Hello and welcome. My name is Raj Tampy and I'm the professor and chairman of the Department of Psychiatry at Creighton University School of Medicine and the past president of the American Association for Geriatric Psychiatry. I'm pleased that you're joining us for today's Emerging Topics webinar series, Action Speak Louder Than Words, Assessing and Managing Agitation, Aggression, and Nursing Home. Today's webinar is part of APA's Emerging Topics in Psychiatry webinar series. Stay up to date on important topics and trends impacting psychiatry by participating in APA's new Emerging Topics webinar series. Presented by specialists across the field, these webinars will explore a range of diverse pertinent topics and offer a chance to interact with peers and subject matter experts. Today's webinar has been designated for 1.5 APA AMA PRA Category 1 credit for physicians. Credit for participating in today's webinar will be available for 60 days. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the attendees control column that is in the bottom of the screen. We will reserve about 20 to 30 minutes at the end of the presentation for question and answers. Next slide, please. It's my pleasure to introduce to all of you, the faculty for today's webinar, my colleague, Dr. Maureen Nash. Dr. Nash is the medical director of the Providence Elder Place PACE program. She's board certified in both internal medicine and psychiatry. She's an associate assistant professor of psychiatry at OHSU. She's a fellow of the American Psychiatric Association, American College of Physicians, and the Royal College of Physicians Canada. Dr. Nash chairs the National PACE Association, that is the NPA Medical Leadership Committee and NPA Behavioral Health Primary Care Integration Work Group. She's a member of the American Psychiatric Association Council for Geriatric Psychiatry, a member of the American Academy of Neurology, Geriatric Neurology Quality Measure Group, and she's a member of the Oregon Quality Measurement Council. She's a former chair of the American Association for Geriatric Psychiatry Clinical Practice Committee and a co-editor for Neurocognitive Behavioral Disorders, an interdisciplinary approach to patient-centered care, which was published by Spring and Nature in 2019. Welcome Dr. Nash for this webinar. Thank you very much. I want to start with I have no financial conflicts of interest and off-label use of medications will be discussed during this presentation. I do want to point out that off-label is a phrase when a medication is used to treat someone for something that has not been approved by the FDA, even though the medication is FDA approved. An off-label is unrelated to that presence or absence of evidence. Because this presentation is really focused on agitation and aggression in the context of neuropsychiatric symptoms and dementia, I want to really start with noting there are many wonderful things about people who have dementia, and this is a painting I purchased at an Alzheimer's Association auction to raise funds that was done by somebody who has Alzheimer's, and I love this painting. There are many beautiful things about people with dementia, and so please don't take what I say today about this one aspect that many people with dementia have to imply something about everybody who has dementia. At the conclusion of this webinar, attendees will be able to describe a system to interpret agitated and aggressive behavior. They will have a list of some tools to track behaviors and really a description of when and how to use behavior tracking tools, and finally, I'm going to describe the evidence base behind several classes of medications commonly used in the nursing home population. I'm going to talk about cholinesterase inhibitors, antipsychotics, benzodiazepines, anticonvulsants such as valproate. Whenever I talk about dementia, I think it's really important to frame it. The World Health Organization defines dementia as a process of functional decline, cognitive impairment, and behavioral disorders. It's certainly a complex neuropsychiatric disorder describing brain failure, and it is one of the most common causes of death in older adults in the United States. One of the things that I think is really surprising for people about dementia is to recognize that even prior to the diagnosis, there is an increase in neuropsychiatric symptoms and an increase in treating those neuropsychiatric symptoms. This is one particular study that was a cohort of about 50,000 people who had a diagnosis of dementia at year zero, and their matched non-demented cohort. They have similar graphs for anxiolytic use and hypnotic use, but clearly, as much as 10 years prior to the diagnosis, an increasing number of people start to exhibit symptoms that end up being treated with antipsychotics and antidepressants. Behavior disturbance is really common in nursing homes, and there are many different slides that look at various types of behavior disturbance and the frequency that they occur in people who live in nursing facilities. This is one such slide of two particularly different nursing homes. Note that more than 20 percent of people with dementia will have dysphoria, aberrant motor anxiety, agitation, aggression, apathy, delusions, irritability. Neuropsychiatric symptoms are not rare in people who have dementia. They're, in fact, common. The Cache County study in the U.S. in Utah followed a group of older adults over time, and those who were diagnosed with dementia, these folks lived in a number of settings, including nursing facilities, assisted livings, and in private homes. But what you saw over the course of five years was that nearly everyone developed some neuropsychiatric symptoms. It is not rare. It is, in fact, very common, and agitation-aggression is quite common. I don't think that this is the major focus for this talk, but catastrophic and severe aggression, especially in those who have untreated psychosis, is quite uncommon but does occur in people with dementia, and these are just some cases that I culled from newspapers over the years, and there are many other cases. Again, it's very rare but obviously catastrophic when it does occur. When is agitation and aggression common? Well, when somebody's told no or something's taken away from them or with personal cares. It is really a symptom that is done by a minority of people, and often the minority of people have repetitive agitation and aggression, so it's not usually something that occurs once and never occurs again. Family members have said things to me like, I don't want my mom's last days filled with fear and terror because she thinks somebody is trying to hurt her or steal her money. I don't want my mom to hurt anyone. If my dad knew what he was doing, he would be so embarrassed, and I'm afraid dad is going to kill my mom. These things were said to me when I was the medical director of a geriatric psychiatry unit here in Oregon. We had a referral unit. We took care of people from the entire Pacific Northwest, including people from Alaska, Northern California, Idaho, Nevada, and Southwest Washington. It was a group of people who were particularly impaired and hard to assess, and they came to us. That is one of the largest groups of people that I have treated over the years, these folks who have really significant behavior disturbance. One of the things that's really true about our evidence base for dementia and treating behavior disturbance and neuropsychiatric symptoms is that the evidence base is not overwhelmingly robust. Studies show things all over the map, and I'm going to tell you some of the reasons why I think that's true. Often, studies focus on treating those who have mild disease or they don't differentiate the stage of dementia, and dementia takes place over a number of years. Neuropsychiatric symptoms can start a decade before dementia. People can live for five