Person Centered, NonPharmacological approach to addressing Behavioral and Psychosocial Symptoms of Dementia (BPSD)
Risley E. Linder, Sr. NHA, CRCFA, CASP Risley E. Linder, Jr. MA, M.Ed, BCAB
2017 ALZHEIMER’S DISEASE FACTS AND FIGURES
MORE THAN
15 MILLION AMERICANS
IN 2016
provide unpaid care for people with Alzheimer’s or other dementias these caregivers provided an estimated
18.2 BILLION HOURS of care valued at over
$230 BILLION In 2017, Alzheimer’s and other dementias will cost the nation $259 billion By 2050, these costs could rise as high as
$1.1 TRILLION
35 %
of caregivers for people with Alzheimer’s or another dementia report that their health has gotten worse due to care responsibilities, compared to
caregivers for older people 19% of without dementia
1 IN 3
ALZHEIMER’S DISEASE IS THE
6TH LEADING CAUSE
seniors dies with Alzheimer’s or another dementia
OF DEATH IN THE UNITED STATES
MORE THAN 5 MILLION AMERICANS ARE LIVING WITH ALZHEIMER’S BY 2050, THIS NUMBER COULD RISE AS HIGH AS 16 MILLION
EVERY
IT KILLS MORE THAN
66
COMBINED
Since 2000, deaths from heart disease have decreased by 14% while deaths from Alzheimer’s disease have increased by 89%
breast cancer and prostate cancer
SECONDS someone in the United States develops the disease
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Dementia (DSM-IV-TR) • Consists of gradual onset of multiple cognitive deficits (involving memory and at least one additional cognitive domain) not occurring exclusively during delirium and representing a decline from a previous level of functioning • NO diagnostic guidance of clinically significant behavioral disturbances
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The Myth of Person Centered Services….. • If you are providing supports and services to Persons with Dementia and are not Person Centered you will fail • The very nature of the disease process is individualized and the manifestation of symptoms is specific to the person • There are generalized clusters of symptoms and stages of the disease process but one size does not fit all • There are generalized approaches to managing the symptoms, but each person will need an individualized plan
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The Myth of “Memory Care” • Dementia is a progressive disease process that will result in eventual death. The prognosis is bleak from the beginning. • I know of no program that reverses the symptoms of Dementia • Certainly secure units, meaningful activities, behavior support plans, environmental modifications, exercise and certain medication designed to slow the progression are helpful • Direct Care staff must be given support in addressing BPSD’s. • A good memory care unit should form the basis for good practices but it must be augmented by specialized individual Behavior Plans to address BPSD’s • 90% of residents with a diagnosis of Dementia will develop BPSD’s
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CMS Statement • Antipsychotic medications are frequently prescribed for residents with dementia who have behavioral or psychological symptoms of dementia (BPSD).1,2 The term BPSD is used to describe behavior or other symptoms in individuals with dementia that cannot be attributed to a specific medical or psychiatric cause.
• When antipsychotic medications are used without an adequate rationale, or for the purpose of limiting or controlling behavior of an unidentified cause, there is little chance that they will be effective. In addition, they commonly cause complications such as movement disorders, falls, hip fractures, cerebrovascular adverse events (cerebrovascular accidents and transient ischemic events) and increased risk of death. 3,4,5,6 The Food & Drug Administration (FDA) Black Box Warnings Regarding Atypical Antipsychotics in Dementia provides, “Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo.” 7
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Behavioral and Psychosocial Symptoms of Dementia (BPSD) Also referred to as: Neuropsychiatric symptoms BPSD is estimated to affect up to 90% of all dementia patients over the course of their illness and is associated with poor outcomes: long term hospitalization, misuse of medication, and increased cost of treatment.
• http://www.effectivehealthcare.ahrq.gov/ehc/index.cfm/search-for-guides-reviewsandreports/?pageAction=displayTopic&topicID=559
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Symptoms/Behaviors • Disturbances in emotional experience • Depression, irritability, hypomania, apathy
• Delusions and abnormal thought content • False beliefs strongly held, enduring and irrefutable • Paranoia,
• Perceptual Disturbance • Sensory types hallucinations visual well formed images of animals of persons that are described in detail
• Disturbances in motor function • Reduced or increased activity rapid speech, agitation
• Circadian rhythms • Sleep pattern changes hypersomnia, insomnia, sleep-wake cycle reversal napping constantly but never sleeping Argentum state conference 2017
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Symptoms/Behaviors continued
• Appetite and eating behavior • Anorexia, Hyperplasia, preference for sweets, abnormal association with foods through taste texture smell Disinhibited Behaviors – tactless rude remarks, bold behavior, exposure fondling re-kindled interest in sexual activity, swearing, profanity, risque comments Age Regression - thinks they are younger than they are confusion over generations - sons become husbands looking for people that are younger
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Source of significant distress and poor quality of life for dementia patients more concurrent BPSD’s higher mortality rates
Profound physical and psychological impact on caregivers
Represents significant risk to Providers
The Burden of BPSD
50% of all patients with BPSD have at least four symptoms simultaneously Argentum state conference 2017
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Who is this?
