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Behavioural and Psychological Symptoms of Dementia
Behavioural and Psychological Symptoms of Dementia (BPSD) (BPSD)
Toolkit Toolkit
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College of Family Physicians and P.I.E.C.E.S. Canada College of Family Physicians and P.I.E.C.E.S. Canada
Supported by a grant from the Ministry of Health and Long Term Care Supported by a grant from the Ministry of Health and Long Term Care
August 24, 2009August 24, 2009
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Acknowledgements
A Special thanks to the P.I.E.C.E.S. Consult Group and the Ontario College of Family Physicians BPSD Handbook Development Group, including W. Dalziel, M.F. Rivard, J. Feightner, S. Feldman, J. Puxty, J.K. Le Clair, A. Hurtubise and D. Harris. Tools, information sheets, frameworks, and algorithms have been included that have been identified and/or developed by leaders in the field including individuals involved the Mobile Interprofessional Coaching Team (MICT II) project, supported by HealthForceOntario, at Providence Care, Kingston, Ontario. The content was gathered by January 2009. We would also like to acknowledge the kindness of many original authors and organizations that have developed informative material that they have published and allowed us to use or have made available in a public domain. Please see individual tools for authors. Finally we would like to acknowledge Eilyn Rodriguez and Sarah Clark for their wonderful support.
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Use of Standardized Assessment Instruments in Collaborative Care
Because using standardized assessment instruments take extra time, we often pass them over, feeling the time and effort is not worth it. What we miss is an opportunity to enhance the assessment, communication and clinical care planning. Such instruments do not replace a holistic person assessment but rather augment our findings. Some of the advantages in using assessment instruments include: • Improving communication with our colleagues. In discussing results of mutually agreeable
instruments, there is a “common language” to measure clinical findings. • Assist in characterizing the population they serve. For example, the Mini Cog provides some
understanding of what the person’s cognitive status is at that time, rather than descriptions such as “quite confused”.
• Standardized measures can be used to document change in clinical presentation. For example, a
depression scale, such as the Cornell can be used to measure whether or not the patient’s symptoms are changing over time.
• Assessment instruments can be used to solve specific clinical problems and for the planning of
clinical interventions. For example, the Cohen-Mansfield Agitation Scale can be used to identify specifically what the problem behaviours are and assist Long Term Care Home staff in implementing the appropriate interventions.
• Standardized assessment tools can be excellent in teaching clinical assessment to students or
colleagues. It helps the clinician understand the areas to be assessed and can even help structure the interview. At other times the results of a standardized assessment tool such as the Clock Drawing Test can be used when appropriate to assist families in understanding why their loved one is no longer able to function as before.
Standardized assessment tools augment the information gained in an interview but are not diagnostic. For example, an individual who does poorly on the Mini Cog may not have an irreversible cognitive impairment, but rather a medical illness or excessive medication.
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Introduction Introduction The intention of this toolkit is to enable primary care providers with a ready to use reference in the detection, assessment and management of cognitive impairment/dementia and co-morbid chronic mental and physical health disorders. The recommended tools are to be used in consideration of the unique clinician, setting, and patient.
The intention of this toolkit is to enable primary care providers with a ready to use reference in the detection, assessment and management of cognitive impairment/dementia and co-morbid chronic mental and physical health disorders. The recommended tools are to be used in consideration of the unique clinician, setting, and patient. The toolkit is organized as follows The toolkit is organized as follows
A) It is divided into topic-specific toolkits focusing on geriatric mental and physical health topics, allowing for quick reference depending on the issue presenting.
A) It is divided into topic-specific toolkits focusing on geriatric mental and physical health topics, allowing for quick reference depending on the issue presenting.
B) Each topic specific toolkit includes: (1) Support tools recommended for periodic health exams. These are intended to be used within practice at an individual’s periodic health exam to promote early detection as well as prevent disability. (2) Support tools recommended for use when an individual presents with an issue that may be a result of a cognitive impairment.
B) Each topic specific toolkit includes: (1) Support tools recommended for periodic health exams. These are intended to be used within practice at an individual’s periodic health exam to promote early detection as well as prevent disability. (2) Support tools recommended for use when an individual presents with an issue that may be a result of a cognitive impairment.
C) This toolkit also identifies tools suggested for use by the single practitioner, as well as those that are more suited for collaborators with the single primary practitioner.
C) This toolkit also identifies tools suggested for use by the single practitioner, as well as those that are more suited for collaborators with the single primary practitioner.
D) Tools are designated into two categories as indicated on the instrument: D) Tools are designated into two categories as indicated on the instrument: Tools / instruments assessed for reliability and validity* Tools / instruments assessed for reliability and validity* Frameworks and checklists to assist in assessment and shared support planning. Frameworks and checklists to assist in assessment and shared support planning.
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B *If a screening*If a screening instrument is reliable and valid, this does not necessarily mean that routine screening has been proven beneficial. Also, a reliable and valid diagnostic instrument does not necessarily mean that it is sufficient on it’s own to confirm that a diagnosis exists.
