Download GNRS4BehavioralProblemsInDementia

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BEHAVIORAL
PROBLEMS
IN DEMENTIA
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OBJECTIVES
• Know and understand:
• Factors precipitating behavioral disturbances
• How to rule out medical, environmental, and
caregiving causes of behavioral problems
• Environmental and non-pharmacologic
management of behavioral disturbances
• When and how to medicate
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TO P I C S C O V E R E D
• Clinical Features
• Assessment and Differential Diagnosis
• Basic Approach to Treatment
• Treatments for Specific Disturbances
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INTRODUCTION
• As many as 80%–90% of patients with dementia
develop at least one psychotic symptom or
behavioral disturbance over the course of their
illness
• Behavioral disturbances or psychotic symptoms
in dementia often precipitate nursing-home
placement
• Disturbances are potentially treatable, so it is
vital to recognize them early
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C L I N I C A L F E AT U R E S
• Psychiatric symptoms may develop that
resemble discrete mental disorders such as
depression or mania
• The course and features are more difficult to
predict, and treatments are less reliably
effective, than in younger adults without
dementia
• Neuropsychiatric symptoms such as apathy,
poor self-care, or paranoia may be the first
indication of dementia
C L I N I C A L F E AT U R E S :
A G I TAT I O N ( 1 o f 2 )
• Reflects loss of ability to modulate behavior in
a socially acceptable way
• May involve verbal outbursts, physical
aggression, resistance to bathing or other care
needs, and restless motor activity such as
pacing or rocking
• Often occurs concomitantly with psychotic
symptoms such as paranoia, delusional
thinking, or hallucinations
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C L I N I C A L F E AT U R E S :
A G I TAT I O N ( 2 o f 2 )
• Caregivers, both professional and family, may
use the word agitation to describe a variety of
behaviors and psychologic symptoms
• The clinician must consider agitation to be a
nonspecific complaint and pursue further
history of the problem
• Overt resistance to care is most often seen in
later stages of dementia, but it may be a first
sign of incipient cognitive decline
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ASSESSMENT
• Obtain a history from both the patient and
an informant
• Elicit a clear description of the behavior:
 Temporal onset and course
 Associated circumstances
 Relationship to key environmental factors, such
as caregiver status and recent stressors
DIFFERENTIAL DIAGNOSIS:
MEDICAL CAUSES
• Disturbances that are new, acute in onset, or
evolving rapidly are most often due to a medical
condition or medication toxicity
• An isolated behavioral disturbance in a demented
patient can be the sole presenting symptom of acute
conditions such as pneumonia, UTI, arthritis, pain,
angina, constipation, or uncontrolled diabetes
• Medication toxicity can present as behavioral
symptoms alone
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DIFFERENTIAL DIAGNOSIS:
E N V I R O N M E N TA L C A U S E S
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• Life stressor (eg, death of a spouse or other family member)
• Change to daylight savings time or travel across time zones
• New routine, new caregivers, or new roommate
• Overstimulation (eg, too much noise, crowded rooms, close
contact with too many people)
• Understimulation (eg, relative absence of people, spending
much time alone, use of television as a companion)
• Disruptive behavior of other patients
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DIFFERENTIAL DIAGNOSIS:
S T R E S S I N C A R E G I V I N G R E L AT I O N S H I P
• May exacerbate/cause a behavioral disturbance
• Relationships with potential for stress include:
 Inexperienced caregivers
 Domineering caregivers
 Caregivers who themselves are impaired by
medical or psychiatric disturbances
M A N I F E S TAT I O N O F D E M E N T I A :
C ATA S T R O P H I C R E A C T I O N