to ten years after a diagnosis, so that is many different years and many different stages of dementia. People are going to present differently. Non-pharm interventions are most effective in early stage dementia, while most drug treatments are most effective in the moderate to severe stages. As dementia has progressed, inclusion criteria, especially around aggression, are very challenging when you look at the literature. They're not well-defined, so you can't compare studies from one study to another because you don't know if the groups were similar. Finally, clinician experience really drives what I think works and what other clinicians think works. If I take care of a population of people who have really mild dementia or if I take care of a group of people who have really severe behavior disturbance, I'm going to have a very different opinion about what I've seen work. I think that that can be really challenging when we talk to each other, and the evidence base doesn't help us differentiate populations. The good news is there's lots of areas for improvement. No discussion of nursing homes is complete without a review of the Omnibus Reconciliation Act of 1987. This was really a landmark report that pointed out the significant challenges that people who lived in nursing homes faced in the United States. At that time, there was significant concern that residents were being drugged to control behaviors, and the most common drugs that people attributed problems to were antipsychotics, but I do want to point out that there were no atypical antipsychotics FDA approved for use at that time. Antipsychotics were approved for only a small number of things, and they are actually used much more commonly for a much larger group of conditions today. Things that I've been told by family members or professionals is that I was just drugging people. The most memorable time that occurred was the family of a patient describing their concerns about a different patient that they didn't know anything about, and the different patient that they didn't know anything about had dementia due to TBI and wasn't on any psychotropic medications. He wasn't being drugged in any way, but he looked like that because of his brain and his brain defects. People really have talked about psychiatric medicines only being appropriate for severe mental illness, antipsychotics being tranquilizers, which is an inaccurate description of their mechanism of action, and some people just don't think anything can be done. When we look at antipsychotics, the FDA put a boxed warning on them, first on risperidone in 2004, on all atypical antipsychotics, and this is the list of antipsychotics approved at the time. There was a boxed warning placed in 2005, and then in 2007, so years later, there was a warning. The same warning was placed on typical antipsychotics, and this warning notes that there's an association with increased mortality for the off-label use of antipsychotics in early dementia, in elderly with dementia. This data, you can go, whenever the FDA puts a boxed warning, you can actually go and read all the evidence that they use to derive their warnings. I did that in 2005 and later in 2008. The average age of the people who died was 85. There was no review of why the antipsychotics were being used. There were lots of different clauses of mortality, and they didn't exclude people who were already dying, such as people who had hospice, people with delirium, which had a very high mortality rate at the time, and other terminal diseases. I managed to get an interview with the top two psychiatrists at the FDA in 2012 because I was so concerned about the impact and the suffering I had seen as a result of the boxed warning. What Dr. Loughran and Dr. Mathis told me was that they didn't understand the signal, so they put a boxed warning out, even though they didn't actually understand the data upon which it was based. They agreed with me that there was no review of data specific to appropriate use of antipsychotics for psychosis or aggression. They agreed with me that hospice patients and others who were already dying weren't excluded. They pointed out to me that no other medications were controlled for, so all of the people who were on antipsychotics who died, as well as those who didn't, may have been on many other risky medicines, but none of that was reviewed. The risk was highest at the start of treatment in the first two weeks, and they pointed out to me what I knew, which is that the boxed warning is not a contraindication to use. I did ask them at the time to consider changing the wording of the boxed warning, but I think that was probably a lot to ask of a federal agency. Within one year of the FDA first boxed warning, use of antipsychotics for everyone and all antipsychotics, but especially atypicals, decreased. Finally, some definitions here. A psychotropic drug is any drug that affects brain activities associated with mental processes and behaviors. Chemical restraints are any drug that is used for discipline or convenience of the staff, not required to treat a medical symptom, and convenience is further defined by CMS as any action taken by a facility to control a resident's behavior or manage their behavior with a lesser amount of effort by the facility and not in the resident's best interest. I want to point out here what may or may not be obvious, which is that agitation and aggression and other neuropsychiatric symptoms related to dementia and brain dysfunction are medical symptoms. What am I talking about when I talk about agitation and aggression anyway, and what about non-pharmacological interventions? What does the evidence tell us? Well, the evidence tells us that aggression is much more common in people with dementia than people who don't have it. The odds ratio is almost five. People who have cognitive impairment, the odds ratio is higher than normal, but not that high, and actually there's little evidence that the type of dementia is related to aggression. The Agency for Healthcare Research and Quality has a very thorough report that you can get online, and they look at the effectiveness of non-pharmacological agents to treat agitation and aggression, and one of the most important things they did in this report was to define what they meant by agitation and aggression, and this slide here might be the most important slide that you see today. Agitation involving unusual motor movements or verbalizations affects primarily the person with dementia, although it can be disruptive to others in the environment. You want to identify and treat the underlying cause of agitation whenever possible, but some types of agitation may not need an intervention and can be tolerated. As differentiated from aggression, verbal threats or physical actions directly involve at least one other person, the target of the aggression, and can represent a real risk. Aggression needs to be dealt with because of the possible risk to others, and I really think that this differentiation between agitation and aggression is very important in helping us discern when to intervene and what types of interventions to try first. They did review measures to use to track agitation and aggression. The three measures they focused on were the Agitated Behavior and Dementia Scale, the Cohen-Mansfield Agitation Inventory, and the Pittsburgh Agitation Scale. They did note that some of the general neuropsychiatric symptom instruments, such as the Neuropsychiatric Inventory, have subscales specific to agitation and aggression, and the MPI, specifically the clinician version, is the instrument that I have seen most commonly reported in the literature, and the earlier slides that I showed really use the MPI. One of the things I like about the MPI is that the most recent version, the NPI-C, reported prevalence rates for agitation measured separately from aggression and found between 30 to 