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A// DEMENTIA / COGNITION _______________________________________9
Dementia / Cognition Algorithms _______________________________________________________9 Dementia Algorithm: Decision Tree for Tool Use________________________________________11 Primary Care Protocol for Behavioural and Psychological Symptoms of Dementia (BPSD) _______13
Tools for Flagging High Risk Individuals _________________________________________________15 Detecting Dementia Medical Checklist ________________________________________________17Dementia Risk Calculator __________________________________________________________1910 Warning Signs for Caregivers_____________________________________________________2310 Warning Signs for Professionals___________________________________________________25
Tools for Dementia / Cognition Assessment and Management ________________________________27 Detecting Dementia / Cognition Recommended Tools ______________________________________27
Mini Cog Plus ___________________________________________________________________29 Montreal Cognitive Assessment (MoCA) ______________________________________________35 Clock Drawing___________________________________________________________________41
Detecting Dementia / Cognition: Other Tools _____________________________________________45 Mini Mental State Exam (MMSE)____________________________________________________47
Types of Dementia __________________________________________________________________49 Determining Types of Dementia _____________________________________________________51
Determining Staging of Dementia ______________________________________________________53 Functional Assessment Staging (FAST) _______________________________________________55 Lawton Brody ___________________________________________________________________59
Investigations and Labs ______________________________________________________________63 Investigations and Labs ____________________________________________________________65
Dementia Collaborative Care Tools______________________________________________________69 Three-Question Template and Summary of U-FIRST / P.I.E.C.E.S __________________________71 P.I.E.C.E.S. Aid for Family Physicians ________________________________________________73 Kingston Standardized Behavioural Assessment (KSBA)__________________________________75 Is it Alzheimer’s Disease? 10 Warning Signs __________________________________________101Dementia Observation System (DOS) ________________________________________________103 Dementia Observation System (DOS) for Families______________________________________107 7 D’s to Define Severity: Monitoring Response for Behaviour and Psychosis _________________109 U-First Wheel (Obtain from www.piecescanada.com) ___________________________________111
B// CONDITIONS EITHER ASSOCIATED AND/OR RESPONSIBLE FOR COGNITIVE IMPAIRMENT ________________________________________113
Delirium ___________________________________________________________________________113 Periodic Health Exam Tools for Screening / Identification __________________________________113
Red Flags for Potential Delirium ____________________________________________________115 Tools for Delirium Assessment / Management____________________________________________117
Confusion Assessment Method (CAM) (see www.rnao.org) ______________________________119 Algorithm for Diagnosing Delirium__________________________________________________121 Causes for Delirium Checklist ______________________________________________________123 Causes of Delirium: DELIRIUMS___________________________________________________125 CHAOS _______________________________________________________________________127
Depression _________________________________________________________________________129 Office and Primary Care Checklists ____________________________________________________129
Signs of Depression: SIG E CAPS __________________________________________________131 Tools for Mood / Anxiety Assessment and Management____________________________________133
Cornell Scale for Depression _______________________________________________________135
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NICE Job Aid___________________________________________________________________139
C// PHARMACOLOGICAL NON PHARMACOLOGICAL APPROACHES____141
Pharmacological Approaches __________________________________________________________141 Behavioural and Psychological Approaches to Dementia (BPSD) Algorithm _________________143
Psychotropic Job Aids ______________________________________________________________145 Psychotropic Job Aids for Physicians ________________________________________________147 Psychotropic Job Aids for Collaborators ______________________________________________149 Cognitive Enhancers: Monitoring Side Effects _________________________________________151
Non Pharmacological Approaches______________________________________________________153Crisis Intervention: Non Pharmacological Approaches ___________________________________155 Top 8 Non Pharmacological Approaches _____________________________________________157
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DEMENTIA / COGNITION TOOLKIT Dementia / Cognition Algorithm
Dementia Algorithm: Decision Tree for Tool Use Primary Care Protocol for Behavioural and Psychological
Symptoms of Dementia (BPSD)
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Dementia Algorithm: Decision Tree for Tool Use
Periodic Health Exam
Triggers to Possible Cognitive Impairment
Screening & Identification Triggers
1) Is individual’s age greater than 75 yrs
and/or 2)Does individual have family history of dementia?
and/or 3) Does individual have multiple vascular risk factors?
Consider using Dementia Risk Calculator
Consider Office Red Flags 1) Detecting Dementia Medical Checklist 2) Primary Care Office Behavioural Checklist
Assessment/ Management Toolkit
Recommended for screening cognition
1) Mini Cog + 2) MOCA 3) Clock Drawing
*If no cognitive difficulties detected, document as
baseline Additional tools for screening cognition
1) MMSE 2) Self Test
Episodic Health Exam
Recommended Tools for Types of Dementia &
Staging 1) FAST 2) Types of Dementia
Collaborative Tools 1) U First PIECES Wheel
Investigation & Labs 1) Complete blood count 2) TSH 3) Serum electrolytes 4) Serum calcium 5) Serum glucose levels 6) CT Scan
Reassess at next health exam
Triggers to Consider Cognitive Impairment as a factor in Assessment
& Management
Screening & Identification Triggers
1) Is individual’s age greater than 75 yrs and/or
2)Does individual have family history of dementia?
and/or 3) Does individual have multiple vascular risk factors?
