Download Behavioral Strategies in Dementia

Behavioral Disturbance
and its Management in
Dementia Patients
PRESENTED BY
KARLA BRENNSCHEIDT, PSY.D.
OWNER, DIRECTOR
CLINICAL NEUROPSYCHOLOGIST – CEDAR VALLEY NEUROSYCHOLOY SERVICES, CEDAR FALLS
Outline
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Aging Society
Iowa Data
Defining Dementia
Dementia Types
Define Behavioral Disturbance
Causes
Comprehensive Assessment
Managing Agitation
Other Behavioral Approaches to Treatment
Case Studies
Aging Society
Supercentenarians
Mortality
http://www.alz.org/alzheimers_disease_facts_and_figures.asp#quickFacts
Iowa
http://www.alz.org/alzheimers_disease_facts_and_figures.asp
Iowa
What is Dementia?
NINDS – National Institute of Neurological Disorders and Stroke
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Not a specific disease.
A descriptive term for a collection of symptoms.
Caused by a number of disorders that affect the brain.
Significantly impaired intellectual functioning that interferes with normal activities and relationships.
Loss of problem-solving ability; loss of and inability to maintain emotional control.
Personality changes and behavioral problems, such as agitation, delusions, and hallucinations.
Memory loss a common symptom of dementia, but by itself not diagnostic of dementia.
◦ Multifactorial, including changes in thinking, memory, executive deficits, language, visual-perceptual
skills, and BEHAVIORS.
Behavioral disturbance most common reason for nursing home admittance.
Dementia Types
ALZHEIMER’S DISEASE
VASCULAR DEMENTIA
Most common type of dementia; accounts for an
estimated 60 to 80 percent of cases.
The second most common cause of dementia after
Alzheimer's disease.
Symptoms: Difficulty remembering names and recent
events is often an early clinical symptom; apathy and
depression are also often early symptoms. Later
symptoms include impaired judgment, disorientation,
confusion, behavior changes and difficulty speaking,
swallowing and walking.
New criteria and guidelines for diagnosing Alzheimer's
were published in 2011 recommending that Alzheimer's
disease be considered a disease with three stages,
beginning well before the development of symptoms.
Symptoms: Impaired judgment or ability to plan steps
needed to complete a task is more likely to be the initial
symptom, as opposed to the memory loss often
associated with the initial symptoms of Alzheimer's.
Occurs because of brain injuries such as microscopic
bleeding and blood vessel blockage. The location of the
brain injury determines how the individual's thinking and
physical functioning are affected.
Brain changes: Hallmark abnormalities are deposits of the
protein fragment beta-amyloid (plaques) and twisted
strands of the protein tau (tangles) as well as evidence of
nerve cell damage and death in the brain.
Brain changes: Brain imaging can often detect blood
vessel problems implicated in vascular dementia. In the
past, evidence for vascular dementia was used to exclude
a diagnosis of Alzheimer's disease (and vice versa). That
practice is no longer considered consistent with pathologic
evidence, which shows that the brain changes of several
types of dementia can be present simultaneously.
Dementia Types
DEMENTIA WITH LEWY BODIES (DLB)
FRONTOTEMPORAL DEMENTIA
Symptoms: People with dementia with Lewy bodies
often have memory loss and thinking problems
common in Alzheimer's, but are more likely than
people with Alzheimer's to have initial or early
symptoms such as sleep disturbances, well-formed
visual hallucinations, and muscle rigidity or other
parkinsonian movement features.
Includes dementias such as behavioral variant
FTD (bvFTD), primary progressive aphasia, Pick's
disease and progressive supranuclear palsy.
Brain changes: Lewy bodies are abnormal aggregations
(or clumps) of the protein alpha-synuclein. When they
develop in a part of the brain called the cortex,
dementia can result. Alpha-synuclein also aggregates in
the brains of people with Parkinson's disease, but the
aggregates may appear in a pattern that is different
from dementia with Lewy bodies.
Symptoms: Typical symptoms include changes in
personality and behavior and difficulty with
language. Nerve cells in the front and side
regions of the brain are especially affected.
Brain changes: No distinguishing microscopic
abnormality is linked to all cases. People with
FTD generally develop symptoms at a younger
age (at about age 60) and survive for fewer years
than those with Alzheimer's.
Behavioral Disturbance
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Leading reason for admission into nursing homes.
Increases stress between patient and caregiver.
Increases morbidity and mortality of dementia patients.
Create more intensive and costly levels of treatments.
Finkel, S., et al., Int Psychogeriatrics, 1996, 8, 497-500
Definition of behavioral disturbance
• A behavior that puts the patient or others at risk.
• A behavior that makes keeping the patient in the milieu difficult for either staff or other patients.
Behavioral (and psychological) Symptoms
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Agitation.
Aggression (e.g., during daily care; hitting, kicking).
Attention seeking behaviors (e.g., perseveration on bathroom activities).
Delusions.
Hallucinations.
Mood disturbances.
Repetitive vocalizations (screaming, incessant calling out).
Sexual disinhibition (verbal or physical).
Wandering.
Behavioral Disturbance
Possible Causes:
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Inherent changes of disease process.
