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Assessment and Management of Disruptive Behaviors in Persons with Dementia
The document provides information on the assessment and management of disruptive behaviors in individuals with dementia, including educational and continuing education credits for healthcare providers involved in dementia care. It outlines the prevalence and impact of dementia-related behaviors, systematic evaluation strategies, and comprehensive care plans incorporating both non-pharmacologic and pharmacologic interventions. The document also highlights various symptoms, contributing factors, and intervention efficacy, emphasizing the importance of tailored approaches to improve outcomes for patients and caregivers.
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Assessment and Management of Disruptive Behaviors in Persons with Dementia
- 1. Assessment and Management ofDisruptive Behaviors in Persons with Dementia
- 2. CME Provider Information •Satisfactory Completion • Learners must complete an evaluation form to receive a certificate of completion. You must participate in the entire activity as partial credit is not available. If you are seeking continuing education credit for a specialty not listed below, it is your responsibility to contact your licensing/certification board to determine course eligibility for your licensing/certification requirement. • Physicians • In support of improving patient care, this activity has been planned and implemented by Amedco LLC and VITAS® Healthcare, Marketing Division. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team. • Credit Designation Statement – Amedco LLC designates this live activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
- 3. CE Provider Information VITASHealthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through: VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved by: Florida Board of Nursing/Florida Board of Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling. VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists through: VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number: 139000207/RT CE Provider Number: 195000028/Approved by the Illinois Division of Profession Regulation for: Licensed Nursing Home Administrators and Illinois Respiratory Care Practitioners. VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2021 – 06/06/2024. Social workers completing this course receive 1.0 continuing education credit(s).VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of Registered Nursing, Provider Number 10517, expiring 01/31/2023. Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois.
- 4. Objectives • Describe theoccurrence and impact of dementia-related behaviors • Construct a systematic evaluation for behavioral changes in persons with dementia • Develop a comprehensive care plan that incorporates caregiver education and non-pharmacologic interventions followed by pharmacologic management for disruptive behaviors
- 5. Most Common Etiologiesof Dementia Alzheimer's Association. (2021). 2021 Alzheimer’s Disease Facts and Figures. Retrieved from https://www.alz.org/media/ Documents/alzheimers-facts-and-figures.pdf Cause Prevalence Pathophysiology Alzheimer’s disease 60-80% Amyloid plaques and neurofibrillary tangles Mixed pathologies >50% Cerebrovascular disease 5-10% More than one neuropathology Lewy Body disease 5% Alpha-synuclein protein Frontal Lobar Degeneration 3% Tau protein
- 6. Epidemiology • 2021 USAlzheimer’s estimate: – 6.2 million people aged 65+ – 2/3 are women, ~ 1 in 3 women develop dementia in their lifetime • More than 1 in 9 persons over the age of 65 have dementia • 1 in 3 persons over the age of 65 dies with dementia • Diagnosis of dementia cuts one’s life expectancy in half • Dementia is the fifth-leading cause of death in persons over 65 • Between 2000-2019, dementia-related deaths increased 145% Alzheimer's Association. (2021). 2021 Alzheimer’s Disease Facts and Figures. Retrieved from https://www.alz.org/media/ Documents/alzheimers-facts-and-figures.pdf
