1. Non-medication Management of Agitated Behavior in Dementia Patients Josepha A. Cheong, MD University of Florida Departments of Psychiatry and Neurology Chief, Division of Geriatric Psychiatry

2. 1. Murphy SL. Natl Vital Stat Rep. 2000;48:1-106. 2. Evans DA. Milbank Q. 1990;68:267-289. Current Prevalence of AD AD is the fourth leading cause of death due to disease for people > 65 years of age in the United States 1 Approximately 4 million people in the United States have AD 2 AD is a progressive, neurodegenerative disease involving: –Loss of memory and other cognitive functions –Decline in ability to perform activities of daily living –Changes in personality and behavior –Increases in resource utilization –Eventual nursing home placement

3. AD Is the Most Prevalent Type of Irreversible Dementia Guttman R et al. Arch Fam Med. 1999;8:347-353. McKeith IG et al. Neurology. 1996;47:1113-1124. Cherrier MM et al. J Am Geriatr Soc. 1997;45:579-583. VaD, vascular dementia; DLB, dementia with Lewy bodies; FTD, frontotemporal dementia., reflects difficulties diagnosing/ reporting dementias; only estimations of prevalence can be made. 0 20 40 60 80 100 ADVaDDLBFTDOther Irreversible dementias (%)

4. Disease Progression in Alzheimer’s Disease 0123456789 Years from diagnosis Cognitive ability Functional ability Behavioral problems Caregiver time 0% 100% Change in disease progression

5. What is Agitated Behavior? Non-cognitive symptom of dementia (cognitive = memory loss, language difficulty) 2 types of non-cognitive symptoms: –Psychiatric –Behavioral

6. Psychiatric Symptoms Personality changes Depression Hallucinations Paranoia Misidentifications Mania »Alzheimer’s Disease International Factsheet

7. Behavioral Disturbances Aggression Agitation Wandering Sexual disinhibition Incontinence Increased eating Screaming 20-30% >80% 25 - 50% 10% 50-60% 5-10% 5% Modified – Alzheimer’s Disease International Factsheet

8. Why Manage These Symptoms? Caregiver stress and burden Stress on the patient Precipitant of nursing home placement Very manageable with non-medication and medication treatment

9. Why Non-medication Management? Less restrictive Effective in early dementia Fewer complications Stresses the importance of family and non- medical caregivers

10. General Principle How would I deal with this problem behavior if this person were a 3-5 year old child?

11. Assessment Rule out any environmental disturbance –change in home setting –change in the staff/family members –death of a pet R/o any possible medical illness –urinary tract infection –dehydration

12. Assessment R/o drug-drug interactions or drug intolerance When does the behavior occur –constant regardless of stimuli –specific time of day –with caregiving activity

13. Assessment Endocrine Iatrogenic - consider non-prescription medications Injury Intoxication

14. Treatment Behavioral Intervention –redirection –no-fail environment adjusting the environment to meet the needs and the limitations of the patient –structure and consistency –avoid overstimulation

15. Specific Problems Wandering >50% of AD pts wander 86% are located w/in 5 miles of home 37% are found w/in 1 mile of home 14% are found > 5 miles from home 2002 – Meredith Rowe – UF College of Nursing, Institute of Aging

16. Wandering Planned activities to counteract boredom Reassurances Redirection Red STOP sign Disguise the door

17. Wandering Safety Appropriate identification Bright vest

18. Wandering Alzheimer’s Association Safe Return Education National photo/info database 24 hour toll-free emergency crisis line –1-888-572-8566 –1-800-272-3900 –www.alz.org

19. Baker Act - 52/32 52 - involuntary evaluation 32 - involuntary committment

20. Referral Shands at UF Inpatient Geriatric Psychiatry Unit Intake Coordinator 352-265-5411

21. GO GATORS!