Consider using Dementia Risk Calculator
Consider Office Red Flags 1) Detecting Dementia Medical Checklist 2) Primary Care Office Behavioural Checklist
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Primary Care Protocol for Behavioural
and Psychological Symptoms of Dementia and Supportive Tools
Is it a cognitive problem/Dementia that is influencing the situation
BPSD Assessment in Primary Care
Type of Dementia Cognition problem
Treatment of
BPSD
Non Pharm
Consider Cholinergics Memantine
Collaboration/ Education U-First!
Urgent Severe
No or Acute Phase Treated
Tools; High Risk Population• Dementia Risk Calculator• Medical Red Flag Checklist• Office Red Flags Checklist
Tools• 3-Q Template• R/O Delirium• Mini Cog• MoCA
• 7 D’s• KSBA
• FAST staging• selection/ monitoring sheets
Yes• Consider Atypicals (see psychotropic template)• Monitor Family Practice (DOS)• 7 “D”s
Tool Top 8
Approach
Tool Types
(Clinical Approach)
Cognitive assessment
Behavioural assessment
Overall assessment
K. LeClair
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Tools for Flagging High Risk Individuals
Detecting Dementia Medical Checklist Dementia Risk Calculator 10 Warning Signs for Caregivers 10 Warning Signs for Professionals
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Detecting Dementia Medical Checklist A. Identifying Populations at Risk
Is individual’s age greater than 75 years? Does individual have a family history of dementia? (Particularly
early onset dementia) Does individual have multiple vascular risk factors (Hypertension,
cholesterol, cardiac disease, smoker, obesity)?
(Consider Using Dementia Risk Calculator for Odds Ratios)
B. Identifying Individuals at Risk
Does the individual have/had…
A disorder with high rates of dementia? (I.e. Parkinson’s, AIDS, Huntington’s)
A history of delirium?
A history of late onset depression? (Particularly if depression had associated cognitive changes)
A recent stroke? (30% risk of dementia in 3 months)
MCI, Particularly amnesic MCI? (Note conversion rate 15% / year up to 45%)
A head injury?
An education <12 yrs? (versus >15 years)
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Detecting Dementia Medical Checklist
Definition: Adapted from literature and expert opinion to indicate medical areas that can be used as flags for possible dementia.
Detecting Dementia Medical Checklist
Link to Tool No Link Available
Time to Administer 2-3 Mins
Type Non Standardized Screening Tool
Setting Primary Care
Administration Review the individual’s medical history in the indicated areas to determine possible dementia
Interpretation If items are flagged consider more testing to determine if individual has a dementia
Reference
Adapted from: Patterson C., Feightner J, Garcia A, Hsiung G, MacKnight C, Sadovnick D. (2008) Diagnosis and treatment of dementia: 1. Risk assessment and primary prevention of Alzheimer’s Disease. Canadian Medical Association Journal. 178 (5) 548-556.
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Dementia Risk Calculator Risk = _____________ %
(Age)
AGE % <65 1 65 2 70 4 75 8 80 16 85 32
Family history (Risk doubles for each first degree relative) Mother x 1 (no family history) Father Risk =____% x 2 (1 relative) Brother (age) x 4 (2 relatives) Sister Risk = _____________ %
(Age + Family History) Vascular risk factors (Risk doubles for each vascular risk factor)
Atrial Fibrillation Diabetes Heart Disease (MI/CAD) x 1(no vascular risk factor) Hyperlipidemia Risk = ________% x 2 (1 vascular risk factor) Hypertension (age + family) x 4 (2 vascular risk factors) Smoking Stroke Obesity Risk = ______________%
(Age + Family History + Vascular Risk Factors)
Overall Risk = ______________%
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Dementia Risk Calculator
This short screening tool allows an overall risk score based on aggregate scores from the individual’s risk factors in three areas: Age, vascular risk factors, and family history. A positive score on the Calculator tool warrants further assessment with the Dementia Quick Screen. Dementia Risk Calculator
Link to Tool http://www.sagelink.ca/uploads/tools/DementiaRiskCalculator.pdfTime to Administer
1 - 2 minutes
Type Non-standardized screening tool.
Setting Primary care.