- 7. Natural History ofDementia ADL Dependency Death Low Time (Slow decline) High Hospice Eligible FAST 7a or 7C plus Disease related complication within the last several months Disease-related complications include, but are not limited to: • UTI • Sepsis • Febrile episode • Delirium • Pneumonia • Hip fracture • Eating difficulty or dysphagia • Dehydration • Feeding tube
- 8. 78 y/o withrapidly progressive Alzheimer’s and vascular dementia after sustaining a fall at home with a hip fracture that was surgically repaired. During the patient’s skilled stay, the patient has become mostly WC and/or bedbound and not participating in PT with both physical and verbal agitation and aggression, especially when trying to engage in activities or move the patient. The agitation is new since the hip fracture. The psychiatrist diagnosed the patient with depression and prescribed sertraline 50mg followed by valproic acid 250mg BID due to refractory symptoms. The patient has been more lethargic but remains agitated at times. Additional changes include 5% weight loss in 1 month due to a poor appetite, functional decline with a PPS decrease from 80 to 40, and dependency in 3/6 ADLs from 1/6 prior to the fall. After completion of skilled care, the patient was transitioned to long term care. The daughter expresses guilt as she recognizes her mom is upset and angry because she never wanted to be in a nursing home. Case
- 9. Delirium Acute Onset and FluctuatingCourse AND Inattention plus either Disorganized Thinking Altered LOC DELIRIUM
- 10. Terminal Restlessness THE USUALROAD THE DIFFICULT ROAD
- 11. Dementia Behaviors Thought andPerceptual Disturbances • Delusions • Paranoia • Hallucination Mood Disturbances • Anxiety • Depression • Irritability Activity Disturbance • Agitation and/or aggression • Wandering • Purposeless hyperactivity • Apathy • Impulsivity • Socially inappropriate behavior • Sleep problems • Repetitive behavior
- 12. Agitation/Aggression Definition International PsychogeriatricAssociation convened a panel of experts with the goal of establishing principles guiding the definition of agitation in elderly populations: 1. Occurring in patients with cognitive impairment or a dementia syndrome; 2. Exhibiting behavior consistent with emotional distress; 3. Manifesting excessive motor activity, verbal aggression, or physical aggression; and 4. Evidencing behaviors that cause excess disability and are not solely attributable to another disorder (psychiatric, medical, or substance-related)
- 13. Neuropsychiatric Symptoms (NPS) byStage of Dementia Radue, et al. (2019). Neuropsychiatric symptoms in dementia. Handbook of Clinical Neurology, 167, 437-454. 4.3% 11.2% 15.2% 44.3% 38.2% 13.3% 32.6% 30.3% 30.0% 31.4% 82.3% 56.0% 54.5% 25.7% 30.4% Normal cognition Mild cognitive impairment Mild dementia Moderate dementia Severe dementia No symptoms 1-2 symptoms 3+ symptoms 7% 16% 17% 31% 32% 34% 36% 39% 39% 40% 42% 49% 0% 10% 20% 30% 40% 50% 60% Euphoria Hallucinations Disinhibition Delusions Aberant motor behavior Appetite disorder Irrtability Sleep Disorder Anxiety Aggression Depression Apathy
- 14. Symptom Experience inPersons With Dementia in the Last Year of Life Mitchell, et al. (2009). The clinical course of advanced dementia. New England Journal of Medicine (361), 1529-1538. 0 5 10 15 20 25 30 35 40 Dyspnea Pain Pressure ulcers Aspiration Agitation Residents With Symptoms (%) Distressing Symptoms Months Before Death (no. of residents alive during interval) >9-12 (N=67) >6-9 (N=96) >3-6 (N=128) 0-3 (N=177)
- 15. DICE Describe the behavior Investigatethe underlying contributors/causes Create intervention: non-pharmacologic and pharmacologic Evaluate the interventions effectiveness
