Dementia, Age Related decline and Rural Psychiatric Management
Dementia, Age Related decline and Rural Psychiatric Management Bhusan Neupane, MD Attending Geriatric Psychiatrist Catawba Hospital Assistant Professor, Virginia Tech Carilion School of Medicine Department of Psychiatry and Behavioral Medicine Geriatric Syndromes Memory loss and dementia Falls Urinary Incontinence Polypharmacy Frailty Geriatric Assessment: Challenges
Atypical presentation of acute illness - e.g. pneumonia or UTI may present as acute neurological event. Sometimes infection may not be accompanied with fever or elevated in white cell count. Impaired thirst mechanism can quickly lead to dehydration Patient with pre-existing psychiatric illness symptoms can be worsened with medical illness e.g. patient with schizophrenia may be more agitated. Altered metabolism of medications due to decreased functioning of liver enzymes, kidney function increase chances of toxicity even after medication discontinued. Dementia: Introduction Syndrome of deterioration of intellectual or cognitive function due to chronic progressive degenerative disease of the brain. Little or no
disturbance consciousness or perception. in Dementia Vs. Amnesia Progressive decline in cognitive function that impairs daily functioning. Memory loss with otherwise preserved intellectual function AMNESIA Amnesia usually temporary or permanent dysfunction of hippocampus and portions of the limbic system. Dementia, in contrast usually results from extensive cerebral cortex dysfunction. emory loss alone is not equivalent to dementi DSM 5 Significant cognitive decline from previous level of performance in one or more complex cognitive domains (complex attention, executive functioning, learning and memory, language, perceptual motor, or social
cognition) based on Concern of the individual or informant or clinician that there has been significant decline in cognitive functioning Impairment in cognitive performance preferably documented by standardized neuropsych testing or clinical assessment Interference with daily activities. Not occurring in context of delirium Cognitive deficits not explained by another mental disorder (e.g. MDD, schizophrenia) DSM 5 Major Neurocognitive Disorder Specifiers Specifiers: Azheimers disease Frontotemporal lobar degeneration Lewy body disease Vascular disease Traumatic Brain injury Substance/medication use HIV infection Prion Disease Parkinsons disease Huntingtons disease
Another medical condition Multiple etiologies Unspecified. Demographics Alzheimers Disease: 60-70% Other progressive disorders: 15-30% (vascular, Lewy body, frontotemporal) Completely reversible dementia: 2-5% (drug toxicity, metabolic changes, thyroid disease, subdural hematoma, normal pressure hydrocephalus) Mild Cognitive Impairment (MCI) Mild Neurocognitive Disorder
MCI consists of memory impairments accompanied by abnormal memory test scores, but normal cognitive function and preserved activities of daily living. Could be a precursor to Dementia 10-20% of persons with MCI develop dementia (compared to 1-2%) Alzheimers Disease Progression Behavioral and Psychological Symptoms of Dementia (BPSD) Psychopathological features Depression Apathy Anxiety Panic Delusions mostly persecutory Hallucinations visual, auditory,
tactile Disturbances in Motor Function Agitation Wandering Repetitive purposeless behaviors Disinhibited behaviors Physical aggression Verbal aggression Circadian Rhythm changes Insomnia Hypersomnia
Sleep wake cycle reversal REM sleep behavior disorders Fragmented sleep Daytime napping and awakenings at night Appetite and Eating Behavior Anorexia Hyperphagia Preference for sweets - FTD Cerejeira J et al. Behavioral and psychological symptoms of dementia. Frontiers in Neurology. 2012 Causes of BPSD Sensory Impairment Can impair sense of isolation May contribute to misperception of the environment Hearing aids, visual aids can
be useful Psychiatric Illness Majority patients with dementia have cooccuring anxiety and depression Concomitant Psychiatric illness Psychosis/affective disorders Medical Illness Unmet Needs Any infection (eg UTI, pneumonia), Pain, Behavior Thirst, Hunger Recent stroke, Metabolic al Environmental Factors Symptom Medications s Psychotropic medications Antipsychotics, Understimulation or overstimulation benzodiazepines, Antidepressants (TCA) Loud noises buzzers, TV, radio Other medications with anticholinergic Excessive lighting, glare properties
Confusion, sedation, falls, akithisia, Social Factors Constipation Loss of meaningful relationships Urinary retention arlson D.L. et al. Management of Dementia-Related Behavioral Disturbances: A Nonpharmacological Approach. Mayo Clin Proc 1 teffens D. C. et al. Textbook of Geriatric Psychiatry. American Psychiatric Publishing, 5 th edn. 2015. Assessment Behavioral symptoms are almost inevitable at some point in patients with dementia. Careful psychiatric evaluation and history critical Determine whether subacute or chronic acute, Assessment Contd
Sudden onset of disruptive behavior usually suggestive of medical etiology Slower, insidious onset response to a change in caregiver, routine or environment. Important to delineate actual features and specifics of behavior (agitation vague) Observe timing, pattern clue to the triggers Assessment Contd Psychiatric symptoms without prior history of psychiatric illness in elderly is RARELY from primary psychiatric disorders (Case, MC) A thorough medical work up is always recommended in these group of patients.