Medical comorbidities.
Environmental disruptions.
Lack of staff knowledge.
Lack of family education about disease process.
Requires Comprehensive Assessment:
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Environment / stressors.
Delirium.
Medical Problems.
Psychotic Disorder.
Affective Disorder.
Anxiety Disorder.
Personality Disorder.
What do we do? – Multiple Goals
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Make the behavior go away.
Treat the underlying cause.
Improve patient outcomes.
Restore calm and safety to the situation and the unit.
Detective Work
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Identifying environmental stressors.
Identifying any trends.
Working on a “crisis plan” with family, patient, or significant others.
Enlist the help of specific staff members.
Use of adjunct therapies and specialized interventions (e.g., sensory room; aromatherapy).
• Call your neuropsychologist!!!
Environmental Stressors
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Room location.
Excess noise (TV, overhead pagers).
Glare from windows, mirrors, floors.
Slamming doors.
Proximity to bathrooms.
Proximity to peers of opposite sex.
Delirium
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Delirium is a syndrome.
Altered or fluctuating level of consciousness – attention deficits / alertness.
Not a final diagnosis.
Acute or subacute onset.
Caused by a variety of illnesses or medications.
Difficult to assess with dementia.
Must identify to treat appropriately.
Causes:
• Acute illness – UTI, respiratory infection.
• Chronic illness – CHF, COPF causing hypoxia, renal insufficiency, anemia.
• Sensory impairment – cataract, hearing loss.
• Iatrogenesis – recent medication change; drugs with anticholinergic effects; r/o withdrawal syndrome.
Medical Issues
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Illnesses: GERD, angina, etc.
Medication side effects.
Pain.
Constipation.
Hearing or vision impairment.
Sleep deprivation.
Dental problems.
Managing Agitation
AREAS TO CONSIDER
TREATMENT IDEAS
Pain
R/O under-medication; assess resting and
procedural pain; pre-medicate for painful
procedures; use standing, not PRN scheduling;
remove or discontinue painful stimuli; consult
pain service in difficult cases.
Over-sedation
Poor sleep
Reduce or d/c benzodiazepines or other
sedative medications if not working.
Examine sleeping medications and sleep
hygiene issues; help patient remain active
during the day.
Managing Agitation cont’d
ENVIRONMENTAL FACTORS
Patient experiences frustration with therapies.
Therapy demands may be too high; increase
success rate to approx. 90%; increase overall
positive reinforcement.
Over-stimulation
Reduce auditory, visual, olfactory, and tactile
stimulation; reduce interaction with others;
restrict visitors in number and frequency.
Confusion / disorientation
Consistent nurses, therapists; frequent visits
and calls from family. Photos and notes from
family members; white boards with salient
orientation information.
Sensory Stimulation Rooms
Not many nursing homes or hospitals have those rooms, but certainly a good investment for those
facilities that have memory or dementia units.
Interventions designed to stimulate one or more of the senses.
Promotes self-soothing in agitated or distressed individuals.
Is based on Dutch concept of Snoelezen ® rooms (to sniff, to doze).
Sensory equipment: sand tray, weighted blankets, aroma therapy, tactile objects, soft lighting, music,
sensory tower.
Other activities: yarn rolling, folding towels, soft blankets.
Managing Other Behaviors
INTERPERSONAL FACTORS
Patient feels threatened / acts aggressively
Lower self below patient’s eye-level, use quiet
calm voice; open posture.
Patient is paranoid
Give detailed information the patient
requests; write it down; write in memory book
and refer patient to what other staff have
written; psychiatry evaluation for antipsychotic
meds.
Managing Other Behaviors
Patient needs restraints for safety
Population at risk: Older patients with
dementia.
Use only as a last resort; associated with poor
outcomes. Facilities are required to have rules
and regulations in place (incl. patients rights
and freedom from inappropriate restraints).
Use bed and chair alarms; frequent check-ins;
1:1 sitter; place near nurse’s station or
common area, if possible.
Questions To Ask
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What has worked before?
Simplify.
Work with the patient’s schedule, do not ask the patient to work with ours.
Be creative. Affect means more than words. Don’t push. Talk to other staff about patient’s responses to
treatment – do co-treat, if possible.
◦ Take cues from patient.
◦ If possible, ask patient.
Case Study
78 year-old widowed female
Lived at home with family until 2 months prior to hospitalization
Admitted to hospital from LTCF because of
◦ aggression with ADL’s
◦ constant calling out
◦ general irritability
◦ refusal to take meds
What was the problem for nursing and therapists?
Case Study – Use of the Sensory Room
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Responded well to 1:1 activity
Yarn rolling
Sand tray
Compression vest
Sometimes, all we have to do is ask the patient – rehabilitation example – a fearful patient with intellectual disability and
limited verbal means
References
1. http://www.ninds.nih.gov/disorders/dementias/dementia.htm
2. Finkel, S., et al., Int Psychogeriatrics, 1996, 8, 497-500
3. http://www.alz.org/alzheimers_disease_facts_and_figures.asp
Dr. Brent Forester’s original presentation on evaluation and management of behavioral
disturbances and psychosis in dementia, was adapted – with his kind permission - and
expanded.