- 16. O’Gorman, et al.(2020). A framework for developing pharmacotherapy for agitation in Alzheimer’s disease: recommendations of the ISCTM working group. The Journal of Prevention of Alzheimer's Disease, 7(4), 274-282. Behavior Description • Characterization • Severity or quantification • Temporal onset and course Scale Measure Cohen-Mansfield Agitation Inventory 4 behavioral categories, 29 total items, caregiver response over last 2 weeks, behavior frequency ranges from 1 to 7, higher scores more behaviors Neuropsychiatric inventory 10 or 12 (sleep and appetite added) behaviors rated by frequency (4 categories) severity (3 categories), caregiver distress (5 categories) over a week, higher scores more behavioral burden Behavioral pathology in Alzheimer’s disease 7 behavioral categories containing 25 symptoms, each scored on a 4-point severity scale ascertained by a caregiver • Context of personal, family, social, and medical history • Associated circumstances, including precipitants and alleviating factors • Caregiver status
- 17. Impact of DisruptiveBehaviors in Dementia Patient • Increased morbidity (cognitive/ functional); lower quality of life • Abuse and neglect • Increased likelihood of hospitalization with a longer length of stay • Nursing home placement • Increased mortality Caregiver • Increased burden, stress, and strain • Sleep disturbances, depression, and anxiety • Lower quality of life • Reduced income from employment • Increased mortality
- 18. Case (cont.) Describe thebehavior and rationale to treat – Agitation and aggression worse with movement and activity, new after fall – Verbal (yelling when trying to move or interact) and physical (resistive to daily care and strike out when try to move) – Intermittent sleeping and agitation and daughter reports a poor quality of life – Unsteady on feet, not wanting to move a round much – Decreased oral intake – Potential risk to staff for physical harm
- 19. DICE • Describe thebehavior • Investigate the underlying contributors/causes • Create intervention: non-pharmacologic and pharmacologic • Evaluate the interventions effectiveness
- 20. Contributors to Agitationand Restlessness Ringman JM, Schneider L. (2019) Treatment Options for Agitation in Dementia. In Current Treatment Options Neurology (Vol 21, 30). Contributor Causes Approach Physical symptom Pain, SOB, constipation Opioid or laxative Psychological symptom Depression, anxiety, delusions, hallucinations SSRI, SNRI, antipsychotic Medical condition Infection, COPD, HF, gout, hyperglycemia, electrolyte disturbance, constipation, insomnia Treat condition Unmet need Hunger, thirst, hot, cold Attend to need Sensory impairment Poor vision/hearing Adaptive Environment Under/over stimulation, change in routine, life stressor, pt-cg relationship Modify Pharmacologic Anticholinergic drug, digitalis, benzodiazepine Discontinue
- 21. Contributors to Agitationand Restlessness Huesbo B, Ballard C, Sandvik R, et al.(2011) Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ Vol. 343. Atee M, Morris T, Macfarlane S et al. (2021) Pain in Dementia: Prevalence and Association with Neuropsychiatric Behaviors. J Pain Symptom Manage Vol 61, p 1215-1226. Step Treatment Study Treatment 1 APAP Maximum dose 3gm 2 Morphine 5mg Twice daily 3 Buprenorphine 5mcg patch, can increase to 10mcg 4 Pregabalin 25mg up to 300mg daily