Assessment Contd Assess for any unmet needs: thirst, hunger, limited social contact. Evaluate for any physical discomfort: inadequate pain control, full bladder, constipation, shortness of breath. Evaluate for any possible infections: UTI (most common), Pneumonia, other infections. Look for any recent
changes/medication side effects: Anticholinergics Opioids medication Management Few points to consider: Behavioral symptoms are common even in context of excellent, well-intentioned care. The targeted behaviors cannot be eliminated completely, but may be reduced to tolerable levels. Patient do
symptoms Pharmacologic no intentionally produce these and Non Pharmacologic Delirium Acute, sudden change in attention and overall cognitive function, usually reversible. Develops over a short period of time hours to few days Change from baseline attention and awareness and tends to fluctuate Can be acute or persistent. Mostly has identifiable cause. Hyperactive, Hypoactive
mixed. Cleason O C. Delirium. American Familyor Physician. March 2003 Evaluation of Delirium History recent med changes, interactions, pain, discomfort evaluate med Vital signs Physical and neurological examination signs of infection, dehydration, acute abdomen, DVT, Neurological and meningeal signs Targeted laboratory evaluation CBC, electrolytes, LFTs, RFTs, Thyroid function, UA, blood/urine culture,
drug toxic level, CK, NH3, CXR, ABG, EKG, Lumbar puncture Targeted neuroimaging (selected patients): Assess for focal neurological changes, stroke can present with Management of Delirium Medication adjustments reduce or remove psychoactive medications anticholinergics, sedative-hypnotics, opioids; lower dosages; avoid PRNs Address acute medical issues infective, metabolic; Maintain hydration and nutrition Reorientation strategies Maintain safe mobility Normalize sleep-wake cycle discourage daytime napping, encourage exposure to bright light during day; sleep hygiene. Pharmacological management only for severe agitation low dosage and temporary use only Steffens D. C. et al. Textbook of Geriatric Psychiatry. American Psychiatric Publishing, 5 th edn. 2015. Delirium Video https://www.youtube.com/watch?v=qm MYsVaZ0zo When to suspect medical causes for psychiatric
presentation? Elderly patient with first onset of psychotic symptoms Multiple Medical conditions (case vignette - W) Multiple medications (Case vignette - B) Recent medication change addition, dosage changes, discontinuation Classes of medications - opioids, benzodiazepines, anticholinergics, lithium, dopaminergic medications (Carbidopa/levodopa, ropinirole) (Case vignette) Acute change in mental status can be challenging in patients with coexisting psychiatric illness (Case vignette) Visual hallucinations exception rare forms of dementia
(Lewy Body Dementia, Charles Bonnet Syndrome, Late stage Alzheimers, Advanced Parkinson's disease) Focal Neurological deficits Confusion, disorientation, impaired attention Always Rule out Medical Cause if Acute onset, sudden change in personality and behavior Multiple medical conditions - hx of cardiac, respiratory, metabolic Multiple medications anticholinergics Addition of new medications, change in medications
Disorientation, confusion, impaired attention. Visual hallucinations vs. auditory hallucinations Focal Neurological deficits Signs of infection Past history of delirium Substance intoxication/withdrawal.