Administration Use the rule of "2" to calculate an elderly patient's risk of dementia: At age 65, the risk is "2%" and every 5 years increased age the risk increases by x 2: - Every vascular risk factor increases the risk x 2 - Every first degree relative with a history of dementia increases risk x 2
Interpretation Add age-associated risk, vascular factor-associated risk and family history-associated risk for an overall total risk. If total risk is > 15- 20%, then perform Dementia Quick Screen: http://www.sagelink.ca/uploads/tools/DementiaQuickScreen.pdf
• Three item recall – house, tree, car (0 - 1 correct) • Four-legged animal naming in one (1) minute (< 15) • Clock drawing (abnormal)
Reference De la Torre J.C. (2004). Is Alzheimer’s disease a neurodegenerative or a
vascular disorder? Data, dogma and dialectics. Lancet Neurology, 3, 184-190.
Gauthier S.J. (1997). Alzheimer disease: current knowledge, management and
research. Canadian Medical Association Journal, 157, 1047-52. Siu A . (1991). Screening for dementia and investigating its causes. Annals of
Internal Medicine, 115, 122-132.
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Completed Dementia Risk Calculator The dementia risk calculator is based on age, vascular risk factors, and family history of dementia (the doubling rule). For example, a 75-year-old man with a history of hypertension, whose mother had dementia, would score 32% risk of cognitive impairment. 8% (75 years of age) X2 (1 first degree relative) X 2 (1 vascular risk factor) = 32%
AGE % <65 1 65 2 70 4 75 8 80 16 85 32
Risk = _____8________ %
(Age)
Family history (Risk doubles for each first degree relative)
Mother x 1 (no family history) Father Risk =__8__% x 2 (1 relative) Brother (age) x 4 (2 relatives) Sister Risk = ______16______ %
(Age + Family History) Vascular risk factors (Risk doubles for each vascular risk factor)
Atrial Fibrillation Diabetes Heart Disease (MI/CAD) x 1(no vascular risk factor) Hyperlipidemia Risk = ____16____% x 2 (1 vascular risk factor) Hypertension (age+ family) x 4 (2 vascular risk factors) Smoking Stroke Obesity Risk = ______32______%
(Age + Family History + Vascular Risk Factors)
Overall Risk = _______32_______% *A risk >= 15% is high risk for cognitive impairment and justifies full cognitive assessment. The higher the risk of cognitive impairment by using the dementia risk calculator, the higher the chance that screening tests will reflect true positives rather than false positives.
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Trouble undersTanding visual images and spaTial relaTionshipsFor some people, having vision problems is a sign of Alzheimer’s. They may have difficulty reading, judging distance and determining color or contrast. In terms of perception, they may pass a mirror and think someone else is in the room. They may not realize they are the person in the mirror.What are typical age-related changes? Vision changes related to cataracts.
neW problems WiTh Words in speaking or WriTingPeople with Alzheimer’s may have trouble following or joining a conversation. They may stop in the middle of a conversation and have no idea how to continue or they may repeat themselves. They may struggle with vocabulary, have problems finding the right word or call things by the wrong name (e.g., calling a “watch” a “hand-clock”). What are typical age-related changes? Sometimes having trouble finding the right word.
misplacing Things and losing The abiliTy To reTrace sTepsA person with Alzheimer’s disease may put things in unusual places. They may lose things and be unable to go back over their steps to find them again. Sometimes, they may accuse others of stealing. This may occur more frequently over time.What are typical age-related changes? Misplacing things from time to time, such as a pair of glasses or the remote control.
decreased or poor judgmenTPeople with Alzheimer’s may experience changes in judgment or decision making. For example, they may use poor judgment when dealing with money, giving large amounts to telemarketers. They may pay less attention to grooming or keeping themselves clean.What are typical age-related changes? Making a bad decision once in a while.
If you or someone you care about is experiencing any
of the 10 warning signs, please see a doctor to find
the cause. Early diagnosis gives you a chance to seek
treatment and plan for your future.
your local alzheimer’s association can help. visit us at alz.org/10signs or call 877-is iT alZ.
WiThdraWal from Work or social acTiviTiesA person with Alzheimer’s may start to remove themselves from hobbies, social activities, work projects or sports. They may have trouble keeping up with a favorite sports team or remembering how to complete a favorite hobby. They may also avoid being social because of the changes they have experienced. What are typical age-related changes? Sometimes feeling weary of work, family and social obligations.
changes in mood and personaliTyThe mood and personalities of people with Alzheimer’s can change. They can become confused, suspicious, depressed, fearful or anxious. They may be easily upset at home, at work, with friends or in places where they are out of their comfort zone.What are typical age-related changes? Developing very specific ways of doing things and becoming irritable when a routine is disrupted.
note: Mood changes with age may also be a sign of some other condition. Consult a doctor if you observe any changes.