• Defined as an acute behavioral, physical, or verbal
reaction to environmental stressors that results from
inability to make routine adjustments in daily life
• Might include anger, emotional lability, or aggression
when confronted with a deficit
• Best treated by identifying and avoiding precipitants,
providing structured routines and activities, and
recognizing early signs so the patient can be
distracted and supported before reacting
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M A N I F E S TAT I O N O F D E M E N T I A :
B R A I N D E T E R I O R AT I O N
• Persistent behavioral disturbances and those with more
insidious onset are likely to relate to brain deterioration
• Behavioral disturbances related to dementia fall into 3
groups, which may overlap: mood symptoms, psychosis,
specific behaviors
• If the disturbance is polysymptomatic, one approach is to
target treatment to the prevailing feature: psychosis
(delusions or hallucinations), mood symptoms (dysphoria,
sadness, irritability, lability), aggression, or agitation
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B E H AV I O R A L S Y M P TO M S
BY DEMENTIA TYPE
• Frontotemporal dementia (Pick’s disease): often
associated with prominent disinhibition, compulsive
behaviors, and social impairment
 In severe cases, a syndrome of hyperphagia,
hyperactivity, and hypersexuality may occur
• Dementia with Lewy bodies: prominent psychosis
characterized by visual hallucinations
• Behavioral problems can occur in all dementia types
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T R E AT M E N T S F O R S P E C I F I C
DISTURBANCES: GENERAL PRINCIPLES
• Management of pain, dehydration, hunger, and
thirst is paramount
• Consider the possibility of positional discomforts
or nausea secondary to medication effects
• Modify environment to improve orientation
• Good lighting, one-on-one attention, supportive
care, and attention to personal needs and wants
are also important
B E H AV I O R A L I N T E RV E N T I O N S
(1 of 3)
• Treat underlying medical precipitants
• Replace poorly fitting hearing aids, eyeglasses,
and dentures
• Remove offending medications, particularly
anticholinergic agents
• Keep the environment comfortable, calm, and
homelike with use of familiar possessions
• Provide regular daily activities and structure; refer
patient to adult day care programs, if needed
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B E H AV I O R A L I N T E RV E N T I O N S
(2 of 3)
• Monitor for new medical problems
• Attend to patient’s sleep and eating patterns
• Install safety measures to prevent accidents
• Ensure that the caregiver has adequate respite
• Educate caregivers about practical aspects of
dementia care and about behavioral disturbances
• Teach caregivers communication skills, how to
avoid confrontation, techniques of ADL support,
activities for dementia care
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B E H AV I O R A L I N T E RV E N T I O N S
(3 of 3)
• Simplify bathing and dressing with the use of
adaptive clothing and assistive devices, if needed
• Offer toileting frequently and anticipate incontinence
as dementia progresses
• Provide access to experienced professionals and
community resources
• Refer family and patient to local Alzheimer’s
Association
• Consult with caregiving professionals, such as
geriatric case managers
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TO R E D U C E S U N D O W N I N G
• Give adequate daytime stimulation
• Maintain adequate levels of light in daytime
• Establish bedtime routine and ritual
• Remove environmental factors that might keep patient
awake
• Discourage drinking stimulants or smoking near bedtime
• Give diuretics, laxatives early in day
• Place familiar objects at bedside
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T E A C H T H E TA D A A P P R O A C H
• T: Tolerate-allow the patient to go with his
flow and monitor.
• A: Anticipate-tethering is going to be a
problem: eliminate nursing and medical
interventions ASAP
• DA: Don’t agitate-Don’t ask or question or
reorient-their world is the right one!
