PROJECT ECHO: Strategies for Managing - PowerPoint Presentation

Slide1

PROJECT ECHO:Strategies for Managing Dementia Behaviors

BRETT LU, MD PHDASSOCIATE PROFESSORUNIVERSITY OF HAWAIIDEPARTMENT OF PSYCHIATRYQUEENS MEDICAL CENTER

AIDA WEN, MDASSOCIATE PROFESSORUNIVERSITY OF HAWAIIDEPARTMENT OF GERIATRIC MEDICINE

APRIL 11, 2017

JABSOM Department of GeriatricsSlide2

2

This presentation was supported in part by the Geriatrics Workforce Enhancement Program (GWEP) DHS, DHHS, Bureau of Health Profes­sions awarded to the Pacific Islands GEC, and by cooperative agreement No. 90AL0011-01-00 from the Administration on Aging (

AoA

), Administration for Community Living (ACL), U.S. Department of Health and Human Services (DHHS) awarded to the University of Hawaii Center on Aging. Grantees carrying out projects under government sponsorship are encouraged to express freely their findings and conclusions. Therefore, points of view or opinions do not necessarily represent official

AoA

, ACL, or DHHS policy.

University of Hawaii Center on AgingSlide3

Mr. SatoYou are seeing Mr. Sato and his family. He is 85 years old. You have known him for at least 10 years. He is a retired professor. He is relatively healthy with PMH

of HTN, BPH and macular degeneration. He was diagnosed with early dementia 5 years ago and has been on Aricept since then. He moved in with his daughter’s family 2 years ago as he needed help with his IADLs. He often refuses help, especially with bathing, and brushing teeth.It is Monday morning and his daughter is exasperated. Slide4

He had a fall…

She tells you that he had an unwitnessed fall Friday night in the bathroom as he was showering, and bruised his left hip. He says abruptly, “I’m fine!” She says he has been more irritable than usual this weekend, yelling and screaming about everything, and telling her to leave him alone. AND to top it all off, he hasn’t been sleeping well at night! He leans forward and says to you

Everyone is spying on me!I’m

FINE!Slide5

“He is driving me crazy!”The daughter appears tired and exasperated.

She tells you that when he first moved into her house, things worked out “fine”, but right now… He is driving me

CRAZY!!!…please help!!!Slide6

Depression risks

:

Female

lower education level

same home

lack of choice

Consequences of burnout

:

poor mental/physical health

earlier institutionalization of pts

care negligence

abuse

Adelman 2014;

Covinsky

2003, NSDUH 2007

Prevalence(%)

of Depression

Caregiver Burnout: the “Invisible Patient”Slide7

General ApproachesHow you communicate matters:

Approach from the frontSpeak slowly calmlyDon’t argue, reason, shame or demand. Instead, reassure, repeat, demonstrate, encourage.TADA! = Tolerate, A

nticipate, Don’t Agitate! If it’s not dangerous, let them be.Anticipate their needs before they get upset. Having a familiar routine is helpful Don’t do or say things to upset them- Restraints make people upset. Sometimes “re-orienting” them can make people upset. Slide8

Safety

:Grab bars, no sharp edges

Concealed exitsOrientation:Routines, clocksEncourage ADLs,

Hearing aids,

Written communications

Environment:

Not

understimulatingNot overstimulating

Ballard 2009, Beier 2007, Gerdner 1993, Kong 2009, Rowe 1999

Courtesy of

Manoa CottagesGeneral ApproachesSlide9

FIRST: Rule out Medical CausesEvaluate for Delirium!

Acute onsetInattentionDisorganized thinkingAltered consciousnessHe may have a Medical illness that should be treated!Rule out “reversible Dementia”- check CBC, TSH, Vit B12, BMP

GET A MEDICAL EVALUATIONSlide10

SECOND: Identify any triggersPHYSICAL: Pain, Hungry, Thirsty, Cold, Constipated?

