Practical Tips on Faculty Management of Patients Richard E. Powers, MD with in the Medical Director and Director Satellite Conference and Live Webcast Bureau of Geriatric Wednesday, May 16, 2007 Alabama Department of Mental and 2:00 - 4:00 p.m. (Central Time) Mental Retardation Associate Professor of Pathology Division of Neuropathology School of Medicine Produced by the Alabama Department of Video Communications and Distance Learning Division University of Alabama Birmingham

Program Objectives Program Objectives • Explain the meaning of dementia. • Explain the of redirection and • Outline common intellectual validation in caring for persons with symptoms of elders with dementia dementia. who live at home. • Explain the role of medications in • Explain the meaning of , slowing deterioration and improving hallucinations, and . behavior. • Discuss common causes of • Describe common delusions that agitation, screaming, , and may be expressed to a home aggressive behavior. healthcare worker.

Program Objectives The Three D’s Of Geriatric • Discuss common why people with dementia begin to lose • Dementia weight. • • Identify important ethnic healthcare differences for dementia. • Depression

1 Dementia Delirium

• Origin: de mens (Out of ) • Origin: de lira (Out of the furrow)

• Definition: Loss of multiple • Definition: Temporary intellectual functions in awake state. caused by medical or neurological .

Prevalence Of Delirium In Symptoms Of Delirium The Elderly • Consciousness • Up to 50% on psychiatric wards •

• Up to 30% in ICU • Psychiatric

• Up to 15% in general medical unit • Motor

• Autonomic

Symptoms of Delirium Comparison of Dementia and Delirium • Abrupt onset Dementia Delirium • Fluctuating symptoms Onset Slow Abrupt Short duration • Days to Duration Years Weeks • Patient to patient variability Symptom Regular Irregular Fluctuation Consciousness Intact Impaired

2 Causes of Delirium in the Drugs and Delirium Elderly • Common: • Medications –Anticholinergic agents (Elavil) – (Valium) • –Pain medications (Demerol) • Metabolic abnormality • Less common: • –Antispasmodics –Antiarrhythmics

Over-The-Counter of Medications And Delirium Delirium • Sleeping medications • Complete vital signs • I & O • Antihistamines • Medication assessment • Cold preparations • Review of flow sheets • • Examination of lab values • One week review of nursing notes

Management of Delirium Incidence Of Depression In • Treatment The Elderly –Treat or medical problem • 7-10% general population –Stop medications • 40-50% post –Maximize sensory function –Hydration • 20-40% chronically medically ill –Improve bowel function • 25-40% dementia –Low dose neuroleptics

3 Symptoms of Geriatric Pseudo-Dementia Depression • S Sleep • A Dementia-like caused by • I Interest depression. • G Guilt • E Energy • C Concentration • A Appetite • P Psychomotor Vitality • S

Suicide in the Elderly Patient Outcome Following Treatment Of Depression With • Among top ten causes of death Tricyclic Antidepressants

• Lethal attempts • 2/3 improve with medication.

• Many seek medical care • 1/3 improve with placebo.

• Few melancholic depressions improve with placebo.

Dementia Dictionary Four Common Causes of Dementia • Dementia • Alzheimer’s Disease 60% • Cognitive • 20% • Mental retardation • Alcoholic Dementia 2-10% • Organic syndrome • Diffuse Lewy Body Disease 2-10%

4 Prevalence of Dementia Cognitive Symptoms

• 10% over age 65 • No pattern of intellectual loss is specific for any disease. • 47% over age 85 • The pattern of loss differs for each person. • No racial differences • The speed of loss is variable.

• Cognitive loss is cumulative over time.

Symptoms of Dementia Four A’s Of Alzheimer’s

• Cognitive deficits •

• Psychiatric symptoms •

• Apraxia

• Agnosia

Amnesia • Recent - (e.g., what you ate • The inability to remember facts or for breakfast). events.

• Remote Memory - (e.g., the appearance of your childhood home).

5 Aphasia Expressive Functions

Left Side Right Side • Inability to understand or communicate with spoken or written • Words and • Emotional grammar quality word. • Musical quality • Cursing

Channels of Human Receptive Aphasia Communication • Inability to understand spoken word. • Meaning of words

• Tone of voice

• Body language

• Facial expression

Expressive Aphasia Apraxia

• Inability to communicate with others. • Inability to do pre-programmed motor tasks (e.g., button a shirt, tie shoes).