T R E AT M E N T O F
MOOD DISTURBANCES
• Reduce aversive environmental stimuli
• Assess physical health comprehensively
• Try recreation programs and activity therapies
• Consider antidepressants for:
 Depression of 2 weeks’ duration resulting in
significant distress
 Depressive features lasting >2 months after
initiation of behavioral interventions
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S E L E C T I V E S E R O TO N I N
R E U P TA K E I N H I B I TO R S ( 1 o f 2 )
Medication
Daily
Dose
Uses
Citalopram
10–20mg Depression, anxiety (offmax dose label)
Escitalopram
5–20 mg
Fluoxetine
10–40 mg Depression, anxiety
Depression, anxiety
Precautions
GI upset,
nausea,
insomnia
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S E L E C T I V E S E R O TO N I N
R E U P TA K E I N H I B I TO R S ( 2 o f 2 )
Medication
Paroxetine
Sertraline
Vilazodone
Daily
Dose
Uses
10–40 mg Depression, anxiety
25-100
mg
Precautions
Inhibits
cytochrome P-450
Depression, anxiety
10-40 mg Depression, anxiety
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Take with food,
dose adjust in
severe hepatic
disease
S E R O TO N I N N O R E P I N E P H R I N E
R E U P TA K E I N H I B I TO R S
Medication
Daily
Dose
Uses
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Precautions
Desvenlafaxine
25–50 mg Depression, fibromyalgia Nausea,
hypertension, dry
mouth,
dizziness,
headaches
Duloxetine
20–60 mg Depression, diabetic
neuropathy
Nausea, dry
mouth, dizziness
Mirtazapine
7.5–30
mg
Useful for depression
with insomnia
Sedation,
hypotension
Venlafaxine
25–150
mg
Useful in severe
depression
Hypertension,
insomnia
TRICYCLIC
ANTIDEPRESSANTS
Medication
Daily
Dose
Desipramine
10–100
mg
Nortriptyline
Uses
Depression, anxiety
10–75 mg High efficacy for
depression if side
effects are tolerable;
therapeutic level 50–
150 ng/dL
Precautions
Anticholinergic
effects,
hypotension,
sedation, cardiac
arrhythmias
Anticholinergic
effects,
hypotension,
sedation, cardiac
arrhythmias
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O T H E R D R U G S TO T R E AT
D E P R E S S I V E F E AT U R E S
Medication
Daily
Dose
Uses
Precautions
Bupropion
75–225
mg
More activating, lack
of cardiac effects
Irritability,
insomnia
Trazodone
25–150
mg
When sedation is
desirable
Sedation, falls,
hypotension
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T R E AT M E N T O F
M A N I C - L I K E B E H AV I O R
• Symptoms resemble those of bipolar disorder
(pressured speech, disinhibition, elevated mood,
intrusiveness, hyperactivity, reduced sleep)
• The important distinction in the dementia patient
is the frequent co-occurrence with confusional
states and a tendency to have fluctuating mood
(ie, irritable or hostile as opposed to euphoric)
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M O O D S TA B I L I Z E R S
F O R M A N I C - L I K E B E H AV I O R ( 1 o f 3 )
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Drug
Geriatric
Dosage
Adverse
Effects
Comments
Carbamazepine
200–1000
mg/day
(therapeutic
level 4–12
μg/mL)
Nausea,
fatigue,
ataxia,
blurred
vision,
hyponatremia
Poor tolerability in older
adults; must monitor
CBC, LFTs, electrolytes
q 2 weeks for first 2
months, then q 3
months
The 4 agents in this table are approved by the FDA for the treatment of
bipolar disorder but are off-label for treatment of manic-like behavior
associated with dementia. Note FDA warning for increase in suicidal
thoughts/behaviors with anticonvulsant agents.
