Home Based Primary Care Home Visit

Ambulatory Geriatrics Curriculum for Internal Medicine Residents

Module on BPSD: Agitation and Behavioral Problems in Dementia

A. Introduction to Module:

In 2012, 5.4 million Americans are diagnosed with Alzheimer’s Disease. Lifetime risk of experiencing BPSD is nearly 100%. BPSD is associated with increased morbidity and nursing home placement and is potentially treatable. The information in this curriculum has been created to help the general internist have a structured approach to the evaluation and management of BPSD.

Curriculum, Resources and Handout for Residents:

I. What Is BPSD?

B(ehavioral)______

P(sychological)______

Mood Symptoms

Psychotic Symptoms

Sleep Disturbances

S(ymptoms)______

D (ementia)______

II. Why Is BPSD Important?

III. Review unfolding clinical case with answers and appendix

Part A: You are seeing Mrs. Robbin Green, a 78-year-old with mild Alzheimer’s disease (MMSE 23 of 30), hypertension, osteoarthritis, and urinary incontinence who comes to the office with her daughter for “acting up” for past 2 weeks. Daughter reports that she repeats stories and packs her bags several times a day, stating that she is “going home.” She is up frequently at night, pacing and wandering. The other day, she struck her home attendant.

Medications: donepezil 5 mg daily, hydrochlorothiazide 25 mg daily, lisinopril 10 mg daily, baby aspirin, tolterodine LA 2 mg, and acetaminophen 500 mg once daily.

1. How would you approach this case?

PART A continued: Daughter reports that patient has been more incontinent these days but has had no fevers, chills, flank pain or hematuria. Pt has been eating a little less as well but reports no nausea, vomiting, diarrhea or constipation. ROS is otherwise negative. There are no new medications and no changes in the care giving environment.

Physical exam is unremarkable except for Temp 100.1, mild suprapubic tenderness without guarding or rebound or CVA tenderness. Neurological exam is non-focal though technically difficult. She is oriented only to person and easily distracted.

Labs are unremarkable except for urine with positive nitrites and leukocyte esterase, and CBC with mild leukocytosis with left shift.

2. What is the most appropriate treatment?

Part B: Mrs. Green is seen as an urgent visit 2 months later for being more agitated. Daughter reports that the patient has been screaming and scratching the new home attendant mainly during bathing. Daughter normally tries to help the home attendant with her mother’s care but has been busier these days as her grandchildren have been visiting. Daughter/pt denies fever, chills, cough, shortness of breath, pain, urinary or bowel symptoms. She has been eating and sleeping as usual. No other symptoms reported nor are there any new medications. Physical exam is unremarkable. Repeat MMSE remains 23/30

3. What is the most appropriate approach?

a. Start haloperidol 0.5 mg at night

b. Start risperidone 1 mg at night

c. Increase donepezil to 10 mg

d. Start citalopram 10 mg daily

e. Review NonPharmacologic, patient-centered Interventions

Part C: In a visit one year later, Mrs. Green is brought in for an urgent visit by her daughter with complaints of trouble sleeping for the past month. Mrs. Green confirms trouble falling sleep but is unable to provide a more comprehensive history. Daughter reports that her mother is usually active in the daytime, but for the last month has caught her napping in the daytime. Patient denies being sad or depressed and appetite and weight are stable. Physical exam and lab studies were within normal limits. PHQ9 was negative.

4. What is your first intervention?

a. Prescribe zolpidem 5 mg

b. Recommend melatonin 1.5 mg

c. Prescribe triazolam 0.125 mg

d. Prescribe trazodone 25 mg

e. Prescribe mirtazapine 7.5 mg

f. Counsel about non-pharmacologic interventions

to promote sleep

Review Appendix B21-23

5. What is your next approach if your first intervention fails?

Prescribe diphenhydramine 25 mg
Prescribe zolpidem 5 mg
Prescribe melatonin 1.5 mg
Increase donepezil to 10 mg

e. Prescribe trazodone 25 mg

Prescribe mirtazapine 7.5 mg

Part D: For the next 6 months, Mrs. Green’s course is unremarkable as the donepezil 10 mg with the intermittent trazodone 25mg has helped.