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10 Warning signs
memory changes ThaT disrupT daily lifeOne of the most common signs of Alzheimer’s, especially in the early stages, is forgetting recently learned information. Others include forgetting important dates or events; asking for the same information over and over; relying on memory aides (e.g., reminder notes or electronic devices) or family members for things they used to handle on their own.What are typical age-related changes? Sometimes forgetting names or appointments, but remembering them later.
challenges in planning or solving problemsSome people may experience changes in their ability to develop and follow a plan or work with numbers. They may have trouble following a familiar recipe or keeping track of monthly bills. They may have difficulty concentrating and take much longer to do things than they did before.What are typical age-related changes? Making occasional errors when balancing a checkbook.
difficulTy compleTing familiar Tasks aT home, aT Work or aT leisurePeople with Alzheimer’s often find it hard to complete daily tasks. Sometimes, people may have trouble driving to a familiar location, managing a budget at work or remembering the rules of a favorite game.What are typical age-related changes? Occasionally needing help to use the settings on a microwave or record a television show.
confusion WiTh Time or placePeople with Alzheimer’s can lose track of dates, seasons and the passage of time. They may have trouble understanding something if it is not happening immediately. Sometimes they may forget where they are or how they got there. What are typical age-related changes? Getting confused about the day of the week but figuring it out later.
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What’s the difference?
Your memory often changes as you grow older. But memory loss that disrupts daily life is not a typical part of aging. It may be a symptom of dementia. Dementia is a slow decline in memory, thinking and reasoning skills. The most common form of dementia is Alzheimer’s (AHLZ-high-merz) disease, a fatal disorder that results in the loss of brain cells and function.
This list can help you recognize the warning signs of Alzheimer’s:
It may be hard to know the difference between
age-related changes and the first signs of Alzheimer’s
disease. Ask yourself: Is this something new? For
example, if the person was never good at balancing
a checkbook, struggling with this task is probably
not a warning sign. But if their ability to balance
a checkbook has changed a lot, it is something to
share with a doctor.
Some people may recognize changes in themselves
before anyone else notices. Other times, friends and
family will be the first to observe changes in the
person’s memory, behavior or abilities.
To help, the Alzheimer’s Association has created this
list of warning signs for Alzheimer’s disease and
related dementias. Individuals may experience one or
more of these in different degrees. If you notice any
of them, please see a doctor.
memory changes that disrupt daily life
challenges in planning or solving problems
difficulty completing familiar tasks
confusion with time or place
Trouble understanding visual images and spatial relationships
new problems with words in speaking or writing
misplacing things and losing the ability to retrace steps
decreased or poor judgment
Withdrawal from work or social activities
changes in mood and personality
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for more information about the 10 warning signs, please contact the alzheimer’s association at 877-is iT alZ (877.474.8259) or visit alz.org/10signs.
The Alzheimer’s Association is the leading voluntary health organization in Alzheimer care, support and research. Our mission is to eliminate Alzheimer’s disease through the advancement of research; to provide and enhance care and support for all affected; and to reduce the risk of dementia through the promotion of brain health. Information is available 24/7 at www.alz.org or by calling our Helpline at 1.800.272.3900.
This is an official publication of the Alzheimer’s Association but may be distributed by unaffiliated organizations and individuals. Such distribution does not constitute an
endorsement of these parties or their activities by the Alzheimer’s Association.
© 2009 Alzheimer’s Association. All rights reserved. 031909.3 773-10-0002
SignS of Alzheimer’S/ DementiA
Poor judgment and decision making
Inability to manage a budget
Losing track of the date or the season
Difficulty having a conversation
Misplacing things and being unable to retrace
steps to find them
typicAl Age-relAteD chAngeS
Making a bad decision once in a while
Missing a monthly payment
Forgetting which day it is and remembering later
Sometimes forgetting which word to use
Losing things from time to time
W I N N E R 2 0 0 8
10 warning signs of alzheimer’s disease©
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10 Warning Signs for Dementia Health Professionals
Can Detect
1. Frequent phone calls/appointments – missing / wrong day
2. Poor historian, vague, seems “off, repetitive questions
or stories
3. Poor compliance meds/instructions
4. Altered appearance / mood / personality / behaviour
5. New passivity - Head turning sign (turning to caregiver for answer)
6. Decline in language skills
7. Unexplained change in function
8. Delirium - surgery/illness/meds
9. Weight loss/dwindles/ “failure to thrive”
10.Driving concerns – accident / problems / tickets/family
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Tools for Dementia Assessment/ Management Detecting Dementia / Cognitive Impairment: Recommended Tools
Mini Cog Plus Montreal Cognitive Assessment (MoCA) Clock Drawing
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Mini Cog Plus
- Probing all Lobes It is important to have sensitive tests that will reveal the functioning of the major parts of the brain.
Parietal Visuospatial Clock
Frontal -Word Generation
Occipital Visual Memory
Temporal (Hippocampal) Recall
A
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Patient Name:
Mini Cog for Primary Care Practitioner A) What year is it? B) Registration House Tree Car C) Clock (See attached) D) Recall Spontaneous Cueing House Tree Car E) Animal 4 legged in 1 minute (N) 15
F) Visual Memory Cue 1:
Date Completed:
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Mini-Cog
This test combines a three-item recall with a Clock Drawing Test (CDT) as a quick measure of cognitive function. It is relatively uninfluenced by level of education or language variations. Mini-cog
Link to Tool http://www.sagelink.ca/uploads/tools/MiniCog.pdf
Time to Administer
3 minutes
Type Standardized assessment tool.
