Download BPSD and the Challenges of Enhancing the LTC Workforce - S-COPE

DEBORAH KLASZKY MSN APN-C
New Jersey Institute for Successful Aging
Rowan University School of Osteopathic Medicine
 Identify the unique behavioral health needs of nursing
facility residents
 Identify the common theoretical models used to
manage
behavioral disturbances
 Describe pharmacological and nonpharmacological
interventions for management of behavioral disturbances
 Describe the importance of providing training on
dementia, delirium and depression to health care
professionals

The average life expectancy in US in 1902:
•
•

Males – 47.88 years
Females – 50.70 years
The average life expectancy in US in 2011:
•
•
Males – 76.20 years
Females – 81.04 years
Arias E. United States life tables, 2010. National vital statistics reports; vol 63 no 7. Hyattsville, MD: National Center for Health Statistics. 2014. Retrieved January 27, 2015 from
http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_07.pdf
Pg. 3
Within the next 25 years —

The population of Americans aged 65+ will roughly
DOUBLE to about 72 million
•

Due to longer life spans and aging baby boomers
By 2030, older adults will account for about 20% of
the U.S. population
Centers for Disease Control and Prevention. The State of Aging and Health in America 2013. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human
Services; 2013. Retrieved January 27, 2015 from http://www.cdc.gov/features/agingandhealth/state_of_aging_and_health_in_america_2013.pdf
Pg. 4

The number of people living with dementia
worldwide is currently estimated at 35.6 million.

This number will DOUBLE by 2030!

...and more than TRIPLE by 2050!!
World Health Organization: Retrieved February 5, 2015 from http://www.who.int/features/factfiles/dementia/en/
Pg. 5
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Diseases of Heart
Malignant Neoplasms
Chronic Lower Respiratory Diseases
Cerebrovascular Diseases
Alzheimer’s Disease
Diabetes Mellitus
Influenza and Pneumonia
Accidents (unintentional injuries)
Nephritis, Nephrotic Syndrome and Nephrosis
Septicemia
Hoyert DL, Xu JQ. Deaths: Preliminary data for 2011. National vital statistics reports; vol 61 no 6. Hyattsville, MD: National Center for Health Statistics. 2012. Retrieved January 27, 2015 from
http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_06.pdf
Pg. 6
Alzheimer's Disease
Vascular Dementia
Lewy Body Dementia
Frontotemporal Dementia
Dementia of Huntington, HIV, Syphilis
World Health Organization: Retrieved February 5, 2015 from http://www.who.int/features/factfiles/dementia/en/
Pg. 7
A range of psychological
reactions, psychiatric
symptoms, and behaviors
resulting from the presence of
dementia
Lawlor BA. Behavioral and psychological symptoms in dementia: the role of atypical antipsychotics. J Clin Psychiatry. 2004;65(Suppl 11):5-10.
Pg. 8
Pg. 9
•
•
•
•
•
•
•
•
•
•
Hitting
Pushing
Scratching
Kicking and Biting
Throwing Things
Wandering / Pacing
General restlessness
Hoarding
Social Inappropriateness
Physical Sexual Advances
•
•
•
•
•
•
•
Screaming
Cursing
Temper Outburst
Complaining or Whining
Repetitive Sentences
Verbal Sexual Advances
Constant request for attention
Cohen-Mansfield, J., & Billig, N. (1986). Agitated behaviors in the elderly I. A conceptual review. Journal of the American Geriatrics Society, 34, 711-721.
Pg. 10