ENVIRONMENT: too much/ too little stimulation?PSYCHOLOGICAL: frustrated, depressed, bored, scared?Slide11

S

taff Training

Pet Therapy

1:

1

I

n

teraction

THIRD: Try Non-pharmacologic StrategiesSlide12

Get Practical Tips for Common Challenges

BathingOral CareUsing the BathroomPacingIn the CarDressingGoing outHolidaysWebsites:

www.alz.org--> Life with Alz Caregiver Center Daily care Personal Care BathingSlide13

SleepAVOID

Too much time in bed at nightToo much daytime nappingGetting over-tiredNot enough exerciseCaffeine/ alcohol

Too much fluid after dinnerHungerSUGGESTMedical evaluation: pain, Restless legs, Sleep apnea, depression, medication side effects, etc. Try

to maintain a routine

Keep occupied/awake in the day (or

short

nap after lunch)

Daytime exerciseDon’t go to bed too earlyTreat pain- Tylenol at bedtimeGive something soft to holdSnack & Early evening activities

Use nightlight, bathroom or hallway lights- darkness can be disorientingWake

up same time of the day…and if all else fails, allow them to be awake at night and hire a nighttime companion!Slide14

Behaviors = CommunicationCant’ find the words

Decreased coping capacityAsk “Why?”Try to see things from the person’s viewpointAdapt the caregiver approach, communication style, environment or activities

Communication of UNMET NEEDSSlide15

Ask about the typical day at home

Daughter is working from home.After the kids go to school, she gets dad up. She tries to leave dad alone most of the morning to read the paper or watch TV, but he is often disruptive.Has lunch with dadShe get kids home from school at 2:30Household becomes busy and noisyEvenings are the worst- full of confrontations.…Weekends are just unpredictable!He is up and down all night long.

RummagingHoardingInterruptingPushing, HittingScreamingSlide16

Ask “Why”?Daughter is working from home.

After the kids go to school, she gets dad up. She tries to leave dad alone most of the morning to read the paper or watch TV, but he is often disruptive.Has lunch with dadShe get kids home from school at 2:30Household becomes busy and noisyEvenings are the worst- full of confrontations.…Weekends are just unpredictable!He is up and down all night long

Why is he rummaging and interrupting me all morning?Why is he yelling and cursing in the afternoon?Why is he hitting in the evening?Slide17

…and Listen to what he is sayingDaughter is working from home.

After the kids go to school, she gets dad up. She tries to leave dad alone most of the morning to read the paper or watch TV, but he is often disruptive.Has lunch with dadShe get kids home from school at 2:30Household becomes busy and noisyEvenings are the worst- full of confrontations.…Weekends are just unpredictable!He is up and down all night long

I can’t find that tool I need to fix the dresserEveryone is busy and the kids are yelling again. Why can’t they just shut up!

I already took a bath! Don’t tell ME what to do! And I don’t need your help!

I need meaningful work

I need a peace and quiet

I need some autonomySlide18

Try to Understand their needs at different stages…

SAPHIRE (very early)- Leaving a legacyDIAMOND (Early)- Wants a sense of control, choiceEMERALD – Enjoys having a jobAMBER- (Mid) Enjoys things to mess with and exploreRUBY- Enjoys holding, rubbingPEARL (Advanced)- enjoys warmth and comfortA more positive approach…

Teepa Snow, OTR

Teach caregivers to understand each person and

their changing

abilities (GEMS

)Slide19

Meaningful Activities & Continuous Programming

Valued by adultsWork activities (being productive and helpful)Ex: gardening, cooking, cleaning, laundry, woodwork, fundraising, etcSelf-care (“independence”, ADLs, exercise)Leisure (visiting, games, watching musical/ movie)Rest (napping, rocking, holding hands, massage, watching fish, petting dog)

Person-centeredEngagingFailure FreeSlide20

Music Therapy (with Protocol

)It is NOT background musicIt is INTERACTIVE!Protocol: Warm up of a well known song, listening to music, then joining in with music (tapping, singing, dancing)

Most studies had music therapy 2-3x per weekMusic therapy improves the mean level of agitation symptomsIt is PERSONALIZEDiPOD Music & Memory Progam: Musical favorites on a playlist

Decreased behaviors, depression and anxiety symptomsSlide21

Sensory Stimulation

Especially for

Later Stages of Dementia

VISUAL COLOR GENTLE TOUCH

AROMATHERAPY QUIET ENVIRONMENT SOOTHING SOUNDS

SNOEZELEN

NAMASTE CARESlide22

What are your ideas?

I can’t find that tool I need to fix the dresserEveryone is busy and the kids are yelling again. Why can’t they just shut up!

I already took a bath! Don’t tell ME what to do! And I don’t need your help!