- 22. Case (cont.) Investigate • AdditionalPMH patient grimaces with movement and braces on the side with the hip fracture repair. The patient is not taking the as-needed acetaminophen and has no other analgesic ordered. Staff report the patient seems to alternate between agitation and over-sedation and is otherwise withdrawn. Appetite is poor but has no apparent nausea or constipation. Insomnia with difficulty falling asleep and early morning awakenings. • Patient’s other chronic medical conditions are well controlled. The patient does not have altercations with staff or her roommate unless trying to be moved. Her daughter reports mom misses her dog and home. Besides the sertraline and valproic acid, no changes in medications. • Physical exam: temporal wasting, hearing and vision seem intact, pain behaviors as described especially with ROM of repaired hip, and bloodwork is unremarkable. Considerations • Pain from hip fracture repair • Depression • Loneliness • Medication
- 23. DICE • Describe thebehavior • Investigate the underlying contributors/causes • Create intervention: non-pharmacologic and pharmacologic • Evaluate the intervention’s effectiveness
- 24. • Caregiver – Learningand behavioral (ABC) – Antecedent to behavior behavior consequence reinforces behavior • Environment – Environmental vulnerability and reduced stress thresholds: a mismatch between the setting and the patient’s ability to deal with it Ayalon, et al. (2006). Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: a systematic review. Archives of Internal Medicine, 166(20), 2182-2188. • Person with dementia – Unmet need: behavior as an underlying need – Agitation etiology culmination from present abilities, level of cognition and function, and past/present interests with physical, psychological, social, and spiritual needs Dementia Behavior Models
- 25. Non-Pharmacologic: Persons With Dementia WattJA et al. Comparative Efficacy of Interventions for Aggressive and Agitated Behaviors in Dementia: A Systematic Review and Network Meta-analysis. Ann Intern Med 2019;171:633-642 Treatment Studies (N) Network Meta-analysis Meta-analysis Standardized Mean Difference CMAI Re-expressed as mean difference on CMAI Massage and Touch 6 (385) -0.75 (-1.12,-0.38) -0.90 (-1.28,-0.518) -10.67 Multidisciplinary Care Plan 4 (552) -0.50 (-0.99,-0.01) -0.44 (-1.0,0.12) -7.11 Music + Massage/Touch 1 (34) -0.91 (-1.75,-0.07) -1.71 (-2.36,-1.05) -12.94 Recreational Therapy 8 (474) - 0.29 (-0.57,-0.01) -0.26 (-0.64,0.12) -4.12 25 Bold text indicates treatment efficacy across all types of agitation and/or aggression, clinically important difference 5.69 (aggression) and 7.11 (agitation)
- 26. Non-Pharmacologic: Persons With Dementia Leng,et al. (2020). Comparative efficacy of non-pharmacological interventions on agitation in people with dementia: A systematic review and Bayesian network meta-analysis. International Journal of Nursing Studies, 102, 103489. Treatment Standardized Mean Difference Massage −5.22 ( −8.21,−2.49) Light Therapy −5.25 (−9.90,−0.61) Music Therapy −3.61 (−7.29, −0.23) Reminiscence Therapy −4.59 (−8.97 to −0.51) Animal-Assisted Intervention −3.14 (−5.89 to −0.46) Personally Tailored Intervention −2.98 (−5.18 to −0.85) For network meta-analysis, demonstrated the following rank probability: – Massage therapy - 1 (43%) – Animal-assisted intervention - 2 (16%) – Personally tailored intervention - 3 (18%) – Pet robot intervention - 4 (11%)
- 27. Hughes, et al.(2017). Research on supportive approaches for family and other caregivers. Research summit on dementia care: Building evidence for services and supports. Non-Pharmacologic: Caregiver Interventions • Elements of caregiver support – Education and skills training (conflict avoidance, support ADL, and communication skills) – Care coordination – Counseling and support groups – Respite • Example Programs – REACH II and REACH VA – The Tailored Activity Program (TAP) - Occupational Therapy and Skills2Care – Savvy Caregiver – New York University Caregiver Intervention • A meta-analysis of 23 randomized clinical trials, involving almost 3,300 community- dwelling patients and their caregivers – Significantly reduced behavioral symptoms (effect size 0.34, p<0.01) and negative caregiver reaction (effect size 0.15, p<0.006) – Similar to antipsychotics for behavior and cholinesterase inhibitors for memory