Psychiatric symptoms can include:
•

Hallucinations are perceptions without stimuli
•

anxiety, depression, hallucinations or delusions
more commonly auditory or visual
Delusions are fixed, false perceptions or beliefs
•
•
with little, if any, basis in reality
not the result of religious or cultural norms
American Geriatrics Society. (2013). Guide to the management of psychotic disorders and neuropsychiatric symptoms of dementia in older adults. Retrieved August 3, 2013, from
http://dementia.americangeriatrics.org/AGSGeriPsychConsult.pdf
Alzheimer
Vascular
Lewy Body
Fronto-temporal
Apathy
Apathy
Visual Hallucinations
Apathy
Agitation
Depression
Delusions
Disinhibition
Depression
Delusions
Depression
Personality Changes
Anxiety
Labile
Sleep Disturbance
Obsessions
Irritability
Anxiety
Aggression
Impulsive
Pg. 12

Treatment is complex and may require several
interventions as part of a comprehensive care plan

The goal is reduction in frequency and intensity rather
than elimination of the distressing behavior
American Geriatrics Society. (2013). Guide to the management of psychotic disorders and neuropsychiatric symptoms of dementia in older adults. Retrieved August 3, 2013, from
http://dementia.americangeriatrics.org/AGSGeriPsychConsult.pdf

Cohen–Mansfield Agitation Inventory (CMAI)

Neuropsychiatric Inventory-Nursing Home version
(NPI-NH)

Behavioral Pathology in Alzheimer's Disease rating
scale (BEHAVE-AD)
Cohen-Mansfield, J., & Billig, N. (1986). Agitated behaviors in the elderly I. A conceptual review. Journal of the American Geriatrics Society, 34, 711-721.
Cummings JL, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA, Gorbein J. 1994. The neuropsychiatric inventory: comprehensive assessment of psychopathology in dementia. Neurology 44: 2308–
2314.
Reisberg,B., Borenstein, J., Salob, S.P., Ferris, S.H., Franssen, E., Georgotas, A. (1987). Behavioral symptoms in Alzheimer's disease: Phenomenology and treatment. Journal of Clinical Psychiatry, 48
(Suppl.):9-15.
1) Biological and Genetic Model
2) Behavioral / Learning Model
3) Environmental Vulnerability/Reduced Stress
Threshold Model
4) Unmet Needs Model
Fisher JE, Drossel C, Yury C, Cherup S. A contextual model of restraint–free care for persons with dementia. In: Sturmey P, editor. Functional analysis in clinical treatment. London: Elsevier; 2007. p.
211–238.
Hall GR, Buckwalter KC. Progressively lowered stress threshold: A conceptual model for care of adults with Alzheimer's disease. Arch Psychiatic Nurs 1987;1: 399–406
Cohen-Mansfield J. Theoretical frameworks for behavioral problems in dementia. Alzheimer's Care Quarterly. 2000;1:8–21.
1) BIOLOGICAL AND GENETIC MODEL
Behavioral symptoms result directly from
neurologic changes and severe brain
deterioration
Craig D, Hart DJ, Carson R, McIlroy SP, Passmore AP. Allelic variation at the A218C tryptophan hydroxylase polymorphism influences agitation and aggression in Alzheimer's disease. Neurosci Lett.
2004;363:199–202.
2) BEHAVIORAL / LEARNING MODEL

Model assumes that a connection between
antecedents, behavior and reinforcement has been
learned

A different learning experience is needed to change
the relationship between antecedents and behavior
 Antecedent
Behavior
Consequence
Fisher JE, Drossel C, Yury C, Cherup S. A contextual model of restraint–free care for persons with dementia. In: Sturmey P, editor. Functional analysis in clinical treatment. London: Elsevier; 2007. p.
211–238.
Antecedent
Behavior
Consequence
Pg. 19
Pg. 20
Pg. 21
“What occurred directly before the behavior?”

Determine what factors are triggering the behavior.
Who was there? What were the circumstances?

If a behavior pattern has a specific trigger then a
strategy can be developed to modify the behavior

Remove the trigger or provide education or counseling
to the patient to develop new behaviors in the
presence of the trigger.
Pg. 22
•
•
•
•
•
•
•
Physical discomfort/pain
Toileting needs
Hunger/Thirst
Feeling tired or overwhelmed
Sensory deficits
Emotions: fear, anxiety, anger,
sadness
Underlying medical conditions
Pg. 23
•
•
•
•
•
•
•
Chaotic environment
Shift change
New or unfamiliar staff
Change in routine
Lack of stimulation – boredom
Demands to achieve beyond
ability
Communication style used by
staff, visitor, or other residents
“What does the behavior look like?”