50 percent of people had agitation, 15 to 20 percent had dementia, and they separated them into two separate issues instead of clumping them together, and I think the reason that this is got pointed out by the AHRQ was because how important the response needs to be, depending on whether you're talking about agitation or aggression. The NPIC has specific questions for agitation, and then it has specific questions for aggression, and I think it's really important to look at the kinds of questions they ask because that can help us help caregivers and family members accurately report what they're seeing. A lot of people will say, oh, so-and-so has behaviors or so-and-so is agitated, but there is a world of difference between somebody who is sitting in a corner and rocking themselves repeatedly and somebody else who is throwing furniture at peers or staff, and really different interventions need to be done, and so the questions one asks are very important, and this is sort of how I practice medicine and what I want to point out. Informed consent is very important, and when you're going to try to treat something to change a behavior, it's very key that you have clearly set out what illness or symptom you're giving a med for or doing a non-pharm intervention for. You need to know how often does it occur and when before you do your intervention, and then you want to know and define for others what changes you're looking for. You want to make sure it's defined how to track those changes, when you expect to see them, what side effects there might be, and then follow up. As part of this, when you're talking to legal decision-makers, medical decision-makers of somebody with dementia, it's really vital to discuss and document risks, benefits, and alternatives, including the risks of no treatment, and because of my decade at the referral center, for that group of people, the common risks of no or delayed treatment of mild dementia of no or delayed treatment of moderate to severe aggression were quite grave. Patients or residents or peers injured, staff injured, a loss of placement or homelessness, social isolation being voided by peers and staff, increased suffering, and decreased quality of life. So, what did the AHRQ find? Well, in sum, they found that patient-level non-pharmacological interventions don't have an evidence base with moderate or high-strength evidence to support any particular intervention. Now, I'm not saying that there are no interventions that actually help, but what I am saying is that we don't have an evidence base, a large group of repeated studies that show us what to do, which I think is part of why there's so much distress and stress around approaching folks who have these problems. So, then the AHRQ looked at nursing home care delivery, so not something targeted just at the person, but something targeted at the nursing home staff, and really they, too, found no significant evidence, there is no evidence base to really support any particular intervention. And this is probably because of those problems with the evidence base I outlined earlier, the way the studies are designed, the lack of specificity and definitions, the lack of really telling us who you're studying, how you're studying it, and what exactly you're looking for. A group of people, Cohen Mansfield in particular, published this study in 2014, looked at when do non-pharm interventions for agitation, not aggression, work? Well, when people, when they have better cognitive functioning, when they're actually able to perform most of their own ADLs, when they're able to speak and communicate well, and when they're responsive. Well, this is exactly the group of people that I was defining as less impaired than people with moderate to severe dementia. Cohen Mansfield also found that agitation was reduced when staff changed their behaviors or when pain was treated or untreated. There was a definite relationship there. So, well, if all of those things, if you can't tell me what's going to help me, then why are you here? Well, let me tell you. I do have some thoughts. One of the really important things to know about all behavior is that it is communication, and I'm a firm believer that actions do speak louder than words. People with dementia, most types of dementia, have notable impairment in their communication. They may be able to use words for social speech, but that doesn't actually mean they can meaningfully describe their internal state, so whenever someone has behavior, including those with dementia, they may very well be telling us about a need, a basic need, and so one of the first things to think about is what need is the person trying to get met? Are they lonely? Are they in pain? Is it too loud or too cold or too hot? Are they sad and grieving? And the most common explanation for behavior disturbance in people who have dementia is really tri-fold. It's when the environment is too challenging for a person, when a person has limited functional abilities and they have unmet needs and they're trying to get their needs met or they're unable to engage due to the demands of the task at hand, and I think this is a lot of the source specifically of agitation and of many other neuropsychiatric symptoms. Not every symptom, though, so when you're going to do person-centered care plan, this is the model that I recommend. You want to identify and assess the cause of behavior, so you want to look for the unmet needs and the environmental cause. This is really important. You need to recognize psychiatric symptoms and address them, and some of those psychiatric symptoms are going to require medications. When you have a behavior change or a behavioral problem, you want to assess for cognition and functional abilities. Our friends, the occupational therapists, are experts at that, and you can use that information to select interventions. You always want to use a behavior scale, even if it's a simple one, so that you can tell whether or not your interventions were effective, so assess, select an intervention, apply the intervention, and then monitor outcomes. Pretty basic, what we do in medicine every day, and for interventions, caregiving approaches and staff training are probably the most important, but looking at the environment and other evidence-based interventions is key, too. For outcomes, you want to use scales. You want to train staff so that they're reliably reporting the same things and make sure you get monitoring information, and then you start over if the behavior is still present, if they're still suffering for the person with dementia or there's still distress among those around the person. OTs really are our friends when it comes to people with dementia. They are experts at testing executive functioning and decision making, and they can give us a lot of advice and support in designing interventions to meet this particular person's abilities and how to modify the environment for them. Person-centered care really is based on a human-to-human relationship. You might not want to drag them into our reality. You might actually want to enter their reality. Remember that people with dementia cannot change. They lose flexibility over the course of the illness, but you can, and reminding staff and family of that, and you want to respect the person. What about aggression? You want to correctly label the behavior, so you don't want somebody urinating in a pot to be called aggressive. You want to make sure that what you're really talking about is aggression, the verbal or physical threats to others. You want to help the person be as successful by themselves as possible. You want to recognize that in some people, such as those with frontotemporal dementia, memory and orientation may be more intact than social and language skills, which is sort of the exact opposite of what we see for most people with Alzheimer's. You want to identify appropriate