- 28. Responses to Non-Pharmacologic Interventions GreaterResponse • Higher levels of cognitive function • Fewer difficulties with ADLs • Speech • Communication • Responsiveness Less Response • Staff barriers (refuse to participate) • Patient in pain
- 29. Case (cont.) Describe behaviorand rationale to treat • Agitation and aggression worse with movement and activities • Risk to patient and staff Investigate • Pain • Depression and anxiety • Loneliness • Medication Create: Non-pharmacologic • Initiate animal-assisted intervention as patient misses her dog • Recreational therapy tailored to the patient’s needs • Consider what additional services hospice could offer • Pain: APAP 1,000mg every 8 hours, morphine 5mg prior to bathing and at night and prn. Bowel regimen • Medication: Wean off valproic acid and optimize depression treatment
- 30. Dementia Behaviors and PharmacologicTreatment Helpful • Psychosis – Delusions – Hallucinations – Paranoia • Depression, anxiety, and irritability • Agitation and aggression Not Helpful • Day/night reversal • Calling out • Repetitive behaviors • Apathy • Resistive to care • Wandering
- 31. Therapeutic Class TrialSide Effects Trazodone + RTC Sedation, hypotension SSRI (citalopram) + RCT Nausea, diarrhea, QTc inc >20mg daily Antipsychotics + RCT Stroke, infection, seizure, QTc inc, DM, death Lorazepam + RCT Sedation, falls, ataxia, agitation Dextromethorphan/quinidine + RCT Falls, dizziness, diarrhea, UTIs Carbamazepine Valproic acid - RCT - RCT Sedation, anemia, liver toxicity, sedation NMDA antagonist - RCT/+obs Constipation, dizziness ACheI - /+RCT/+obs Nausea, dizziness, weight loss Cannabinoids - RCT Low dose used, oral form Pharmacologic Treatment of Agitation Radue, et al. (2019). Neuropsychiatric symptoms in dementia. Handbook of Clinical Neurology, 167, 437-454. Ringman, J. et al. (2019). Treatment options for agitation in dementia. Current Treatment Options in Neurology, 21(7), 1-14.
- 32. Trazadone • Several smallrandomized controlled trials indicate benefit – Cochrane review inconclusive evidence • Dosing: – 25-100mg BID-TID and q 2hrs prn, maximum dose 300mg daily (150mg in frail older adults) • Adverse effects: – Orthostasis, syncope, hypotension, dizziness – Priapism – SIADH – Somnolence – QTc prolongation
- 33. Dementia Related Agitationand Citalopram Antonsdottir, et al. (2015). Advancements in the treatment of agitation in Alzheimer’s disease. Expert Opinion on Pharmacotherapy, 16(11), 1649-1656. Neurobehavioral Rating Scale (NBRS) - Agitation Subscale No. of participants Citalopram 94 87 85 86 Placebo 92 84 84 81
- 34. Citalopram Considerations • Startingdose 10mg, up to 40mg daily • QTc prolongation, which is dose-dependent above does of 20mg • Confusion increased at doses of 30mg daily or higher • Consider 2x daily dosing – 10mg daily for 2 weeks – 10mg 2x daily thereafter • Other SSRI side effects • Onset of action within a week in one study
- 35. Antipsychotics • Most-studied pharmacologicintervention for dementia-related agitation • Moderate efficacy across trials and agents (18% respond above placebo response) – Typical antipsychotics – Atypical antipsychotics • Substantial side effects • Black box warning: cerebrovascular events and death (1% difference) • Lowest dose possible for the shortest duration feasible
- 36. Antipsychotics (Cont.) Antipsychotic Recommended Dose Formulations FrequencyCharacteristics Risperidone 0.5-2.0mg Tab, liquid, IM 2x daily Extrapyramidal symptoms Olanzapine 2.5-15mg tab Daily Wt gain, inc sugar Quetaipine 25-400mg tab 3x daily (unless ER) Sedating, least extrapyramidal Aripiprazole 5-30mg Tab, liquid, IM Daily Less QT Haloperidol 0.5-5mg Tab, liquid, IM, IV, sub q 2-4x daily Chlorpromazine 10-200mg Tab, liquid, IV, rectal 2-3x daily Very sedating