M O O D S TA B I L I Z E R S
F O R M A N I C - L I K E B E H AV I O R ( 2 o f 3 )
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Drug
Geriatric
Dosage
Adverse
Effects
Comments
Lithium
150–1000
mg/day
(therapeutic
level 0.5–0.8
mEq/L)
Nausea,
vomiting,
tremor,
confusion,
leukocytosis
Poor tolerability in older
adults; toxicity at low
serum levels; monitor
thyroid and renal function
Divalproex
sodium
250–2000
mg/day
(therapeutic
level 40–100
μg/mL)
Nausea, GI
Requires monitoring of
upset, ataxia, CBC, platelets, LFTs at
sedation
baseline and q 6 months;
better tolerated than other
mood stabilizers in older
patients
M O O D S TA B I L I Z E R S
F O R M A N I C - L I K E B E H AV I O R ( 3 o f 3 )
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Drug
Geriatric
Dosage
Adverse
Effects
Comments
Lamotrigine
25–200
mg/day
Sedation,
skin rash,
rare StevensJohnson
syndrome,
anemia,
neutropenia
Increased adverse events
and interactions when
used with divalproex,
slow-dose titration
required
T R E AT M E N T O F D E L U S I O N S
A N D H A L L U C I N AT I O N S
• Delusions (paranoid or unfounded ideas) or
hallucinations (false perceptions) typically require
pharmacologic treatment if:
– The patient is disturbed by these experiences
– Symptoms lead to disruptions in the patient’s
environment that cannot otherwise be controlled
• Clinical criteria for the diagnosis of Alzheimer’s dementia
with psychosis specifies the presence of delusions or
hallucinations for at least 1 month, at least intermittently,
that cause distress for the patient
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ANTIPSYCHOTIC AGENTS (1 of 5)
Drug
Daily
Dose
Adverse Events
Aripiprazole
5–15
mg
Mild sedation,
mild hypotension
Tablet, liquid
concentrate
Asenapine
5-10
mg
Sedation
Only
sublingual
Clozapine
12.5– Sedation,
200 mg hypotension,
anticholinergic
effects,
agranulocytosis
Comments
Weekly CBC
required; poorly
tolerated by older
adults; reserve
for treatment of
refractory cases
Forms
Tablet,
rapidly
dissolving
tablet
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ANTIPSYCHOTIC AGENTS (2 of 5)
Drug
Daily
Dose
Adverse
Effects
Haldol
0.5 – 3 Sedation,
mg
extrapyramidal
symptoms
Comments
1st generation
agent
Iloperidone
1-12
mg
Sedation,
Dose reduce with
orthostatic
CYP3A4 &
hypotension CYP2D6 inhibitors
Lurasidone
40-80
mg
Sedation
Do not exceed
40mg daily with
CYP3A4 inhibitors
Forms
Tablet, liquid,
IM, long-acting
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ANTIPSYCHOTIC AGENTS (3 of 5)
Drug
Olanzapine
Daily
Dose
Adverse
Effects
2.5–10 Sedation,
mg
falls, gait
disturbance
EPS,
sedation
Comments
Forms
Weight gain
Tablet, rapidly
dissolving
tablet, IM
injection
1st generation
agent
Tablet
Perphenazine
2 -12
mg
Paliperidone
1.5 – Sedation,
12 mg fatigue, GI
upset, EPS
Dose reduce in
Sustained
renal impairment release, depot
IM
Quetiapine
25-200 Sedation,
hypotension
Ophthalmologic Sustained
exam every 6 mo release tablet
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ANTIPSYCHOTIC AGENTS (4 of 5)
Drug
Daily
Dose
Risperidone
0.5–2
mg
Ziprasidone
40–
160
mg
Adverse
Effects
Sedation,
hypotension,
EPS with
doses > 1
mg/day
Higher risk of
prolonged
QTc interval,
hyperglycemia
Comments
Forms
Tablet, rapidly
dissolving
tablet, liquid
concentrate,
depot IM
injection
Little published
Capsule, IM
information on
injection
use in older
adults. Warning
about increased
QTc prolongation
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A N T I P S Y C H OT I C A G E N T S ( 5 o f 5 )
• All of these medications have warnings about
hyperglycemia, cerebrovascular events and
increase in all-cause mortality in patients with
dementia
• All of these medications are off-label for
treatment of psychosis in dementia
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C H O L I N E S T E R A S E I N H I B I TO R S
• In patients with mild to moderate Alzheimer’s
disease, donepezil or galantamine are better
than placebo in reducing psychosis and
behavioral disturbances
• In patients with dementia with Lewy bodies, who
are sensitive to the EPS of antipsychotic agents,
cholinesterase inhibitors have been reported to
reduce visual hallucinations
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MANAGING SLEEP DISTURBANCES
• Improve sleep hygiene (see next slides)