communication techniques and do education. What do these symptoms mean when somebody's pacing or has a clenched fist? They're hitting, pushing away, screaming. They're inconsolable. Well, the very first thing I want you to think about is pain. The pain AD or advanced dementia scale was developed really for people with dementia who were non-verbal, and I highly recommend off-label use of this scale to measure. When you have these types of symptoms, you always need to think about pain. People with dementia are often, when stressed, which we're all stressed when we're in pain, unable to reliably communicate to you about their pain, but their behaviors are communicating that to you if you are listening. Millie was a patient I met, and she had perhaps the most profound impact on me of any patient I ever met. She had become verbally hostile. She was scratching and biting with care, and she came to our inpatient geriatric psychiatry unit. She screamed and physically charged at every single person who came into her room, including me. She was refusing all medication, food, and care. She'd been on her unit for over 24 hours and hadn't had anything to eat or drink, and that was very unusual. In fact, I don't think it had ever happened before, and I was really concerned about Millie, who was in her late 70s and a pretty frail, small lady, and nobody could figure out what to do, so I pulled up a chair, because I happened to have a couple hours in my schedule. I pulled up a chair, and I just watched, and what I found was fascinating. Every single staff person who entered Millie's room asked her a question. They all started with, Hi, Millie. How are you feeling today? Hi, Millie. Do you have any trash? Hi, Millie. What do you want to eat? Hi, Millie. Are you willing to take some medicines? And I, too, when I had entered the room, I had given her a question, and she was actually relatively calm until you ended your question, and that's when she would scream at you and physically charge and chase you out of the room, and so I went down to the charge nurse, and I talked to her about my observations, and we decided to do a small test, so I went in, and I said, Hi, Millie. You're in the hospital. You have been sick. I'm Dr. Nash. We're going to help you, and then I left. She didn't scream at me. She didn't charge me. It was totally different. She still looked terrified. She still was shrinking back, but it was a very different interaction, and so we ended up coming up with a very specific care plan for Millie, and it involved never, ever asking her a question, and we had signs all over her room, on the door to her room, on the door to the bathroom, and developed a plan that over the course of a week led to Millie actually walking around hand in hand with staff, smiling, not talking. She really wasn't able to use language anymore, but she didn't look terrified. She was eating and drinking, and so that is the kind of assessment that can be required for severe agitation and aggression, and Millie is the person who taught me to be very careful with questions and to consider not using them when I work with people. Shelby was somebody who was younger, and she frantically paced all of the time and periodically screamed. She muttered under her breath about being beaten up. She would cry or scream sort of randomly. She always was frowning. She's totally unable to care for herself, and she would become aggressive when staff tried to help her with care. She was on our unit for months because we couldn't figure out any way to help her. Ultimately, an LPN came up to me and said, have you looked at Shelby's feet, which of course I had not actually helped put her socks and shoes on, so I hadn't looked at her feet, but her feet were swollen. The skin was cracked, and the LPN said to me, I bet she's in pain, and I treated Shelby's pain, and we just saw a whole different person. She stopped muttering about being beaten up, and I think what happened was she had pain, and her explanation her brain gave her was that she was being assaulted. What about pharmacological interventions? Well, just to note, what medications lead to ED visits? What medications lead to death most commonly? Well, those are medicines that make you bleed or medicines that lower your blood glucose to unsafe levels, so warfarin, coumadin, aspirin, clopidogrel, blood thinners, oral hypoglycemics. Those are the medicines that actually are the most dangerous, but when I talk to geriatricians and I ask that question, they almost always think it's antipsychotics. Well, so let's do a not a randomized control time, but let's look at an observational database of a large number of people living in nursing homes. This is from Canada, and Hubert's group did it. They used atypical antipsychotics as their comparison point, so it had a risk of 1.0, and what did they find? Well, older antipsychotics and antidepressants were much more associated with a risk of death. Older antipsychotics and antidepressants were much more associated with a risk of femur fractures, and benzodiazepines were associated with a very high risk of death, heart failure, and pneumonia, and here's sort of this in a picture. The FDA approves medicines when a drug company spends millions of dollars and applies for something. Once a medicine is FDA approved, physicians and other providers use those medicines based on the evidence base, based on the mechanism of action, based on what we think is going to help the people who are suffering in front of us. Valproate, which is valproic acid, diproproate, depakote, depakine, is commonly used and much more commonly than it used to be to treat agitation and dementia. I really want to highlight this. There's no evidence that it actually works to do that. There is evidence that the adverse effects are extremely high when we do use this class of medicines, and there's suggestive evidence that brain atrophy in people with dementia is accelerated and cognitive decline may be increased. Benzodiazepines, again, there is no evidence base to support their use for behavioral disturbances in dementia, and they definitely are associated with falls, worsening cognition, speeding decline, delirium. That doesn't mean you never use it, but you really need to think carefully and watch for side effects if you are going to use them. Well, what about antipsychotics, which arguably are one of the most common medications used? Well, what do antipsychotics do anyway? Well, they lower dopamine in the brain. They treat psychosis regardless of what is causing the psychosis. Do they work for everybody with psychosis? No. Do they work for most people with psychosis? Yes. They were discovered when they were looking for antihistamines, so allergy medicines, and the older antipsychotics often do make people sleepy as the older antidepressants also do. Antipsychotics also preferentially hit the vomit centers in the brain and they help decrease that. They're used in a number of different illnesses under both FDA and non-FDA indications. Well, what does psychosis have to do with aggression? Not everybody who's aggressive has psychosis, but many people do, so what they found in aggressive behavior was much more frequent among people who had hallucinations. Physical aggression was associated with people who had psychomotor activity disturbance and hallucinations. Verbal aggression was associated with delusions, so that might be one reason why antipsychotics are helpful for people with agitation and aggression. We even this year have a newly approved medication for agitation and aggression in Alzheimer's disease. We don't have a large robust evidence base yet because it's just a new drug on the market, but it's the first time that we have a medication FDA approved for agitation and aggression and dementia. Well, what does the APA say about it? Well, we have a practice guideline published in 2016 and really there