Setting Primary Care, Emergency, and other settings where rapid cognitive assessment is required.
Administration 1. Three-item recall: Ask the individual to remember the following three words to be recalled later:
House Tree Car
2. Clock drawing test: “Draw a clock. Put in all the numbers and set the time to 10 after 11.” The CDT serves as the distractor for the three-item recall.
3. Three-item recall: ____________ ____________ ______________ Give 1 point for each recalled word after the CDT distractor. Score 1–3. Interpretation
A score of O indicates positive screen for dementia. A score of 1 or 2 with an abnormal CDT indicates positive screen for dementia. A score of 1 or 2 with a normal CDT indicates negative screen for dementia. A score of 3 indicates negative screen for dementia.
The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands display the requested time with one shorter and one longer hand. There are a number of scoring methods described in the following link:
http://www.neurosurvival.ca/ClinicalAssistant/scales/clock_drawing_test.htm#scoringmethods
Clock errors may be divided into categories including visuo-spatial, perseveration, and gross disorganization. Common errors in Alzheimer's disease include perseveration, counter-clockwise numbering, absence of numbers and irrelevant spatial arrangement. Errors following stroke may reflect spatial neglect, hemianopsia and sensory loss, in addition to errors suggestive of cognitive dysfunction. A variety of psychiatric conditions such as depression and schizophrenia contribute potentially to abnormal clock drawing.
Reference Borson, S., Scanlan, J., Brush, M., Vitaliano, P., & Dokmak, A. (2000). The mini-cog: a
cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry, 15(11),1021–1027.
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Individual’s Name:__________________________
Date: ___________________
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Individual’s Name: __________________________
Date: _______________
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POINTS
TOTAL
M E M O R Y
N A M I N G
VISUOSPATIAL / EXECUTIVE
ATTENTION
LANGUAGE
ABSTRACTION
DELAYED RECALL
ORIENTATION
Read list of words, subject must repeat them. Do 2 trials. Do a recall after 5 minutes.
Subject has to repeat them in the forward order [ ] 2 1 8 5 4Subject has to repeat them in the backward order [ ] 7 4 2
Read list of letters. The subject must tap with his hand at each letter A. No points if ≥ 2 errors
[ ] F B A C M N A A J K L B A F A K D E A A A J A M O F A A B
Serial 7 subtraction starting at 100 [ ] 93 [ ] 86 [ ] 79 [ ] 72 [ ] 65
Repeat : I only know that John is the one to help today. [ ]The cat always hid under the couch when dogs were in the room. [ ]
Similarity between e.g. banana - orange = fruit [ ] train – bicycle [ ] watch - ruler
Draw CLOCK (Ten past eleven)Copy cube
__/5
__/3
Nopoints
1st trial
2nd trial
FACE VELVET CHURCH DAISY RED
__/5
__/2
__/1
__/3
__/2
Fluency / Name maximum number of words in one minute that begin with the letter F _____ [ ] (N ≥ 11 words) __/1
__/2
__/6
__/30
B
Begin
End5
E
1
A
2
4 3
C
D
Read list of digits (1 digit/ sec.).
NAME :Education :
Sex :Date of birth :
DATE :
© Z.Nasreddine MD Version 7.0 www.mocatest.org Normal ≥ 26 / 30
Add 1 point if ≤ 12 yr edu
MONTREAL COGNITIVE ASSESSMENT (MOCA)
[ ] Date [ ] Month [ ] Year [ ] Day [ ] Place [ ] City
[ ]Contour
[ ][ ] [ ]Numbers
[ ]Hands
[ ] [ ] [ ]
4 or 5 correct subtractions: 3 pts, 2 or 3 correct: 2 pts, 1 correct: 1 pt, 0 correct: 0 pt
( 3 points )
Category cue
Points for UNCUED
recall onlyWITH NO CUE
Optional
Has to recall words
Multiple choice cue
FACE VELVET CHURCH DAISY RED[ ] [ ] [ ] [ ] [ ]
Administered by: ___________________________________________________
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Montreal Cognitive Assessment [MoCA]
The MoCA has been designed as a screening instrument for mild cognitive dysfunction and is readily available in 17 languages via the internet. This tool has been standardized and normative data has been collected. Clinical utility of this tool is based upon the ease of availability, presence of normative data, ease of clinical administration and the fact that the clinician requires only the form and writing implement for administration. This tool can be used to screen for cognitive deficits in the absence of delirium. It is valuable to track and monitor cognitive functioning over a period of time. Montreal Cognitive Assessment (MoCA)
Link to Tool http://www.mocatest.org/pdf_files/MOCA-Test-English.pdf
Time to Administer
10 Minutes
Type Standardized assessment tool.