What, when, where?
What (be specific) happened?
 How long did it last?
 When did it occur?
 Where did it occur?


If a behavior readily occurs because it achieves some
result –
 Educate the patient on a more suitable behavioral response to the
trigger.
Pg. 24
“What occurred directly after the behavior?”

Determine what the patient avoids or receives as a
result of the behavior.
•
Pg. 25
“What was achieved by the behavior?”
 Physical
Discomfort
 Attention
Seeking
 Avoidance/Escape
 Tangible
Reinforcement
 Self Regulation
Adapted from Desai A., Grossberg G. Recognition and management of behavioral disturbances in dementia. Primary Care Companion, Journal of Clinical Psychiatry 2001;3(3) 93-109.
Pg. 26
3) ENVIRONMENTAL VULNERABILITY /
REDUCED STRESS THRESHOLD MODEL

Dementia process results in a lowered stress threshold
which causes decreased ability to cope and manage
stress as the disease progresses

Behavioral symptoms such as agitation, night
wakening and combativeness emerge when internal or
external stressors exceed patient’s stress threshold
Hall GR, Buckwalter KC. Progressively lowered stress threshold: A conceptual model for care of adults with Alzheimer's disease. Arch Psychiatic Nurs 1987;1: 399–406
4) UNMET NEEDS MODEL

Behavioral disturbances occur due to an inability of
the individual to verbalize their needs

Behaviors are seen as an attempt to communicate
physical or emotional distress

Behavior viewed in this way is seen as a symptom of
unmet needs
Cohen-Mansfield J. Theoretical frameworks for behavioral problems in dementia. Alzheimer's Care Quarterly. 2000;1:8–21.
4) UNMET NEEDS MODEL

Some dementia patients may exhibit inappropriate behaviors as
a result of their basic needs being overlooked

These behaviors might be misinterpreted by caregivers as
acting-out behaviors:
 Fatigue due to poor sleep
 Vision loss or lack of proper
eyeglasses
 Hearing loss or lack of working
hearing aid
 Dehydration
 Need to urinate
 Hunger / Thirst
 Pain / Discomfort
 Loneliness / Boredom
Nonpharmacological Interventions
should ALWAYS be considered as
THE FIRST COURSE OF TREATMENT
in Behavioral and Psychiatric
Symptoms of Dementia
in non-emergent situations

Assess for Danger to Self, Others or Property

Treat Medical Conditions

Treat Psychiatric Symptoms

Encourage Medication Adherence

Modify the Environment

Create a Behavior Monitor Log

Develop and Implement the Resident Centered Care Plan

Encourage Activities

Interdisciplinary Behavioral Team

Provide Ongoing Training of Staff



Ensure that the resident is not in imminent danger to
self, others or property
Is the resident Suicidal or Homicidal?
If the resident is a danger to self, others or property,
the resident should be evaluated immediately by the
local Screening / Crisis Center
Conduct a careful medical evaluation

Assess for…
•
•
•
•
•
Delirium
Treat them!
Comorbid medical illness
Pain
Drugs
Other factors that may be causing the behavioral
disturbance
Pg. 36

Delirium secondary to an underlying condition (e.g.
dehydration, urinary tract infection, pneumonia,
medication toxicity or pain) is a common cause of
abrupt behavioral disturbances in patients with
dementia