was evidence for risperidone treating psychosis. Risperidone, olanzapine, and aripiprazole treating agitation and aggression. There's insufficient evidence about quetiapine, although it looks like there's an exception for Lewy body and Parkinson's disease dementia around clozapine and quetiapine. So there is some evidence for both psychosis and agitation aggression of antipsychotics. The APA practice guidelines talk about how to use them, about how to get informed consent, and they spend time talking about the decision about tapering, and they really recommend that it be person-centered with input from the family and others involved, and if a person has negative past experience with removing an antipsychotic medication, then you really have to think about that before you do it, and then they recommend monitoring if you do decide to taper or stop an antipsychotic. KDAD was another study that showed clinical efficacy of certain antipsychotics, mostly risperidone and olanzapine, perhaps for quetiapine compared to placebo. What about when people have responded? Well, Devenin's group followed people who had been taken off antipsychotics and they only looked at the people who had responded, so people who had benefited from an antipsychotic, and what they found was very high rates of relapse once the antipsychotics were stopped. Well, what about the atypicals versus the typicals? Because, you know, the atypicals had that warning placed in 2005. It wasn't until 2007 that typicals were given a boxed warning by the FDA, so clearly the atypicals must be much more dangerous than the typicals. Well, that, I would say, could not be farther from the truth. There's a number of different studies that have shown conventional antipsychotics have significantly higher risk of death, significantly higher risk of side effects. Dementia-specific meds, so what do I mean by that? Cholinesterase inhibitors and memantine. Memantine has been shown to help with agitation, aggression, eating appetite, irritability, and mood lability, but again, from this study, this was the thing that jumped out at me. People who didn't have aggression had less emergence of it after being treated with memantine, and remember, the natural course of the illness is that neuropsychiatric symptoms increase over time, if you remember the Cache County data. What about cholinesterase inhibitors? Well, there is some evidence that they assist with reducing agitation and a reduced need for other classes of medicines, including antidepressants and antipsychotics. Guidance on cholinesterase inhibitors has changed over the years. The UK now recommends their use in Alzheimer's disease. The European Union notes that cholinesterase inhibitors plus memantine has a high quality of evidence for combined therapy for treating behavior, but not so much for treating other signs or symptoms of dementia. Canada also recommends the use of cholinesterase inhibitors for people with dementia. So, what about Donna? What about real people? What have I seen? Well, Donna was a lady who had a long history of schizoaffective disorder, and she developed dementia. She came to us because the dementia unit in the nursing home thought she might be catatonic, and she was more psychotic. She'd taken to bed. She was screaming and uncooperative and agitated. She came to our unit, and I got a phone call from the occupational therapist who was doing the assessment, and the occupational therapist said, hey, I'm really worried about Donna's hip. Every time she moves her leg or we do anything with her anywhere near her left hip, she just screams and pushes us away, so I got an x-ray of her hip, and it's the first time I've had a radiologist call me in less than an hour after a film. The radiologist called me and said, this person has screws and wires floating around in the muscle area of where her left hip should be, but her left hip has been resorbed, and the bone is no longer there, and that was why she had taken to bed, and that's why she was agitated and screaming. She was having terrible pain, and she couldn't get up, so trying to force her up was not helping her, so we treated her pain, and that really helped. It didn't help her psychosis. She was on an antipsychotic already at a dose that had worked for her in the past, so we did end up adding a cholinesterase inhibitor, and that did seem to decrease psychosis, and her verbalizations of suffering appeared to improve, and we were able to discharge her back to her nursing facility. Mary didn't live in a nursing home, but I've treated many people like Mary. She was 84 when I met her. She was independent in her ADLs. She wasn't driving because she was legally blind, and she was obsessed about a man named Jack, somebody who she used to hire, so he was coming into her apartment at night. He moved things around. She saw him. He never did speak to her, but she could vividly describe what he looked like, and she was quite concerned. I don't know what he's going to do to me, and Mary was somebody who we diagnosed with Lewy body dementia, and she required a cholinesterase inhibitor, and that really decreased her psychosis and her distress by about 50%, but she was still pretty distressed, and we ended up having to use some quetiapine. Frank, a 79-year-old fellow, retired carpenter, very large, like 6'4", very imposing. He came up to the nurse's station. He started screaming about his car being stolen. He was pounding on the desk and really scaring everybody, so the LPN walked around the corner and called the phone, which happened to be right next to Frank, so we answered the phone, and she said, hand the phone to Frank. We handed the phone to Frank, and she said to Frank, I hear your car was stolen. He's like, yes, it was, and she said, well, I'm from the police, and I'm taking a report. What kind of car was it? What color was it? What make? What model? How many miles did it have on it? Did it have any scratch or dents? When's the last time you saw it, and she started asking. She didn't ask them that fast, but she asked them question after question after question about his car, and after about 15 minutes, he looked at the phone, and he said, this lady is crazy, and he hung up the phone, and I looked at him, and I said, hey, Frank, it's dinner time. Why don't we go down to dinner, and so Frank said, okay, I'm hungry, so we took him down to dinner, and things were better, so that was somebody who was like, well, why don't you just use non-pharmacological interventions like you just did with Frank? Well, in the hospital, A, we have lots more staff, but B, a lot of the other patients on the unit were very frightened by what Frank had said and done, and everybody was avoiding him for the next day or two, and so it really impaired the quality of life of the other people on the unit, and frankly, he had been pretty darn upset for quite a while, nearly an hour, and this had happened multiple times a day about different things, not always about his car being stolen. We didn't tell him that he didn't have a car. We didn't reality-orient him. We did what you should do. If somebody has got something stolen, you should report it to the authorities, and that's what we did, and that helped in this incident, but what was really going to help Frank was if we could find something that would prevent him from getting so distressed in the first place that he ended up getting possibly aggressive. He had been aggressive before he came to the hospital, and we treated Frank with some risperidone, and he improved greatly. He didn't have any side effects. We were able to use a half a milligram twice a day, and we started him on some dementia-specific medication, and we were able to stabilize him and discharge him. In 2012, CMS began the Partnership to Improve Dementia Care in Nursing Homes. They did mention some things about non-pharmacological interventions. However, they didn't