ©AAHCM8

9.  PATIENT CONSIDERATIONS ◦ Rule out any untreated medical conditions (i.e. delirium, infection, pain) ◦ No recent changes in medications; no medical conditions (i.e. UTI), but sleep cycle deregulated (i.e. sleeping during the daytime); patient gets attention when caregiver yells  CAREGIVER CONSIDERATIONS ◦ Caregiver lacks understanding of connection between dementia and behaviors (thinks he is doing things on purpose); communication style (yelling at him); unrealistic expectations (i.e. tries to reason with him)  ENVIRONMENTAL CONSIDERATIONS ◦ Patient is trying to navigate around the house at night in the dark; lacks pleasant events and under stimulated /bored during the day ©AAHCM9

10.  PATIENT CONSIDERATIONS ◦ Work with patient and caregiver to improve sleep hygiene (i.e. changing routines)  CAREGIVER CONSIDERATIONS ◦ Provide caregiver education to target specific or general behaviors (i.e. brochures, books, support groups, websites); Refer caregiver for therapy; Enlist other social support; Teach caregiver to reinforce positive behaviors  ENVIRONMENTAL CONSIDERATIONS ◦ Increase safety in the environment (i.e. install alarms, night lights, ID bracelet); Increase stimulation in environment (i.e. increase meaningful interactions with caregiver/family, increase involvement in the home, join senior day programs) ©AAHCM10

11.  PATIENT CONSIDERATIONS ◦ Did the intervention/s address the target behavior/s?  Patient now spending more time interacting and less time sleeping in the day; he is more tired at night and feeling more useful at home  CAREGIVER CONSIDERATIONS ◦ Which intervention/s did caregiver implement? Why/why not?  Interventions that were easy to incorporate into her existing schedule; decreased worries about patient’s safety; increased time for self-care  Enrolling patient in day program and increasing supervision presented some challenges, but got easier with education and team/family support  Wife reports improvement in sleep; feels less irritable and more empowered (i.e. learning more about dementia and trying to get other family members on board)  ENVIRONMENTAL CONSIDERATIONS ◦ What changes were made?  Alarms (i.e. door and floor alarms); ID bracelet; Increased supervision; Enrolling in local day program; Family visiting more ©AAHCM11

12.  Effectiveness and feasibility of non-pharmacological approaches ◦ Manage NPS that medications may not (i.e. caregiver-related issues) ◦ Address multiple contributing factors (i.e. patient, caregiver, environment) ◦ Can be delivered by any discipline/provider (do not need to be delivered within a VA setting, by Mental Health Provider, or solely within the context of psychotherapy) ◦ Variety of training and educational resources available to providers and caregivers  Utility of DICE in home care setting ◦ Enhance clinical practice in the home by providing a structured method to assess and manage some of the most challenging behaviors in dementia care ◦ Provide support to caregivers  Questions/Comments? ©AAHCM 12

13.  Gitlin, L.N., Kales, H.C., & Lyketsos, C.G. (2012). Managing behavioral symptoms of dementia using nonpharmacologic approaches: An Overview. JAMA, 308, 2020-2029.  Kales, H.C., Gitlin, L. N., & Lyketsos, C. G. (2014). Management of Neuropsychiatric Symptoms in Dementia in Clinical Settings: Recommendations from a Multidisciplinary Expert Panel. Journal of American Geriatric Society, 62, 762-769.  Logsdon, R.B., McCurry, S.M., & Teri, L. (2007). Special Section: Evidence-based psychological treatments for older adults. Psychology and Aging, 22, 1, 28-36.  Nichols, L.O., Martindale-Adams, J., Burns, R., Graney, M.J., & Zuber, J. (2011). Translation of a dementia caregiver support program in a health care system-REACH- VA. Archives of Internal Medicine, 171, 353-359 http://www.ncbi.nim.nih.gov/pubmed/21357811.  Nowrangi, M.A., Lyketsos, C.G., & Rosenberg, P.B. (2015). Principles and management of neuropsychiatric symptoms of dementia in Alzheimer’s disease. Alzheimer’s Research & Therapy, 7, 12, DOI 10.1186/s13195-015-0096-3.  Centers for Medicare and Medicaid Services National Partnership to Improve Dementia Care in Nursing Homes: http://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/SurveyCertificationGenInfo/National-Partnership-to-Improve-Dementia- Care-in-Nursing-Homes.html.http://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/SurveyCertificationGenInfo/National-Partnership-to-Improve-Dementia- Care-in-Nursing-Homes.html  Alzheimer’s Association (www.alz.org). ©AAHCM13