A change in behavior is often the first sign of onset of
a health problem

Hallucinations, particularly visual hallucinations, can
be a symptom of delirium
•
Acute onset
•
Altered level of
consciousness
•
Fluctuating course
•
Inattention
•
Perceptual disturbances
•
Disorganized thinking
•
Altered sleep wake cycle
•
Cognitive deficits
•
Emotional disturbances
Pg. 38
1.
History of acute onset of change in patient’s normal
mental status & fluctuating course
AND
2.
Lack of attention
AND EITHER
3.
Disorganized thinking, OR
4.
Altered Level of Consciousness (alert, hyperalert,
lethargic or drowsy, stupor, coma)
Inouye S, van Dyck C, Alessi C, Balkin S, Siegal A, Horwitz R. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine. Dec 15
1990;113(12):941-948.
Pg. 39
Screen for and treat:
Mental Illness or specific psychiatric
symptoms
•
•
•
•
Depression
Psychosis
Delusions
Hallucinations
All of the above respond better to
pharmacological interventions
Adapted from Desai A., Grossberg G. Recognition and management of behavioral disturbances in dementia. Primary Care Companion, Journal of Clinical Psychiatry 2001;3(3) 93-109.
Pg. 40

Depression is common among residents in NFs

Maintain a high level of suspicion for the presence of
depression or depressive symptoms in long-term care
residents
•
especially with residents with a history of depression,
psychiatric disorder(s), and/or treatment of hospitalization.

Late-life depression may be overlooked or inadequately
treated

Major depression can lead to an increase in cognitive
decline in dementia
Adapted from Rapp, M., Schnaider, M., Wysocki, M., Guerrero, E., Grossman, H., Heinz, A., & Haroutunian, V. (2011). Cognitive decline in patients with dementia as a function of depression. American
Journal of Geriatric Psychiatry, 19(4), 357–363.
Pg. 41

Seen in up to 40% of Alzheimer’s patients; may
precede onset of dementia.

Signs include sadness, loss of interest in usual
activities, anxiety and irritability

Suspect if patient stops eating or withdraws

May cause acceleration of decline if untreated

Recreational programs and activity therapies have
shown positive results
American Geriatrics Society. (2013). Guide to the management of psychotic disorders and neuropsychiatric symptoms of dementia in older adults. Retrieved August 3, 2013, from
http://dementia.americangeriatrics.org/AGSGeriPsychConsult.pdf

Depression is common among residents in NFs

Treatment is often effective

Some appropriate screening tools include:
•
•
•
Geriatric Depression Scale
Cornell Scale for Depression in Dementia
Patient Health Questionnaire (PHQ-9)
•
Behavioral disorders in general, and verbal
agitation in particular, have been shown to be
associated with pain
•
Large controlled study showed that use of
ANALGESICS significantly decreased behavioral
disorders in persons with dementia
•
Agitation was significantly reduced in the
intervention group compared with control
group after eight weeks
Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomized clinical trial. BMJ.
2011;343.
•
Educate the resident and
caregivers on the
importance of medication
adherence to manage
symptoms of pain, mental
illness and/or dementia
Pg. 45
Modify the environment to reduce
stress, anxiety and frustration:
• Decrease noise, crowding, task
demands
• Decrease the institutional
appearance of the nursing
facility
• A wall mural over an exit door
can decrease exit attempts
• One dining room
Calkins M. Evidence-based design for dementia. Long-Term Living. 2011;60:42–6.
Pg. 46

Identify patterns in behaviors and likely triggers

Document all antecedents (triggers), target behaviors
and consequences

Analyze the data to identify any patterns of behaviors

Success in management of behavioral disturbances
depends on accurate identification of the cause

Develop interventions in an
effort to decrease the target
behavior

Document the behavioral
intervention in the resident’s
care plan

Monitor the resident’s behavior to determine the
effectiveness of the intervention

Document in the resident’s chart all behavioral
disturbances and incidents, nonpharmacologic
interventions and the effectiveness of the
interventions
Physician / Nurses focus
on keeping residents
healthy and alive, but…
ACTIVITIES
…make their lives worth
living

An integrated interdisciplinary approach to diagnosing
and managing dementia is highly recommended in
clinical practice