measure any clinical outcomes or the quality of care. The only thing they looked at was the percentage of nursing home residents who were given an antipsychotic, and most notably, they didn't look to see if the same people were still living in nursing homes over a period of time, and those of us who worked in the hospital can tell you nursing homes stopped accepting people who were on antipsychotics for admission. They stopped taking people back who were on an antipsychotic, so the number did go down. The number of people with an antipsychotic did go down. That's this line here, but what went up was the use of valproate, and lots of people with dementia in nursing homes were on psychotropic meds, more or less statistically the same amount of people before and after the partnership. Some people look at this and say, oh, well, this is clear evidence that people are being drugged, and I would really disagree. What, to me, this is is clear evidence that people with dementia who live in nursing facilities have a very high level of neuropsychiatric symptoms, and the people caring for them are trying to treat their symptoms, and we actually don't have data that would tell us whether I'm correct or anybody else is correct in their explanation of this data, but I don't think there is a clear and convincing amount of evidence to support people not needing medications for their neuropsychiatric symptoms, and in nursing homes, CMS requires everyone receiving psychotropic meds to go through a gradual dose reduction. Now, they always do say you want it to be consistent with accepted standards of practice. They always say we defer to the prescriber who knows this patient, but nursing homes put a lot of pressure on providers who are taking care of people. They want to do the gradual dose reduction. Surveyors who come into nursing homes want gradual dose reduction. New CMS language has come out around that, which I think is hopefully to improve gradual dose reductions. They recommend it should occur only in modest increments. They say over adequate periods of time, though they don't define that, and then they give an example of what appropriate gradual dose reduction might be, trying to take people off of a psychotropic med twice in the same year in different quarters, and I think, from my chair, that really concerns me. What I know is that there are a lot of people with chronic illnesses who live in nursing facilities, and I've cared for quite a few over the years, but what's the difference between people who suffer from this list of illnesses? Well, the people, if you have an orange illness and I give you medicines, say, to stabilize your blood pressure, then we all say, fantastic. Let's keep those meds going because we want to reduce high blood pressure because of all the damage it can do to your heart and your brain and your organs, but if you happen to have one of the green illnesses, oh no, we have to do a gradual dose reduction. We have to lower the doses of medicines until you have symptoms so that we know that it has failed, and we have to do it repeatedly, and I, myself, find that deeply troubling because people who have chronic illnesses, including chronic psychiatric illnesses, actually need their psychotropic medications, and people who have dementia with neuropsychiatric symptoms also need medicines if they are benefiting them, and there is not a large evidence base that we should randomly taper people off of medications, especially if what we're talking about is aggression, so do I have any evidence about what happens in a nursing home-eligible population if you use dementia-specific meds? To qualify for PACE, the program of all-inclusive care for the elderly, you have to qualify for a nursing home, and so when I joined our program here, I came actually from the acute psychiatric unit and I came to join the PACE program as the medical director, and one of the things that I did was start to strongly encourage the use of dementia-specific medications. The geriatricians and doctors and nurse practitioners caring for our patients actually had noted that the evidence base for cognitive improvement with dementia-specific meds is not robust and you don't really get very much cognitive improvement with dementia-specific meds, so they were pretty discouraged, actually, in their use, and when I came, I said, well, that is all true, but what we're really looking for is changes in neuropsychiatric symptoms, and so when we looked at our group of people and put them on dementia-specific medicines, what we found over time was a significant improvement, a significant decrease in neuropsychiatric symptoms, and which particular symptoms did we see improvement in? We saw improvement in agitation and aggression. We saw improvement in depression dysphoria. We saw some improvement in apathy and indifference and in appetite. So, what I take away from this is there are good reasons to consider using dementia-specific medicines, at least in our population, in the population of people that we're treating in our PACE program, which is very different than the population I used to treat in the inpatient psych unit. This is the most notable slide that we have from that study that we did of our own participants, and if you see here, this is before and this is after, before and after, and red is severe symptoms, neuropsychiatric inventory symptoms, so delusions were severe in a big chunk of people before using dementia-specific meds. After six months, the number of people with severe delusions was much less. The number of people with severe agitation and aggression was much less. The number of people who had severe depression and dysphoria was, we couldn't find any. We couldn't find anybody with severe hallucinations in the group of people that we were treating in our patients, and so this is the kind of data that I use to support my use of dementia-specific medications in the population of people that I treat, and I do think it's really important that we look at the population that we're treating and design our interventions. I'm a big fan of measurement. You want to measure neuropsychiatric symptoms before you do interventions and you want to measure it afterwards. You want to see, oh, we might not be able to make delusions go away, but if we can make them milder, that's a big win for that person if the delusions cause suffering. If a person is agitated or aggressive, we definitely are hoping, especially for aggression, to move people into the mild or no symptoms. In sum, antipsychotics have a robust and significant evidence base for treating agitation and aggression in dementia. They are encouraged in multiple countries. Risperidone is FDA-equivalent approved in Canada for treating neuropsychiatric symptoms in dementia. Brexy Brazil is now FDA-approved in the United States as an antipsychotic to treat neuropsychiatric symptoms of agitation and aggression in dementia in the United States. Europe has found a very robust evidence base, as has the UK, for using dementia-specific medications to treat these symptoms. I really like to discourage routine across-the-board prescribing of valproate or anticonvulsants or benzodiazepines for neuropsychiatric symptoms in those with dementia. There may be times when that is actually the right intervention for the person you're working with, but there's not good evidence that across-the-board those medicines help, and those medicines have grave and significant risks, and there is actually a pretty robust evidence base to support the risks of those classes of medicines. Thank you for your time and attention, and I don't know if we have any questions. I'm going to just review. Here are my references that I have used throughout this presentation. Thank you very much, Dr. Nash, for that wonderful and comprehensive presentation. Just a friendly reminder, if people can just add their questions to the Q&A section