Setting This tool is useful in any practice setting for assessment of cognition including attention, concentration, executive function, memory, language, visuo-constructional skills, conceptual thinking, calculations and orientation.
Administration Detailed administration instructions in 21 languages are available through the following link: http://www.mocatest.org/default.asp Normative data is available through the following link: http://www.mocatest.org/validation_study.html
Interpretation
The screen is scored out of 30 where a score of 26 or above is considered normal. Use of this screen may indicate the need for further assessment, intervention and/or referral to specialized services.
Interpretation Data: Normal MCI AD Average MoCA 27.4 (+/-2.2) 22.1 (+/- 3.1) 16.2 (+/- 4.8) MoCA Score Range 25.2-29.6 19.0-25.2 11.4-21.0
Suggested Cut Off
≥ 26
Usually 21 - 25 Usually < 20 Presence of
Functional (IADL) losses
A full reference list is available through the following link: http://www.mocatest.org/references.html
Reference
Nasreddine, Z.S., Phillips, N.A., Bedirian, V., Charbonneau, S., Whitehead, V., Collin,
I., Cummings, J.L. and Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatric Society, 53(4), 695-699.
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MoCA Version November 12, 2004 © Z. Nasreddine MD
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Montreal Cognitive Assessment
(MoCA)
Administration and Scoring Instructions The Montreal Cognitive Assessment (MoCA) was designed as a rapid screening instrument for mild cognitive dysfunction. It assesses different cognitive domains: attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. Time to administer the MoCA is approximately 10 minutes. The total possible score is 30 points; a score of 26 or above is considered normal. 1. Alternating Trail Making:
Administration: The examiner instructs the subject: "Please draw a line, going from a number to a letter in ascending order. Begin here [point to (1)] and draw a line from 1 then to A then to 2 and so on. End here [point to (E)]."
Scoring: Allocate one point if the subject successfully draws the following pattern: 1 −A- 2- B- 3- C- 4- D- 5- E, without drawing any lines that cross. Any error that is not immediately self-corrected earns a score of 0.
2. Visuoconstructional Skills (Cube):
Administration: The examiner gives the following instructions, pointing to the cube: “Copy this drawing as accurately as you can, in the space below”.
Scoring: One point is allocated for a correctly executed drawing.
• Drawing must be three-dimensional • All lines are drawn • No line is added • Lines are relatively parallel and their length is similar (rectangular prisms are
accepted) A point is not assigned if any of the above-criteria are not met.
3. Visuoconstructional Skills (Clock):
Administration: Indicate the right third of the space and give the following instructions: “Draw a clock. Put in all the numbers and set the time to 10 after 11”.
Scoring: One point is allocated for each of the following three criteria:
Contour (1 pt.): the clock face must be a circle with only minor distortion acceptable (e.g., slight imperfection on closing the circle);
Numbers (1 pt.): all clock numbers must be present with no additional numbers; numbers must be in the correct order and placed in the approximate quadrants on the clock face; Roman numerals are acceptable; numbers can be placed outside the circle contour;
Hands (1 pt.): there must be two hands jointly indicating the correct time; the hour hand must be clearly shorter than the minute hand; hands must be centred within the clock face with their junction close to the clock centre.
A point is not assigned for a given element if any of the above-criteria are not met.
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4. Naming:
Administration: Beginning on the left, point to each figure and say: “Tell me the name of this animal”.
Scoring: One point each is given for the following responses: (1) camel or dromedary, (2)
lion, (3) rhinoceros or rhino. 5. Memory:
Administration: The examiner reads a list of 5 words at a rate of one per second, giving the following instructions: “This is a memory test. I am going to read a list of words that you will have to remember now and later on. Listen carefully. When I am through, tell me as many words as you can remember. It doesn’t matter in what order you say them”. Mark a check in the allocated space for each word the subject produces on this first trial. When the subject indicates that (s)he has finished (has recalled all words), or can recall no more words, read the list a second time with the following instructions: “I am going to read the same list for a second time. Try to remember and tell me as many words as you can, including words you said the first time.” Put a check in the allocated space for each word the subject recalls after the second trial. At the end of the second trial, inform the subject that (s)he will be asked to recall these words again by saying, “I will ask you to recall those words again at the end of the test.”
Scoring: No points are given for Trials One and Two. 6. Attention:
Forward Digit Span: Administration: Give the following instruction: “I am going to say some numbers and when I am through, repeat them to me exactly as I said them”. Read the five number sequence at a rate of one digit per second. Backward Digit Span: Administration: Give the following instruction: “Now I am going to say some more numbers, but when I am through you must repeat them to me in the backwards order.” Read the three number sequence at a rate of one digit per second.
Scoring: Allocate one point for each sequence correctly repeated, (N.B.: the correct response for the backwards trial is 2-4-7).