Interdisciplinary team meets on a regular basis to
assess the severity of behavioral problems

Develop individualized behavioral interventions for
residents and track effectiveness

Modify interventions as needed
US Department of Veterans Affairs conducted a
systematic evidence review of non-pharmacological
interventions for behavioral symptoms of dementia:
 Aromatherapy
 Light Therapy
 Pet Therapy
 Music Therapy
 Exercise
 Massage and Touch
O'Neil M, Freeman M, Christensen V, Telerant A, Addleman A, and Kansagara D. Non-pharmacological Interventions for Behavioral Symptoms of Dementia: A Systematic Review of the Evidence. VAESP Project #05-225; 2011
Pg. 52

Remove the Stimulus that Triggers the Behavior

Relieve any Physical Discomfort and Attend to any Unmet Needs

Provide Comfort Measures: Soft Blanket, Favorite Item, Food, Drink

Provide Calm Reassurance and Unconditional Positive Regard

Distract and Redirect Activities

Move the patient to a tranquil, quiet setting

Reduce environmental stress – too many people in area

Eliminate misleading stimuli such as TV, radio, mirrors
Pg. 53

Maintain daily routine - simplify, adhere to preferences

Outdoor activities

Provide calm or rest periods at the same time every day

Avoid putting excessive demands on the resident

Honor cultural, religious, ethnic values and traditions

Identify and reduce anxiety provoking situations

Place individuals that need the most supervision closer to the nurses’
station

Have a box of activities to give to individuals who are up and roaming
during the night
Pg. 54

Ongoing education and training provides staff
with the appropriate knowledge, skills and
abilities to improve the care and quality of life
of NF residents

It is essential for staff to stay informed on current
research to ensure residents are given the most up
to date and effective treatments

Education and training programs have been found
to be effective in the reduction of BPSD in both
nursing home environments and the community
Deudon A, Maubourguet N, Gervais X, et al. Non-pharmacological management of behavioural symptoms in nursing homes. Int J Geriatr Psychiatry. Dec 2009;24(12):1386–1395.

Grant funded by The Health Resources and Services
Administration (HRSA) - part of the U. S. Department
of Health and Human Services

Rowan University / NJ Institute for Successful Aging
has partnered with S-COPE to provide statewide
training on dementia and nonpharmacological
behavioral interventions to AL staff, family and
caregivers

Provides trainings, monthly tele-education
conferences, case based review and mentoring
Pg. 56

Drug therapy for behavioral disorders aims to
decrease behavioral disinhibition by changing the
balance of neurotransmitters

The most common class of drugs for behavioral
disorders is antipsychotic medication
•
severe side effects including increased mortality
rates
Schneider LS, Dagerman K, Insel PS. Efficacy and adverse effects of atypical antipsychotics for dementia: meta analysis of randomized, placebo-controlled trials. Am J Geriat Psychiatry. 2006;14:191–
210.
Huybrechts K, Gerhard T, Crystal S, Olfson M, Avorn J, Levin R, et al. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort
study. BMJ. 2012;344:977–89.
•
The FDA has determined that the
treatment of behavioral disorders in
elderly patients with dementia with
both conventional and atypical
antipsychotic medications is associated
with increased mortality
•
There are NO approved antipsychotics
to treat behavioral disorders or agitation
in patients with dementia
United States Department of Health and Human Services. Food and Drug Administration. Public Health Advisory: Deaths wit Antipsychotics in Elderly Patients with Behavioral Disturbances (April
2005). Retrieved on February 1, 2015 from http://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/ucm053171
United States Department of Health and Human Services. Food and Drug Administration. Information for Healthcare Professionals: Conventional Antipsychotics (June 2008). Retrieved from
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm124830.htm#
Ballard CG, Gauthier S, Cummings JL, et al. Management of agitation and aggression associated with Alzheimer disease. Nat Rev Neurol. 2009 May;5(5):245-55.