at the bottom of the screen. So, Dr. Nash, if there are no questions, I'm going to ask a couple of questions just to So, you know, you have made some very important points, which I think are takeaways for our audience, is I think each person should have an individualized treatment plan, and to develop an individualized treatment plan, and to develop an individualized treatment plan, you need to have an observation of what are the antecedents, the behaviors, and the consequences. I think one of the issues that people face in any sphere in the continuum of care is time management, because you talk to anyone, they're all in a rush to see 30 patients, 40 patients, 50 patients a day, and many of these patients, you will not be able to understand them well unless you spend the time. Like you said, you had time, you sat down, you observed, you made an intervention. So, you know, any sort of takeaways for how people can work through that if they're working in the skilled nursing facilities? I think that is an outstanding point, and I agree. I don't know if we would have been able to help Millie if I hadn't happened to have not had appointments for two hours in my clinic, but this is why it's so important to use behavior rating scales and to actually train your staff in how to use them so that when people report symptoms or signs with words, when they say agitation, you're all talking about the same thing, or when they say aggression, you're all talking about the same thing, and this is actually the reason I really like the neuropsychiatric inventory clinician version, because they give you specific questions, and those questions really help you understand what delusions mean, what hallucinations are, what agitation and aggression is, and I think if you have a common language, it takes less time to communicate, and it takes less time to actually understand what people are trying to communicate, and I think it's really important because our patients or nursing home residents who have dementia are not going to be able to use language to really help us help them, which is why it's so important that staff are able to do that, and I think that I didn't show the data, but there is data that staff training is actually extremely impactful in helping improve neuropsychiatric symptoms in people with dementia and is probably the most impactful thing, and that comes back to who can change. The person with dementia isn't going to change, but you can change, so I think it helps with time if you have standardization and knowledge around that and good communication, and I think that's one thing I recommend, and the other thing is really use your occupational therapists. They are experts in analyzing behavior. They're experts in functional cognition, and so they can really help you figure out and discern what kind of things to help recommend, so the big picture, find ways to have others help you help the residents, and so there are different ways to do that, but if you're all using the same language, the amount of time that's going to save you is very significant. Thank you. So, Dr. Elliott Stein has asked a question. Thank you, Elliott, for asking that question. He says, Thank you, Maureen. Which behavior skills do you think staff can learn and use most easily? Yeah, that's a great question, and I do think that some of the behavior scales that are listed by, I hope I'm not making anybody dizzy, that are listed by the AHRQ, I do think that the Cohen-Mansfield agitation inventory seems to be pretty easily learned. I also think the pain AD, and I routinely ask for the pain AD every single time somebody wants to talk to me about agitation or aggression. They know that I'm going to ask for vital signs, I'm going to ask for problem lists, I'm going to ask for medication lists, and I am always going to ask for a pain AD, and I think that is one of the really important scales, and I think it's very straightforward to use. As well, because of the population I care for, these are people who have very advanced dementia. They're often near the end of life, which can be very challenging, so there's a scale called the mini-suffering state exam. Now, that's not a scale of agitation or aggression, but it's a scale that helps us predict who is near the end of life who has dementia, and that is the FAST scale, which is commonly used in nursing homes. It's not actually specific enough or helpful enough for predicting prognosis accurately, whereas the mini-suffering state exam, which was developed by a group in Israel, and there are a number of studies of it, so that can be helpful, and that's ten yes or no questions. One of the questions is for medical staff or caregivers. Do you think this person is suffering?, and one of the questions is for family or natural supports. Do you think this person is suffering? Those are two of the ten questions, so ten yes or no questions can be easily done, so those are some of the scales that I routinely use, and I do use the NPIC. I don't use the whole thing, because as you saw from the slides, there can be ten or fifteen questions under each symptom, but I use that to pick out the questions that work for people, but those are the ones I use, which is really different from what Dr. Stein was asking about, what works for caregivers. The other thing I would say is you mentioned using the ABC-type approach. What are the antecedents? Specifically, what behaviors are you seeing, and what are the consequences of those behaviors?, and I often use that, and we actually have turned the ABC into a phone phrase when we get a telephone call from a caregiver or a family member about somebody with dementia and behaviors, and so we've turned the ABC into questions that our receptionists can use to ask people about. Thank you, Maureen. If you have any questions, please put it in the Q&A section. If no questions, I'm going to ask you another one. You described a lot of the different medication classes, and people do get calls in the middle of the night saying, okay, can you give me some PRN medication that I can use for treating agitation and aggression, so based on evidence, what would you recommend in order of severity from the mildest to the most severe? How do you choose which medication or medication process you would recommend for use among these people? The class of medicine that I use, and again, the population I'm dealing with are people who have moderate to severe dementia, and I always say, is this person, do they have palliative care on their list, and if they have palliative care on their list, the very first medication I use tends to be an opiate to treat pain, because pain is so hard to recognize, so that's actually the first medicine that I reach for. If this is someone who has a chronic psychotic illness or if this is someone who has a history of psychosis, then I would use a risperidone m-tab, which is a meltable form of risperidone, or possibly an olanzapine, which comes also in a meltable tablet form, so those are some of the medications that I go for first, and I definitely avoid a benzodiazepine, because it sits on the same receptors in the brain as alcohol, and I just find giving somebody who's upset some alcohol often leads things into a negative direction. Somebody who's calm already might really benefit from an after-work drink, but when somebody's really upset, I just find that alcohol can easily lead things into a negative direction, so I avoid benzodiazepines for those middle-of-the-night calls, and often that's what I'm asked for. Can I give them a lorazepam, and I almost always say no. If you have to, I mean, do you use intramuscular or parenteral medications in any of these situations? You know, that's a great question. We don't tend to, if behavior is that out of control that there is significant risk of harm, we tend to send people to the emergency department, which I know is never preferred. The