- 37. CATIE-AD Schneider, L. S.,et al. (2008) Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease. The New England Journal of Medicine; 355(15), 1525-1538. Greatest benefits in persons demonstrating anger, aggression, and paranoia
- 38. Relapse Risk With AntipsychoticDiscontinuation Devanand, et al. (2012). Relapse risk after discontinuation of risperidone in Alzheimer's disease. New England Journal of Medicine, 367(16), 1497-1507. Severe baseline symptoms at initiation, increases likelihood of worsening symptoms with discontinuation
- 39. Watt, et al.(2019). Comparative efficacy of interventions for aggressive and agitated behaviors in dementia: a systematic review and network meta-analysis. Annals of Internal Medicine, 171(9), 633-642. Antipsychotic Summary • Modest efficacy for treatment of agitation and aggression in dementia • Studies usually short duration: 6 to 12 week • Large placebo effect: 30% or higher on average • No difference in efficacy between typical and atypical antipsychotics • Typical antipsychotics greater side effects – Somnolence, urinary tract infection, incontinence – Extrapyramidal symptoms and abnormal gait and falls – Anticholinergic effects, postural hypotension, prolonged QT – Weight gain, diabetes, and metabolic syndrome – Cognitive worsening; seizures – Stroke (NNH 99) and death (NNH 47)
- 40. FDA-Approved Medications for Alzheimer’sDisease *Cholinesterase inhibitors: Nausea, vomiting, diarrhea, dizziness, and agitation Medication Severity Dose Side Effects Donepezil (Aricept) Mild to severe 5-10mg; 23mg *Nightmares Rivastigmine (Exelon) Mild to moderate 4.6 & 9.5mg (13mg) patch *Weight loss Galantamine (Razadyne) Mild to moderate 8-24mg * Memantine (Namenda XR) Moderate to severe 28mg QD Constipation, dizziness, HA Rivastigmine improves apathy, anxiety, delusions, and hallucinations in LBD All cholinesterase inhibitors may delay onset/reduce behavioral symptoms in Alzheimer’s/LBD
- 41. Benzodiazepines • Binds toGABA receptor in CNS • Anxiolytic, sedative, and hypnotic effects (anterograde memory) • Some evidence lorazepam and alprazolam to reduce agitation • Increased risk of adverse events – Cognitive impairment/ confusion/delirium – Falls – Hip fracture – Sedation – Paradoxical agitation Benzodiazepine Half-life Dosage range Diazepam 20-50 hours Over 100 OA 2-10mg 2-4x day Lorazepam 12 hours 0.5-2mg 2-3x day Alprazolam 16 hours (9-27 range) 0.25-3mg 2-4x day Clonazepam 30-40 hours 0.25-5mg 2-3x day
- 42. Pimavanserine • 5-HT2A antagonistindicated for hallucinations and delusions associated with Parkinson’s disease • Three trials for agitation or psychosis in dementia, all of which were essentially negative • Black box warning for increased mortality in dementia and is associated with QT prolongation, peripheral edema, and confusion
- 43. Cummings, et al.(2015) Effect of dextromethorphan-quinidine on agitation in persons with Alzheimer’s disease dementia. A randomized clinical trial. JAMA vol 314(12), 1242-54. Dextromethorphan-Quinidine for Dementia Agitation in Alzheimer’s Disease • FDA approved for the treatment of pseudobulbar affect • Modulates glutamate, serotonin, and norepinephrine • Only one randomized controlled trial to date for agitation • Side effects include – Falls – UTIs – Diarrhea – Dizziness • QTc prolongation
- 44. Phenobarbital • No dataavailable • Many clinicians, health systems, and long-term care facilities leverage its use • 30 to 120mg TID and q2 prn • Adverse Reactions – Respiratory depression – Stevens-Johnsons – Anemia, TTP, and blood dyscrasias – Withdrawal symptoms with abrupt withdrawal – Lethargy and drowsiness – Nausea, vomiting, and hepatitis
- 45. DICE • Describe thebehavior • Investigate the underlying contributors/causes • Create intervention: non-pharmacologic and pharmacologic • Evaluate the interventions effectiveness