- esp benzos, opioids, Case 78-year-old female with history of dementia diagnosed about a year ago with gradual decline of her cognitive status. Patient currently lives at her home. She is independent of her ADLs. However, she needs help with her medications, finances and transportation. Last year, patient forgot to pay several of her bills and her daughter started helping her with her finances. She stopped driving few months ago since she was involved in an accident and injured her knee. The daughter recently hired a caregiver to help with Ms. Ms chores at home. The daughter fills Ms. Ms pill box every week and Ms. M takes her medications by herself. Ms. Ms medical problems are significant for HTN, DM and osteoarthritis. Ms. M is usually calm and pleasant and an overall
amiable personality as per the daughter. Ms. M has notable cognitive deficits most importantly difficulty with naming objects, remembering recent events and misplacing her items. Recently, she was taken to her PCP for increase in her knee pain which kept her from sleeping at night. She was added couple of medications to her current medications. A week later, patient becomes increasingly irritable and angry. She was also more confused. She accused the caregiver for stealing her things Case 78-year-old female with history of dementia diagnosed about a year ago with gradual decline of her cognitive status. Patient currently lives at her home. She is independent of her ADLs. However, she needs help with her medications, finances and transportation. Last year, patient forgot to pay several of her bills and her daughter started helping her with her finances. She stopped driving few months ago since she was involved in an accident and injured her knee. The daughter recently hired a caregiver to help with Ms. Ms chores at home. The daughter fills Ms. Ms pill box every week and Ms. M takes her medications by herself. Ms. Ms medical problems are significant for HTN, DM and osteoarthritis. Ms. M is usually calm and pleasant and an overall amiable personality as per the daughter. Ms. M has notable cognitive deficits most importantly difficulty with naming objects, remembering recent events and misplacing her items. Recently, she was taken to her
PCP for increase in her knee pain which kept her from sleeping at night. She was added couple of medications to her current medications. A week later, patient becomes increasingly irritable and angry. She was also more confused. She accused the caregiver for stealing her things History Duration, Progression, ADLs, IADLs Living at home ? Stage of dementia Possible visual hallucinations Is it likely with the type of dementia. What more information would you want? What medical work up do you suggest? Any previous interventions that might have prevented this? Non Pharmacological Management of BPSD Why Important? First line No
FDA approved medication to control behavioral symptoms in dementia Most commonly used medications - antipsychotics and/or benzodiazepines both
class with significant side effects. Not used unless clear indication that benefits outweigh the risks Side effects are inevitable with medications Non Pharmacological Interventions Behavior Management Techniques Cognitive/Emotion oriented Interventions Reminiscence therapy Simulated presence therapy Validation therapy Sensory stimulation interventions Acupuncture Aromatherapy Light therapy
Massage/touch therapy Music therapy Snoezelen multisensory stimulation Psychosocial interventions Animal assisted therapy and exercise Cerejeira J et al. Behavioral and psychological symptoms of dementia. Frontiers in Neurology. 2012 Non Pharmacological Interventions Cognitive/Emotion oriented Interventions Reminiscence therapy Using to recount pleasurable experiences Simulated presence therapy Playing tape recordings of patients caregiver Found to reduce anxiety and challenging behavior Validation therapy Focuses on responding to the emotion rather than the content what patient says
Cerejeira J et al. Behavioral and psychological symptoms of dementia. Frontiers in Neurology. 2012 Behavioral Management for BPSD Patients with dementia reasoning and language skills are gradually lost Communication is overtly behavioral Even speech is intact limited expression because of difficulty with expression. Behaviors are usually an attempt to express their feelings and needs ~ crying out in young child. rlson D.L. et al. Management of Dementia-Related Behavioral Disturbances: A Nonpharmacological Approach. Mayo Clin Proc 19 Behavioral Management for BPSD Things to Say: May I help you? Do you have time to help me? You are safe here. Everything is under control I apologize Im sorry that you are upset I know its hard I will stay with you till you feel better.