During today’s visit, Mrs. Green reports feeling depressed about her loss of function and memory. She is no longer interested in going outdoors or watching some of her favorite TV shows. Patient reports anorexia and has lost 4.5 kg (10 lb) in past four months. Pt reports no suicidal ideation. On exam, patient affect appears flatten. PHQ9= 15 (c/w moderate-severe depression) but MMSE remains 23 which is unchanged. Physical exam is otherwise unremarkable. Lab work up including chemistries, CBC and TSH are negative.

6. What are the differential diagnoses?

7. How would you treat this patient?

Enrollment in Adult Day Health Care Center
Caregiver education and training in coping skills.
Prescribe nortriptyline 25 mg

d. Prescribe citalopram 10 mg

ECT (Electroconvulsive Therapy)

Part e: Mrs. Green’s returns 2 weeks later and reports that the initial treatment was unhelpful.

8. What would you do next?

a. Switch to another agent in same class

b. Switch to another agent in another class

c. Titrate dose of initial medication

d. Add methylphenidate 5 mg daily

Part F: Mrs. Green responds well to citalopram 20 mg which you continue for the next 12 months. Over the next 2 years, daughter reports that Mrs. Green gradually requires more assistance with all of her ADLs despite addition of memantine 10 mg twice a day. She has developed urinary incontinence over past six months. The daughter has hired Carol to help with Mrs. Green’s care six months ago. Today daughter reports that Mrs. Green has been more and more resistant to personal care including bathing, shower and toileting over past two months. In few instances she became physically aggressive toward her daughter and her aide Carol. The daughter and Carol have employed appropriate non-pharmacologic interventions without much success. Again there are no new medications, no change in the care giving environment. Her physical exam and laboratory workup are negative. Delirium has been ruled out. Pain is optimized.

9. When would you consider any medications?

10. What medication would you consider in treating her symptoms?

a. Time-limited trial of haloperidol 0.5 mg

b. Time-limited trial of risperidone 0.5 mg

c. Time-limited trial of olanzapine 5 mg

d. Time-limited trial of valproate 250 mg

e. Start a trial of prazosin 1mg daily

Part G: Mrs. Green does not respond to the risperidone 0.5 mg so you titrate it to 1mg and the symptoms subside. You continue this for 4 weeks and eventually you are able to wean it off74.

TAKE HOME POINTS:

• Always obtain a thorough history about the “disturbance”

• Rule out delirium and other environmental factors contributing to the disturbance

• Use nonpharmacologic interventions for BPSD first

• Consider “targeted,” time-limited pharmacologic trials for severe or persistent BPSD symptoms given modest evidence of efficacy and moderate potential for harm

Appendix A: 4 Effective Nonpharmacologic Interventions 1-20

1. CG education Interventions about

Disease, prognosis, realistic expectations
5 Techniques to minimize development of BPSD

1) Maintain a structured daily routine of meaningful activities

2) Environmental modifications-safe, comfortable, orienting

3) Communication Techniques-speak slowly, clearly, in nonconfrontational manner

4) Encourage independence in ADLs

• Correct sensory impairments

• Simplify routines, set up, limit choices

• Finger foods, Velcro, snaps

5) Patient –Centered Care ie Person-Centered Showers and Towel Baths12 (www.bathingwithoutabattle.unc.edu) 13

http://www.alz.org/care/alzheimers-dementia-bathing.asp14

Suggests the following:

• Create environment based on patient comfort and preference

• Cover with towels to maintain warmth and modesty

• Use no-rinse soap and warm water

• Use gentle massage to cleanse

• Modify shower spray

2. Unmet Needs Interventions- make sure hunger, thirst, pain, boredom are addressed as pt may “act out” when they are unable to communicate their needs