6 Agnosia Alzheimer’s Stages

• Inability to recognize previously • Early  2 - 5 Years learned sensory input (e.g., the face • Middle  3 - 5 Years of your or the shape of a car key). • Late  5 - 10 Years

Alzheimer’s Understanding the Disease • Body  No physical that Kills the Brain with • Brain  Only organ damaged Dementia: Looking Under the Microscope

Common Neurological Symptoms of The Impact of Heavy Drinking • Memory problems on the Brain • Falls

• Numb feet

7 Predictors of Psychiatric Psychiatric Disorders in Symptoms Dementia

• Age of onset • Thought

• Premorbid psychiatric disease • Mood

• Behavior

Disorders of Thought Hallucinations in Dementia

• 25% incidence • Hallucinations • Auditory or visual • Delusions • Increased risk with sensory • impairment

• Common in middle stages

Differential Diagnosis of Treatment of Hallucinations in Hallucinations in Dementia Dementia

• Delirium • Maximize sensory function

• Depression • Reassure patient

• Sensory impairment • Antipsychotic medications

• Hypnogogic hallucinations • Other medications

8 Indications for Antipsychotic Delusions of Hallucinations • 25% - 40% incidence • Patient distress • Common in middle stage • Dangerous patient response • Distressing to • safety

Common Delusions of Delusions • Life circumstances • Delirium • Stealing • Depression • Infidelity • Cognitive dysfunction • • Accusations are correct

Management of Delusions Behavioral Problems with Dementia • Stage of dementia • Redirection and distraction • Medical problems • Reassurance • Premorbid function • Antipsychotic medications • Environment

9 Behavioral Disturbances Aggression Male Female Aggression 40% 14% • Dementia • Prevalence Wandering 19% 21% Urinary –Mild –8% 47% 48% Incontinence –Moderate –17% Rages 36% 45% Sexual 8% 7% –Severe –24% Disinhibition / 36% 42% Withdrawal

Wandering Common Reasons that Demented Patients Become • Dementia • Prevalence Restless • Fear –Mild –0 • Hunger –Moderate –10% • Fatigue –Severe –27% • Frustration • Pain

Safety Issues Misidentification of Caregiver

• Firearms • Causes • Intervention / treatment • Dangerous instruments (e.g., knives) –Agnosia –Tolerance • Dangerous equipment (e.g., stoves) –Delusions –Antipsychotic • Automobiles medications

10 Poor Wandering

• Causes • Intervention / • Causes • Intervention/treatment treatment – Disorientation – Recreational activities –Apraxia –ADL assistance – /boredom – Recreational activities –Aphasia –Non-verbal communication – Urinary/fecal – Toileting schedule urgency – –Antipsychotic – Hunger – Frequent feedings medication – Rectal impaction – Disimpact

Important Considerations for Verbal or Physical Threats Dietary Service and Dementia Causes Intervention/treatment • Disorientation Reorientation • Presentation of food • Antipsychotics • Food consistency/texture • Hunger Feed Patient • Pain Analgesics • Utensils • Aphasia Non-Verbal Communication • Entree selection • Delirium See Delirium Fact Sheet • Fear Reassurance • Frequency of feedings • Fatigue Naps • Rectal Impaction Disimpact Dining room environment • • Sensory Impairment Check Vision and Hearing

Incontinence Disrobing Causes Interventions/treatment Causes Interventions/treatment

• Disorientation Toileting Schedule • Amnesia Recreational Activities • UTI Treat UTI • Apraxia Jumpsuits • Medication Change Medication • Anxiety Recreational Activities • GU Problem Urology Consultation • Delirium See Delirium Fact Sheet • Delirium See Delirium Fact Sheet • Boredom Recreational Activities • Rectal Impaction Disimpact

11 Screamers Screamers Management

• 25% of residents scream four times • Treat underlying cause (e.g., pain, per week. depression)

• Associated with dementia, • Reduce isolation depression, isolation and poor ADL function. • Tolerance by staff

• More screaming with social isolation.

Snack’em or Nap’em

don’t

Zap’em

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