I need meaningful work

I need a peace and quiet

I need some autonomySlide23

Maintaining Quality of Life in Dementia

Symptom

Severity

Quality

of Life

non-pharm approaches

non-pharm approaches

+ appropriate medications

+ inappropriate medications

no treatmentSlide24

Indications: Poor Quality of Life, Safety Concerns-distressing psychosis/anxiety, severe depression

-elopement, physical aggression-to avert institutionalization, emergency servicesUse medications with the highest benefit to risk ratio

Clear surrogacy/Transfer Decision-making AppropriatelyBalance between no treatment and overtreatmentClear symptom description allows specific, effective plans

FOURTH: Medications

for Dementia-related

Behaviors

“judicious use of pharmacological interventions, including antipsychotics, is appropriate, necessary, and ethically justified

…”

Desai 2012Slide25

Depression

20-40%

Psychosis

hallucinations/delusions

25%

Altered circadian rhythms

disrupted sleep patterns

Anxiety

Agitation

often persistent

Behavioral

and Psychological Symptoms of Dementia (BPSD)

Apathy

A clear

description of

symptoms

helps to

facilitate

specific and effective treatmentSlide26

Beers criteria: avoid benzodiazepines, anticholinergics, sedatives; associated with neuropsychiatric symptoms/cognitive decline

Avoid medications with opposing mechanisms:

25-35% patients on cholinesterase inhibitors also

received anticholinergic medications

BPSD: Limiting Medication Side-effects

Chew 2008, Fick 2003, Gray 2015

Carnahan 2004, Mann 2003Slide27

Some BPSD Options

There are No

“FDA-approved” medication for

behaviors

in

dementia, However…

Dementia Medications-

AChE

inhibitors and Namenda may help

Prazosin- Used to treat PTSD/nocturnal/hyperarousal symptoms.

Especially helps agitation/aggression in Alzheimers (3-5 mg bid)Antidepressants (SSRI’s)- improves mood/agitation, anxiety, fewer side effectsAtypical Antipsychotics- can help, more sedation/serious side effectsAnticonvulsants/ Mood StabilizersBenzodiazepines- associated with fallsFor insomnia- consider melatonin and trazodoneSlide28

Paranoia

mild citalopram, prazosin,

sertraline, escitalopram

severe risperidone, olanzapine, aripiprazole,

quetiapine

Depression

antidepressants

Apathy

cholinesterase inhibitors (

ChEI

), methylphenidate buproprionAnxiety/Agitation mild citalopram, trazodone, prazosin, ChEI/memantine severe risperidone, olanzapine

quetiapine, benzos, valproate, gabapentin,

buspirone

Sexual Aggression

citalopram, risperidone

Insomnia

melatonin, doxepin, trazodone,

mirtazepine

PRNs

mild behaviors trazodone

emergency IM haloperidol, IM olanzapine

Second line options in italics

Symptom-based Medication Options for BPSD

Desai 2012Slide29

citalopram,

escitalopram, sertraline

prazosin

methylphenidate

memantime

prn trazodone

risperidone

olanzapine

aripiprazole

trazodone

?

valproic

acid

gabapentin

benzodiazepines

depression

anxiety

paranoia

screaming

agitation

aggression

prn risperidone,

olanzapine, quetiapine

apathy

donepezil

insomnia

trazodone

melatonin

zolpidem/

temazepam

gabapentin/(Newer agents)

doxepin

mild

mild

mod/severe

mod/severe

Honolulu Medication Algorithm for Behavioral Symptoms in Dementia

Lu 2016Slide30

Caregivers don’t have to do it on their own

Case ManagementAdult Day Care CentersRespite CareCare HomesNursing HomesSlide31

Community ResourcesAlzheimer’s Association –Aloha Chapter

www.alz.org/hawaii/Tel: 591-2771 Elderly Affairs Divisionwww.elderlyaffairs.comTel: 768-7700Hawaii Memory Care NavigatorsTel: 956-8340Slide32

Alzheimer’s Association (activity ideas)http://www.alz.org/care/alzheimers-dementia-stages-behaviors.aspNIA

http://www.nia.nih.gov/alzheimers/managing-alzheimers-disease-communication-and-behavior-problems-resource-listElectronic Dementia Guide for Excellence (EDGE) Projecthttp://www.health.ny.gov/diseases/conditions/dementia/edge/index.htmOther Communication and Behavior ResourcesSlide33

Remember…

a person with dementia lives from

moment to moment……Focus your energies on

-- Jolene

Brackey

Creating

Moments

Of

JOY