- 46. Case (cont.) Describe behaviorand rationale to treat • Agitation and aggression worse with movement and activities • Risk to patient and staff Investigate • Pain • Depression and anxiety • Loneliness • Medication Create Contributors APAP 1,000mg every 8 hours, morphine 5mg every 8 hours, plus bowel regimen; stop sertraline and initiate citalopram Non-pharmacologic Animal-assisted intervention/recreational therapy Pharmacologic Citalopram and wean off valproic acid; trazadone 25mg as needed
- 47. Case (Cont.) Describe behaviorand rationale to treat • Agitation and aggression worse with movement and activities. • Risk to patient and staff Investigate • Pain • Depression and anxiety • Loneliness • Medication Create Contributors APAP 1,000mg every 8 hours, morphine 5mg every 8 hours plus bowel regiment; Citalopram 10mg twice daily Non-pharmacologic Animal assisted intervention/recreational therapy Pharmacologic Citalopram 10mg twice daily, off valproic acid; trazadone 50mg nightly and able to discontinue as needed
- 48. References Al Ghassani, etal. (2021). Agitation in people with dementia: A concept analysis. Nursing Forum, 56(4), 1015-1023). Alzheimer's Association. (2021). 2021 Alzheimer’s Disease Facts and Figures. Retrieved from https://www.alz.org/ media/Documents/alzheimers-facts-and-figures.pdf Antonsdottir, et al. (2015) Advancements in the treatment of agitation in Alzheimer’s disease. Expert Opinion on Pharmacotherapy, vol 16(11), 1649-1656. Gaugler, et al. (2021). Alzheimer’s Association. 2021 Alzheimer’s Disease Facts and Figures. Alzheimer’s Dementia: Chicago, IL, USA, 17. Atee et al. (2021) Pain in Dementia: Prevalence and Association with Neuropsychiatric Behaviors. Journal of Pain Symptom Manage Vol 61, p 1215-1226. Ayalon, et al. (2006). Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: a systematic review. Archives of Internal Medicine, 166(20), 2182-2188. Ballard, C. et al. (2009). Management of agitation and aggression associated with Alzheimer disease. Nature Reviews Neurology, 5(5), 245-255. Cohen-Mansfield, et al. (2014). Predictors of the impact of nonpharmacologic interventions for agitation in nursing home residents with advanced dementia. The Journal of Clinical Psychiatry, 75(7), 15076. Cummings, J. (2015). Effect of dextromethorphan-quinidine on agitation in patients with Alzheimer disease dementia: a randomized clinical trial. JAMA, 314(12), 1242-1254.
- 49. References Devanand, et al.(2012). Relapse risk after discontinuation of risperidone in Alzheimer's disease. New England Journal of Medicine, 367(16), 1497-1507. Husebo, et al. (2011). Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ, 343. Hughes, et al. (2017). Research on supportive approaches for family and other caregivers. Research summit on dementia care: Building evidence for services and supports. Leng, et al. (2020). Comparative efficacy of non-pharmacological interventions on agitation in people with dementia: A systematic review and Bayesian network meta-analysis. International Journal of Nursing Studies, 102, 103489. Mitchell, et al. (2009). The clinical course of advanced dementia. New England Journal of Medicine (361), 1529-1538. O’Gorman, et al. (2020). A framework for developing pharmacotherapy for agitation in Alzheimer’s disease: recommendations of the ISCTM working group. The Journal of Prevention of Alzheimer's Disease, 7(4), 274-282. Radue, et al. (2019). Neuropsychiatric symptoms in dementia. Handbook of Clinical Neurology, 167, 437-454. Ringman, J. et al. (2019). Treatment options for agitation in dementia. Current Treatment Options in Neurology, 21(7), 1-14. Schneider, L. S., et al. (2008) Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease. The New England Journal of Medicine; 355(15), 1525-1538. Watt, et al. (2019). Comparative efficacy of interventions for aggressive and agitated behaviors in dementia: a systematic review and network meta-analysis. Annals of Internal Medicine, 171(9), 633-642.