• Use bright-light therapy
• Treat associated depression, delusions
• If the above do not succeed, consider (off-label):
 Trazodone 25–150 mg at bedtime
 Mirtazapine 7.5–15 mg at bedtime
 Zolpidem 5 mg at bedtime
• Avoid benzodiazepines or antihistamines
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SLEEP HYGIENE (1 of 2)
• Establish a stable routine for going to bed and
awakening
• Pay attention to noise, light, and temperature
• Increase daytime activity and light exercise
• Reduce or eliminate caffeine, nicotine, alcohol
• Reduce evening fluid consumption to minimize
nocturia
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SLEEP HYGIENE (2 of 2)
• Give activating medications early in the day if
patient unable to eliminate
• Control nighttime pain
• Limit daytime napping to brief periods of 20 to
30 minutes
• Use relaxation, stress management, and
breathing techniques to promote natural sleep
MANAGING AGGRESSION
A N D A G I TAT I O N
• Behavioral interventions: distraction,
supervision, routine, structure, caregiver
education and support, music and physical
therapy, or aromatherapy
• Behavior modification using positive
reinforcement of desirable behavior
• Avoid physical restraints
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MANAGING HYPERSEXUALITY
• Treat any underlying syndrome, such as a
mania-like state
• Consider antiandrogens for men who are
dangerously hypersexual or aggressive:
 Progesterone 5 mg/day orally; adjust dose to
suppress testosterone well below normal
 If patient responds, may treat with 10 mg IM
depot progesterone weekly
 Leuprolide acetate 5–10 mg IM monthly is an
alternative
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S U M M A RY ( 1 o f 2 )
• The need to express basic needs such as hunger,
thirst, or fatigue, which the patient cannot
adequately communicate in dementia, may
precipitate a behavioral disturbance
• Delirium secondary to an underlying condition
such as dehydration, urinary tract infection, or
medication toxicity is a common cause of abrupt
behavioral disturbances in patients with dementia
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S U M M A RY ( 2 o f 2 )
• Medication effects on behavioral disturbances
in dementia tend to be modest and should be
implemented only after trying environmental
and other nonpharmacologic techniques
• Antipsychotic medications may reduce
agitation, and antidepressants may be helpful
if symptoms of depression are evident in the
patient with a behavioral disturbance
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CASE 1 (1 of 4)
• An 80-year-old woman is brought to the office because
for 6 weeks she has had intermittent severe agitation
characterized by shouting, grabbing, and nearly running
away from helpful overtures.
• The patient has had Alzheimer disease for several
years, which is now in the moderate stage.
• Medications include donepezil 10 mg/d. She has no
adverse effects, and she takes no other psychotropic
medications.
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CASE 1 (2 of 4)
• The patient has been living at home with two younger
sisters since her husband died 2 years ago. During
this time, despite increasing cognitive impairment, the
patient has had only occasional emotional outbursts
from which she could be distracted easily.
• With the onset of severe agitation, her sisters and
home-health aides feel overwhelmed.
• Physical examination and laboratory findings do not
suggest any causes for her agitation.
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CASE 1 (3 of 4)
Which of the following is the most appropriate
next step?
A. Increase donepezil from 10 mg/d to 23 mg/d.
B. Prescribe risperidone 0.25 mg/d.
C. Recommend placement in an assisted-living
facility or nursing home.
D. Inquire further about potential environmental
triggers.
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CASE 1 (4 of 4)
Which of the following is the most appropriate
next step?
A. Increase donepezil from 10 mg/d to 23 mg/d.
B. Prescribe risperidone 0.25 mg/d.
C. Recommend placement in an assisted-living
facility or nursing home.
D. Inquire further about potential environmental
triggers.
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CASE 2 (1 of 3)
• An 86-year-old man is admitted to a nursing facility.