3. Behavioral Interventions

3 R’s (Repeat, Reassure, Redirect)

· Positive reinforcement (by praising, encouraging or reassuring) to encourage desirable behaviors

· Distraction technique-redirection

Be a Sleuth: Do the “ABC’s” and Avoid triggers –look at the Antecedant Behaviors that lead to a particular Consequence and AVOID itàIdentify the precipitating factor and avoid the triggers

4. Psychosocial Interventions

5 Techniques to minimize development of BPSD (above)

b. Preferred Calming Music

c. Aromatherapy-lavender

d. Thermal bath

e. Bright Light and Pet Therapy

f. Snoezelen-Multisensory: light, sound, aroma, massage

g. Exercise and Structured activity therapies

***Physical restraints should be avoided

*alz.org-caregiver centeràget supportàTraining and Resources

*http://www.agingbraincare.org/. Look under Tools, then ABC Care Protocols.The nonpharmacologic protocols are available in the Care Protocols upon registration20.

Appendix B: Non-pharmacologic Interventions for Insomnia: McCurry SM et al. Nighttime insomnia treatment and education for Alzheimer's disease: a RCT. JAGS. 200521— employs 4 of the 6 traditional techniques for insomnia mgt: sleep hygiene, stimulus control, sleep restriction and circadian rhythm manipulators (No Cognitive Behavioral Therapy (CBT) or “relaxation”)

1. Follow Structured sleep and rising times that were not to deviate no more than 30 minutes from the selected times (circadian)

2. Encouraged patients not to nap after 1 PM and limit naps to 30 minutes or less (sleep hygiene, circadian, sleep restriction)

3. Walk for 30 minutes, exercise daily (circadian)

4. Bright light tx at dawn/dusk (circadian)

5. Eliminate triggers for nighttime awakenings ie control night time pain, give nightly snack, take activating meds in the AM (stimulus control)

6. Reduce light/noise levels in their sleeping areas (stimulus control)

7. Switch to decaffeinated drinks and reduce evening fluid consumption (stimulus control)

8. If nocturia affected sleep, encourage toileting schedules at night, use of incontinence pads, exclude urinary tract infections (stimulus control)

Appendix C:

Appendix D: 2013 Management of the Behavioral and Psychological Symptoms of Dementia. NaRCAD (the National Resource Center for Academic Detailing) with support from a grant from the Agency for Healthcare Research and Quality 2,34-39, 51-54, 61-64, 67

• Nonpharmacologics

• Pharmacologics:

– FOR EMERGENT BPSD 34-39 60

• Antipsychotics:

• Use faster acting, higher risk medications

• Limited evidence for longer term efficacy (≥6 months)

– NONemergent BPSD 2, 31-36, 48-51, 58,-61, 64

• Memantine

• Carbamazepine

• Citalopram

• Prazosin

Appendix E: Possible medication for Agitation, Aggression, and Psychotic symptoms in BPSD. (Medications listed are not FDA approved to treat BPSD and are off-label recommendations)