Alzheimers Association; alz.org Behavioral Management for BPSD Dos Donts Use calm, positive statements Back off and ask permission Reassure Slow down Add light Offer guided choices between two options Focus on pleasant events Offer simple exercise options Try to limit stimulation
Raise your voice Make sudden movements Show alarm or offense Corner, crowd or restrain Demand, force or confront Rush or criticize Ignore or argue Shame or condescend Alzheimers Association; alz.org Management strategies for specific behaviors Behavior Potential causes
Management strategies Wandering Stress noise, Clutter, crowding Restless, Bored no stimuli Medication side effects Needing to use toilet Environmental stimuli exit signs, people leaving Reduce excessive stimulation Provide familiar objects, signs, pictures, offer to help find objects or place, reassure Meaningful activity Monitor, reduce or D/C medication Institute toileting schedule Signs or pictures on bathroom door Suspiciousn ess/ Paranoia
Forget where objects were placed Misinterpreting actions of words Misinterpreting who people are; suspicious of their intentions Change in environment or routine Misinterpreting environment Physical illness Social isolation Someone actually taking something from patient Offer to find help; have more than one object available DO NOT argue or try to reason; try to distract; do not take personally Introduce self and role routinely; draw old memories, connections Reassure, familiarize, set routine Assess vision, hearing, modify environment as needed Evaluate medically if needed Encourage and provide familiar social
opportunities rlson D.L. et al. Management of Dementia-Related Behavioral Disturbances: A Nonpharmacological Approach. Mayo Clin Proc 19 Management strategies for specific behaviors Behavior Agitation Potential causes Management strategies Discomfort, pain Physical illness (eg UTI) Fatigue Overstimulation - noise, pagers, radio, television, activities Mirroring of caregivers affect Patient being asked multiple questions that exceed their cognitive abilities Unfamiliar people or environment; change in schedule
or routine Assess and manage sources of pain, constipation, infection, full bladder; check clothing for comfort Evaluate medically as necessary Eliminate excess caffeine Schedule adequate rest Reduce noise, over crowding, loud radio/television Control your own affect, calm with low tone of voice and speak slowly Redirect, ask for meaningful activity appropriate to their cognitive level Simplify tasks; avoid arguments and reprimands Be consistent; avoid changes; surprises; make changes gradually rlson D.L. et al. Management of Dementia-Related Behavioral Disturbances: A Nonpharmacological Approach. Mayo Clin Proc 19 Management strategies for specific behaviors Behavior
Potential causes Management strategies Sleep disturbance Illness, pain, medication effect (medications causing excessive daytime sleeping leading to nocturnal awakening) Depression/anxiety Less need for sleep Poor temperature control (too hot, too cold) Disorientation from darkness Caffeine Hunger Urge to void Age related sleep changes (decreased total sleep time, reduced sleep efficiency, decreased slow-wave and REM
sleep and increased stage 1 and 2 sleep) Medical evaluation and treatment as appropriate Antidepressants for depression Schedule later bedtime; allow activities for tasks safely done at night; plan more daytime exercise Adjust temperature Use night lights Reduce or eliminate caffeine, especially after evening Provide night time light snacks ensure clear, well-lit pathway to bathroom Eliminate daytime naps; provide activity and exercise instead; for naps use recliner rather then bed Provide soft music, massage arlson D.L. et al. Management of Dementia-Related Behavioral Disturbances: A Nonpharmacological Approach. Mayo Clin Proc 1 teffens D. C. et al. Textbook of Geriatric Psychiatry. American Psychiatric Publishing, 5 th edn. 2015. Management strategies for specific behaviors
Behavior Inappropriat e or impulsive sexual behavior Potential causes Management strategies Dementia related decreased Do not overreact or confront, respond judgment and social awareness calmly and firmly; distract and redirect Misinterpreting caregivers Do not give mixed sexual messages; interaction
avoid nonverbal messages; distract while Uncomfortable too warm, performing personal care; bathing clothing too tight; need to void; Check room temp; comfortable weather genital irritation appropriate clothing; ensure elimination Need for attention, affection, needs are met; examine for groin rash; intimacy perineal skin problems; stool impaction Self stimulating, reacting to
Model for appropriate touch; offer what feels good soothing objects (stuffed animals); provide hand or back massage Offer privacy; remove from inappropriate place rlson D.L. et al. Management of Dementia-Related Behavioral Disturbances: A Nonpharmacological Approach. Mayo Clin Proc 19 Thank You
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