Centers for Medicare & Medicaid Services launched a national
initiative targeting nursing facility (NF) residents to improve
their behavioral health and reduce their use of antipsychotic
medications

A new national goal of reducing the use of antipsychotic
medications in NFs residents by 30% by the end of 2016
Department of Health and Human Services, Centers for Medicare & Medicaid Services. Center for Medicare and Medicaid Services. Press release: National Partnership to Improve Dementia Care
exceeds goal to reduce use of antipsychotic medications in nursing homes: CMS announces new goal. Retrieved January 30. 2015 from http://www.cms.gov/Outreach-andEducation/Outreach/NPC/Downloads/2013-07-10-Dementia-NPC.pdf
Department of Health and Human Services, Centers for Medicare & Medicaid Services. Partnership to Improve Dementia Care in Nursing Homes Antipsychotic Drug use in Nursing Homes Trend
Update. Retrieved January 30, 2015 from http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2014-10-27-Trends.pdf

Don’t prescribe antipsychotic medications to patients for any indication
without appropriate initial evaluation and appropriate ongoing monitoring.

Don’t routinely prescribe 2 or more antipsychotic medications
concurrently.

Don’t use antipsychotics as first choice to treat behavioral and
psychological symptoms of dementia.

Don’t routinely prescribe antipsychotic medications as a first-line
intervention for insomnia in adults.

Don’t routinely prescribe any antipsychotic medication to treat behavioral
and emotional symptoms of childhood mental disorders in the absence of
approved or evidence-supported indications.
American Psychiatric Association (September 2013), "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation (American Psychiatric Association),
Retrieved January 30, 2015 from http://www.choosingwisely.org/doctor-patient-lists/american-psychiatric-association

If nonpharmacologic interventions fails or if “agitated”
behaviors are too harmful to patient or others,
consider pharmacological interventions

Utilize time-limited pharmacologic trials for severe or
persistent BPSD symptoms that have some evidence of
efficacy and low potential for harm
Pg. 63

The elderly patient population requires special
consideration when it comes to chemical sedation

Elderly patients require careful evaluation for delirium
vs. dementia as these are two of the more common
causes of acute agitation

Doses should be lowered in the elderly
SSRIs include:

Celexa (citalopram)

Lexapro (escitalopram)

Prozac (fluoxetine)

Luvox (fluvoxamine)

Paxil (paroxetine)

Zoloft (sertraline)
The CitAD study:
•
•
•
randomized, placebo-controlled, double-blind, parallel group
trial
enrolled 186 patients with probable Alzheimer disease and
clinically significant agitation
from 8 academic centers in the U.S. and Canada from August
2009 to January 2013.
CONCLUSION:
Participants treated with Celexa showed significant decrease in
agitation compared with those treated with placebo
Porsteinsson AP, Drye LT, Pollock BG, Devanand DP, Frangakis C, Ismail Z, Marano C, Meinert CL, Mintzer JE, Munro CA, Pelton G, Rabins PV, Rosenberg PB, Schneider LS, Shade DM, Weintraub D,
Yesavage J, Lyketsos CG, CitAD Research Group. Effect of citalopram on agitation in Alzheimer disease: the CitAD randomized clinical trial. JAMA. 2014 Feb 19;311(7):682-91.
Pg. 66
•
Xanax (Alprazolam)
•
Ativan (Lorazepam)
•
Librium (Chlordiazepoxide)
•
Serax (Oxazepam)
•
Klonopin (Clonazepam)
•
Restoril (Temazepam)
•
Tranxene (Clorazepate)
•
Halcion (Triazolam)
•
Valium (Diazepam)

Benzodiazepine use remains highly prevalent and is
often chronic in older people

Some studies have found that benzodiazepine use is
associated with an increased risk of Alzheimer’s
disease