Class / Starting Dose / Theraputic Dose / Comments
Antipsychotics / Black Box warning
Watch for: Extrapyramidal effects, tardive diskinesia, neuroleptic malignant syndrome, hypotension, QTc prolongation and torsades de pointes, anticholinergic side effects (ie Constipation, xerostomia, and somnolence), agranulocytosis, blurred vision, May Lowers seizure threshold
Haloperidol
56-58 / 0.5-2mg q2-12 hrs / *Class effect as above. Watch esp for Extrapyramidal effects can occur with doses >4.5 mg/d
*More effective for treating aggressive agitation
* Available as Oral, IV , IM, subcutaneous
Risperidone
51, 54-56 / 0.25-0.5 mg / 1-2mg / *Class effect as above and EPS with doses > 1 mg/day
* Clinical experience suggest better results in patients with hypoactive delirium
*Risperidone and olanzepine effective for aggressive agitation but risperidone may be more helpful for psychotic symptoms.
* Available as tablet, rapidly dissolving tablet, liquid concentrate, IM
Olanzapine / 2.5-5 mg / 5-15 mg / *Class effect as above. Watch especially for hyperglycemia and cerebrovascular events in patients with dementia.
*Risperidone and olanzepine effective for aggressive agitation.
*Literature suggests that older age, preexisting dementia, and hypoactive delirium are associated with poor response
*Available as tablet, rapidly dissolving tablet, IM injection
Quetiapine / 12.5-25mg / 100–200 mg / *Class effect as above. Watch especially for orthostatic, and hyperglycemia.
* Preferred in patients with Parkinson disease or Lewy body dementia due to its lower risk of extrapyramidal adverse effects
*Ophthalmologic exam recommended every 6 months
*Available as tablet
Aripiprazole / 2.5-5 mg / 5-15mg / *Class effect as above. Watch especially for increased cerebrovascular events in dementia, hyperglycemia and weight gain
*Clinical experience suggests better results in hypoactive delirium
*No adjustment needed with age, renal or hepatic impairment
*Available as Tablet, disintegrating tablet, liquid concentrate, IM (convert to oral ASAP)

* Ziprasidone and clozapine are both poorly tolerated in older adult. Might consider in rare refractory cases.

Note. CBCs = complete blood cell counts

EPS = extrapyramidal symptoms

IM = intramuscular

Anticonvulsants / Starting dose / Therapeutic dose / Comments
Carbamazepine 68 / 50-100mg / 200-1000mg / *Main side effects are sedation, ataxia, nausea
*Monitor for hyponatremia and pancytopenia
Divalproex sodium 70 / 125-250mg / 250-1000mg / *Main side effects nausea and sedation.
*Monitor for Liver function abnormality, thrombocytopenia, pancreatitis.
* NOT recommended in most recent guidelines and Cochrane review 2004, 2009

Appendix F: Black Box Warning for Typical and Atypical Antipsychotics 71-73

http://www.fda.gov/cder/drug/infopage/antipsychotics/default.htm April 2005

• Increased risk of mortality. Rate of death was 1.6 to 1.7 times that of placebo in 6-12 wks of use

• Death appeared to be heart related or from infections (eg, pneumonia)

• Diabetes mellitus, hyperglycemia, ketoacidosis, and hyperosmolar states

Bibliography:

1 Gitlin LN, Kales HC, Lyketsos CG. Nonpharmacologicmanagement of behavioral symptoms in dementia. JAMA. 2012 Nov 21;308(19):2020-9. doi: 10.1001/jama.2012.36918.

2 Osser, David; Fischer, Michael. Management of the behavioral and psychological symptoms of dementia. NaRCAD (the National Resource Center for Academic Detailing) with support from a grant from the Agency for Healthcare Research and Quality to the Division of Pharmacoepidemiology and Pharmacoeconomics of the Brigham and Women’s Hospital Department of Medicine. December 28, 2013

3 Gitlin LN, Winter L, Dennis MP, Hodgson N, Hauck WW. A biobehavioral home-based intervention and the well-being of patients with dementia and their caregivers: the COPE randomized trial. JAMA. 2010 Sep 1;304(9):983-91.

4 Gitlin LN, Winter L, Dennis MP, Hodgson N, Hauck WW. Targeting and managing behavioral symptoms in individuals with dementia: a randomized trial of a nonpharmacological intervention. J Am Geriatr Soc. 2010 Aug;58(8):1465-74.

5 Cohen-Mansfield J, Thein K, Marx MS, Dakheel-Ali M, Freedman L. Efficacy ofnonpharmacologicinterventions foragitationin advanced dementia: a randomized, placebo-controlled trial. J Clin Psychiatry. 2012 Sep;73(9):1255-61. doi: 10.4088/JCP.12m07918.

6 Eun-Hi Kong, Lois K. Evans and James P. Guevara. Nonpharmacological intervention for agitation in dementia: A systematic review and meta-analysis. Aging & Mental Health. July 2009, 512–520