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Hint: Supreme Court Justice……………………………. Husband developed Dementia Husband placed in a specialized Dementia Unit Husband met a new companion………………………..
WHAT DID SHE DO? She accepted it…….. Justice Sandra Day O’cconor Argentum state conference 2017
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What? • Net effectiveness
• FOR EVERY 100 PATIENTS WITH DEMENTIA TREATED WITH AN ANTIPSYCHOTIC MEDICATION,
•ONLY 9 T0 25 WILL BENEFIT AND 1 WILL DIE • Drs. Avorn, Choudhry & Fishcher Harvard Medical School • Dr Scheurer Medical University of South Carolina • Source: Independent Drug Information Service (IDIS) Restrained Use of antipsychotic medication: rational management of irrationality 2012
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Assessment of BPSD • Neuropsychiatric Inventory NPI • Scores 12 symptoms • npiTest Nursing Home Version (NPI-NH) • Permission granted by Dr. Jeffrey L. Cummings for citations and non clinical trial usu • http://npitest.net
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Management of BPSD is a key component of a comprehensive approach to the treatment of dementia requiring the judicious combination of pharmacological and non-pharmacological interventions. There is an increased risk of psychotropic medication misuse . Current guidelines recommend nonpharmacological interventions as the first line treatment.
Management of BPSD Argentum state conference 2017
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Behavioral and Psychological Symptoms of Dementia (BPSD) • BPSD include agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes. • It is estimated that BPSD affect up to 90% of all dementia subjects over the course of their illness, regardless of the subtype of dementia. • BPSD is independently associated with poor outcomes, including distress among patients and caregivers, long-term hospitalization, misuse of medication, and increased health care costs.
Cerejeira, J., Lagarto, L., & Mukaetova-Ladinska, E. B. (2012). Behavioral and psychological symptoms of dementia. Frontiers in neurology, 3.
Functional assessment and treatment of behavioral issues (Setting Event, Antecedent, Behavior, Consequences)
Attention, Tangible Item/Activity, Escape/Avoidance, Sensory
Systematically identifies why (i.e. function) a behavior occurs, so that an intervention that matches the function can be provided in an appropriate manner Management vs. Change of behaviors
Applied Behavior Analysis (ABA)
ABA in Action PROBLEM BEHAVIOR
Overnight Wandering
DISTANT SETTING EVENT
ANTECEDENT (PREDICTOR)
S/E Psychotropic medications
Need to urinate
Confusion of day and night Daytime inactivity
Lack of daytime routine
Environmental stimuli
MAINTAINING CONSEQUENCE
Response to internal stimuli/thoughts Access to attention Access to items/activity
ABA in Action PROBLEM BEHAVIOR Verbal Aggression
DISTANT SETTING EVENT Continued
denial/delay/termin ation of desired item/activity
ANTECEDENT (PREDICTOR)
MAINTAINING CONSEQUENCE
Misinterpretation of Access to attention environmental stimuli/communicati Access to on items/activity
Continued Denial/delay/termin presentation of nonation of desired preferred item/activity activities/demands
Presentation of nonpreferred activities/demands
Escape from nonpreferred stimuli
TAKE AWAYS……
Take aways….
BPSD’s represent a significant challenge to all caregivers providing supports and services to persons with Dementia.
A high degree of clinical expertise is crucial to appropriately recognize and mange the neuropsychiatric symptoms
There is an urgent need to develop new nonpharmacological approaches to improve the adverse outcomes associated with BPSD
Providing non pharmacological interventions must be the first step in providing quality services to persons with Dementia
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Person Centered, NonPharmacological approach to addressing Behavioral and Psychosocial Symptoms of Dementia (BPSD)
Risley E. Linder, Sr. Risley E. Linder, Jr.