History includes advanced Alzheimer disease.
• He had been in a different facility, where he had a
history of behavioral disturbances manifested by
restlessness, wandering, repetitive vocalizations, and
occasionally striking out at caregivers.
• His wife says, “They wouldn’t give him anything to
calm him down at the other place because of a black
box warning.” She wants to know what that means
and why nursing homes “won’t give medications to
keep people from hitting and scratching.”
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CASE 2 (2 of 3)
Which of the following should form the basis of further
discussion?
A. Providers are prohibited by law from prescribing a
drug that has a black box warning about a potential
adverse effect in certain groups of patients.
B. Newer second-generation antipsychotic drugs are
approved by the FDA to treat dementia-associated
behavioral disturbances that pose a threat to others.
C. The initial step in addressing the patient’s behavioral
disturbances is to understand what triggers them.
D. Mood stabilizers such as valproic acid often benefit
residents exhibiting similar behavioral disturbances.
E. In the nursing facility, judicious use of restraints is an
effective intervention for wandering.
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CASE 2 (3 of 3)
Which of the following should form the basis of further
discussion?
A. Providers are prohibited by law from prescribing a
drug that has a black box warning about a potential
adverse effect in certain groups of patients.
B. Newer second-generation antipsychotic drugs are
approved by the FDA to treat dementia-associated
behavioral disturbances that pose a threat to others.
C. The initial step in addressing the patient’s behavioral
disturbances is to understand what triggers them.
D. Mood stabilizers such as valproic acid often benefit
residents exhibiting similar behavioral disturbances.
E. In the nursing facility, judicious use of restraints is an
effective intervention for wandering.
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CASE 3 (1 of 4)
• An 84-year-old man with probable Alzheimer disease
is admitted to a nursing home for long-term care.
• His family believes he can no longer live in his
apartment, even with round-the-clock home-health
aides, because of irritability and easily triggered
aggressive behaviors, including hypersexuality.
• The family refuses all psychotropic medication
because they are concerned about increased
mortality. They allow treatment for dementia, and the
patient is given donepezil and memantine, neither of
which has improved this behavior.
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CASE 3 (2 of 4)
• The patient continues to have private-duty aides in his
first days at the nursing home, and they are largely
able to redirect any aberrant behavior. When private
assistance is discontinued, his behavior immediately
deteriorates: he has angry interchanges with other
residents and staff, insists on leaving the facility, and
touches female residents inappropriately.
• A number of nonpharmacologic approaches fail, and
the patient’s family continues to refuse antipsychotic
agents. The patient’s community neurologist suggests
valproate, which the family is willing to consider
because they have read that it may have neuroprotective properties.
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CASE 3 (3 of 4)
Which of the following outcomes is most likely?
A. Improvement of behavioral symptoms; no effect on
clinical progression Alzheimer disease
B. Improvement of behavioral symptoms; delay in
clinical progression of Alzheimer disease
C. No effect on behavioral symptoms; delay in clinical
progression of Alzheimer disease
D. No effect on behavioral symptoms; no effect on
clinical progression of Alzheimer disease
E. Improvement of behavioral symptoms; worsening of
clinical progression of Alzheimer disease
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CASE 3 (4 of 4)
Which of the following outcomes is most likely?
A. Improvement of behavioral symptoms; no effect on
clinical progression Alzheimer disease
B. Improvement of behavioral symptoms; delay in
clinical progression of Alzheimer disease
C. No effect on behavioral symptoms; delay in clinical
progression of Alzheimer disease
D. No effect on behavioral symptoms; no effect on
clinical progression of Alzheimer disease
E. Improvement of behavioral symptoms; worsening of
clinical progression of Alzheimer disease
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GNRS4 Teaching Slides Editor:
Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF
GNRS4 Teaching Slides modified from GRS8 Teaching Slides
based on chapter by Melinda S. Lantz, MD
and questions by Blaine S. Greenwald, MD
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2014 American Geriatrics Society