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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]