Use of benzodiazepines in the elderly can contribute
to falls and injuries

Use benzodiazepines very carefully in the elderly

Start Low, Go Slow
American Geriatrics Society 2015 Beers Criteria Update Expert Panel (2015). "American Geriatrics Society 2015 Updated Beers
Criteria for Potentially Inappropriate Medication Use in Older Adults". J Am Geriatr Soc. 63 (11): 2227–46. doi:10.1111/jgs.13702
Billioti de Gage Sophie, Moride Yola, Ducruet Thierry, Kurth Tobias, Verdoux Hélène, Tournier Marie et al. Benzodiazepine use and risk of Alzheimer’s
disease: case-control study BMJ 2014; 349 :g5205

An antipsychotic is a psychiatric medication primarily
used to manage psychosis particularly in schizophrenia
and bipolar disorder

The exact mechanism of action of antipsychotic drugs
remains unknown but is believed to block the
neurotransmitter dopamine in the brain

Antipsychotic Medications:
•
•
First-generation antipsychotics (FGAs)
Second -generation antipsychotics (SGAs)

Also known as:
•
typical antipsychotics, dopamine antagonists,
neuroleptics and conventional antipsychotics

Used primarily for the treatment of schizophrenia and
related psychotic disorders

Higher risk of neurological side effects.
•

Some of these include, tardive dyskinesia and
extrapyramidal symptoms (EPS)
Less expensive than newer antipsychotics
•
Thorazine (Chlorpromazine)
•
Mellaril (Thioridazine)
•
Prolixin (Fluphenazine)
•
Haldol (Haloperidol)
•
Trilafon (Perphenazine)
•
Navane (Thiothixene)
•
Stelazine (Trifluoperazine)
•
Loxitane (Loxapine)

Second -generation antipsychotics are also known as:
• atypical antipsychotics
• dopamine/serotonin antagonists

Atypical antipsychotics have a decreased incidence of
extrapyramidal side effects (EPS)









Clozaril (Clozapine)
Zyprexa (Olanzapine)
Seroquel (Quentiapine)
Risperdal (Risperidone)
Geodon (Ziprasidone)
Abilify (Aripiprazole)
Invega (Paliperidone)
Latuda (Lurasidone)
Saphris (asenapine)

Risk of mortality with a FGA in individuals with
dementia was generally greater than the risk with a
SGA.

Data from randomized placebo-controlled trials
suggest efficacy for Risperdal in treating psychosis and
for Risperdal, Zyprexa and Ability in treating agitation.
Reus VI, Fochtmann LJ, Eyler E, Hilty DM, Horvitz-Lennon M, Jibson MD et al. The American Psychiatric Association Practice Guideline on the use of antipsychotics to treat agitation or psychosis in
patients with dementia. Am J Psychiatry. 2016; 173: 543-546.
Pg. 74

Choice of a medication will also depend on factors
such as:
•
•
•
patient’s prior responses to a specific agent
co-occurring medical conditions
pharmacokinetic properties of the medication

•
e.g. absorption, half-life
potential for drug interactions and additive side effects
with other medications that the patient is already taking
Reus VI, Fochtmann LJ, Eyler E, Hilty DM, Horvitz-Lennon M, Jibson MD et al. The American Psychiatric Association Practice Guideline on the use of antipsychotics to treat agitation or psychosis in
patients with dementia. Am J Psychiatry. 2016; 173: 543-546.
Pg. 75
- Behavioral and Psychological symptoms are common
in dementia
- Common theoretical models used to manage
behavioral disturbances are:
•
Biological and Genetic Model
•
Behavioral / Learning Model
•
Environmental Vulnerability/Reduced Stress
Threshold Model
•
Unmet Needs Model
- Nonpharmacological interventions should be the FIRST
course of treatment in behavioral symptoms of
dementia in non-emergent situations
- If nonpharmacologic interventions fail and behaviors
are too harmful to patient or others, consider using
pharmacological interventions - USE WITH CAUTION
If you have any questions or comments, please contact:
DEBORAH KLASZKY MSN APN-C
Rowan University SOM
NJ Institute for Successful Aging
[email protected]