other thing I would say is this is where it's really important to look at a person's history, because if a person has a history of significant aggression or significant psychosis and they have brain failure, there is every reason to expect and predict that this is going to recur, and so I think one of the other important things is to consider scheduled medications so that you can help avoid these severe outbursts, and I think part of the reason we don't get very many of these calls is because we do use dementia-specific medications routinely with everyone who has a diagnosis of Alzheimer's, vascular dementia, Lewy body dementia, or Parkinson's disease dementia, and then we also are very active with our palliative care program for people who have advanced dementia and are getting closer to the end of life, and those folks often have lots of reasons to have pain, and so those folks do tend to have pain medications regularly scheduled, and so I think because we aggressively do those two things, we don't have a lot of those severe episodes. I did look in 2015. I pulled all of our charts for everybody who was hospitalized with agitation or everybody who had an ED presentation for agitation-aggression related to dementia, and I looked at those people. I did this in 2017. I looked back at these 2015 charts, and what I found was all but one of those folks who presented to the ED with severe agitation and aggression due to dementia, all but one died in less than six months. The one who didn't died at eight months post-ED visit, and I think that really supports my theory that at least for the group of people I treat, significant agitation and aggression is associated with being near the end of life, and I think it's really hard to forget that. I think people don't think about dementia as a brain failure or a fatal illness. Thank you. Thank you, Maureen. We also brought up a point about breptropasol now being approved for treating agitation among individuals with Alzheimer's disease dementia. Now, is there any specific documentation or anything specific that you need to do because pharmacists are always calling for gradual dose reduction, or is there anything that people should be aware that because nursing homes are always auditing what psychiatrists are doing or physicians are doing, so anything specific that you would do with now breptropasol being approved? So, I definitely would do the kind of things I'm already doing, which is documenting informed consent, but the other thing that I like to do in my initial evaluations and to update periodically is to highlight what is the most severe agitation or aggression this person has had. So, I treated a man who thought his wife had been replaced by somebody who looked and sounded just like his wife but wasn't his wife, and he tried to strangle her, which is how he ended up on my unit, and a year and a half later, after we had discharged him and he was on an antipsychotic to treat his paranoia and delusion, I got a phone call from his family. He had tried it again because the outpatient psychiatrist had taken him off of his, had tapered him off of his antipsychotic over four months, and besides taking my breath away and being very glad that his wife, who was now much more severely injured and never took him home again after this, I was glad she was still with us, but I did take my breath away that the outpatient psychiatrist thought that that was okay, and I think when somebody, you have to look at what is their worst episode and you have to look at what's the severity of the episodes, because the natural course and progression of the disease is for these symptoms to worsen. It's very unusual that a person goes from no symptoms to the most severe symptoms, so I think it's really important to document that and then to document why a gradual dose reduction in this particular person is medically contraindicated, and that's where the informed consent and really taking the families, the families or natural supports opinions into account, and sometimes people really want to try people off of medicines, so when I do reduce medicines, I do it very slowly. Side effects go away quickly. Efficacy can take months or even years to go away, and you have to then monitor carefully for early signs that something is coming back. You don't want to wait until somebody tries to strangle their wife a second time. I mean, that is not safe. So, what you're highlighting is that whatever you do, always involve family and caregiver and document and have a plan of action, and maybe also is to have a plan of action. If you do a gradual dose reduction, what would you do in those situations if the behaviors emerge again? Right, exactly, and of course, the first thing I do is restart whatever was working before, but I think, and I think that what we're going to see with the Brexipiprazole is the same thing as what we've seen with other antipsychotics that aren't FDA approved, but that is if a person responded to it in the past, they are very likely, though not assured, to respond to it again. Well, how did I learn that? Why do I think that? Well, actually, the PACE program I work for now, they used our inpatient geropsych unit, so I knew them sort of through all their treatment failures, and what I found was they would call two or three months after we discharged someone, and they would say, they're having the same problem, and you would look at the med list, and they had tapered off all the meds we started. So, I took people back once or twice, and then I just called them up, and I said, I'm not going to use this bed for your person. Put them back on the meds that we know help them. Thank you, Maureen. You know, please, for the audience, please put your questions in the Q&A section, which is on the bottom of the screen. If no further question, I will ask one more question, because we are coming to the close of our time. You know, what about cannabinoids for treating agitation? Because you do take care of a lot of patients who are nearing hospice care or at that stage. Yes, and I live in practice in Oregon, where over-the-counter cannabinoids are quite readily available. I am in a conservative camp regarding that class so far. I don't see the evidence that they are helpful. The only times that I have actually run across it is when somebody comes to me already on them, but they're coming to see me because they're having problems. So, what I usually suggest is stopping them. I, myself, am concerned about the link between psychosis, which may or may not be as strong with certain forms of CBD cannabinoids, but I am waiting for the evidence that it works. It is actually on the list of things in Oregon. Dementia is on the list of things that you can get it for, medical marijuana, but I'm waiting for more evidence. Thank you very much, Maureen, for a very informative session and a very detailed look into treating agitation and aggression among dementia patients and nursing homes. If you can just go to slide 100. I can. So, just a quick information that you will be receiving a follow-up email within one hour of the webinar concluding. The email will contain instructions to access the activity evaluation and claim your credit and certificate. We have an upcoming webinar information. Please join us on the upcoming webinar, emerging topic webinar titled non-pharmacological management of ADHD on Wednesday, August 16th, from 3 to 4 p.m. Eastern Standard Time. Thank you all for joining our webinar today. If you have any follow-up questions, please reach out to education, that is educme at psych.org. Thank you again, everyone, and take care. Have a good evening.

Action Speak Louder Than Words

Assessing and Managing Agitation

Aggression

Nursing Home

Dr. Maureen Nash

Dementia

Behavior Disturbance

Person-Centered Care

Assessment Strategies

Management Strategies

Antipsychotic Medications

Treatment Options