Vigilance: Administration: The examiner reads the list of letters at a rate of one per second, after giving the following instruction: “I am going to read a sequence of letters. Every time I say the letter A, tap your hand once. If I say a different letter, do not tap your hand”.
Scoring: Give one point if there is zero to one errors (an error is a tap on a wrong letter or a failure to tap on letter A).
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Serial 7s: Administration: The examiner gives the following instruction: “Now, I will ask you to count by subtracting seven from 100, and then, keep subtracting seven from your answer until I tell you to stop.” Give this instruction twice if necessary.
Scoring: This item is scored out of 3 points. Give no (0) points for no correct subtractions, 1 point for one correction subtraction, 2 points for two-to-three correct subtractions, and 3 points if the participant successfully makes four or five correct subtractions. Count each correct subtraction of 7 beginning at 100. Each subtraction is evaluated independently; that is, if the participant responds with an incorrect number but continues to correctly subtract 7 from it, give a point for each correct subtraction. For example, a participant may respond “92 – 85 – 78 – 71 – 64” where the “92” is incorrect, but all subsequent numbers are subtracted correctly. This is one error and the item would be given a score of 3.
7. Sentence repetition:
Administration: The examiner gives the following instructions: “I am going to read you a sentence. Repeat it after me, exactly as I say it [pause]: I only know that John is the one to help today.” Following the response, say: “Now I am going to read you another sentence. Repeat it after me, exactly as I say it [pause]: The cat always hid under the couch when dogs were in the room.”
Scoring: Allocate 1 point for each sentence correctly repeated. Repetition must be exact. Be alert for errors that are omissions (e.g., omitting "only", "always") and substitutions/additions (e.g., "John is the one who helped today;" substituting "hides" for "hid", altering plurals, etc.).
8. Verbal fluency: Administration: The examiner gives the following instruction: “Tell me as many words as you can think of that begin with a certain letter of the alphabet that I will tell you in a moment. You can say any kind of word you want, except for proper nouns (like Bob or Boston), numbers, or words that begin with the same sound but have a different suffix, for example, love, lover, loving. I will tell you to stop after one minute. Are you ready? [Pause] Now, tell me as many words as you can think of that begin with the letter F. [time for 60 sec]. Stop.”
Scoring: Allocate one point if the subject generates 11 words or more in 60 sec. Record the subject’s response in the bottom or side margins.
9. Abstraction:
Administration: The examiner asks the subject to explain what each pair of words has in common, starting with the example: “Tell me how an orange and a banana are alike”. If the subject answers in a concrete manner, then say only one additional time: “Tell me another way in which those items are alike”. If the subject does not give the appropriate response (fruit), say, “Yes, and they are also both fruit.” Do not give any additional instructions or clarification. After the practice trial, say: “Now, tell me how a train and a bicycle are alike”. Following the response, administer the second trial, saying: “Now tell me how a ruler and a watch are alike”. Do not give any additional instructions or prompts.
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Scoring: Only the last two item pairs are scored. Give 1 point to each item pair correctly answered. The following responses are acceptable: Train-bicycle = means of transportation, means of travelling, you take trips in both; Ruler-watch = measuring instruments, used to measure. The following responses are not acceptable: Train-bicycle = they have wheels; Ruler-watch = they have numbers.
10. Delayed recall:
Administration: The examiner gives the following instruction: “I read some words to you earlier, which I asked you to remember. Tell me as many of those words as you can remember. Make a check mark ( ) for each of the words correctly recalled spontaneously without any cues, in the allocated space. Scoring: Allocate 1 point for each word recalled freely without any cues. Optional: Following the delayed free recall trial, prompt the subject with the semantic category cue provided below for any word not recalled. Make a check mark ( ) in the allocated space if the subject remembered the word with the help of a category or multiple-choice cue. Prompt all non-recalled words in this manner. If the subject does not recall the word after the category cue, give him/her a multiple choice trial, using the following example instruction, “Which of the following words do you think it was, NOSE, FACE, or HAND?” Use the following category and/or multiple-choice cues for each word, when appropriate: FACE: category cue: part of the body multiple choice: nose, face, hand VELVET: category cue: type of fabric multiple choice: denim, cotton, velvet CHURCH: category cue: type of building multiple choice: church, school, hospital DAISY: category cue: type of flower multiple choice: rose, daisy, tulip RED: category cue: a colour multiple choice: red, blue, green Scoring: No points are allocated for words recalled with a cue. A cue is used for clinical information purposes only and can give the test interpreter additional information about the type of memory disorder. For memory deficits due to retrieval failures, performance can be improved with a cue. For memory deficits due to encoding failures, performance does not improve with a cue.
11. Orientation:
Administration: The examiner gives the following instructions: “Tell me the date today”. If the subject does not give a complete answer, then prompt accordingly by saying: “Tell me the [year, month, exact date, and day of the week].” Then say: “Now, tell me the name of this place, and which city it is in.” Scoring: Give one point for each item correctly answered. The subject must tell the exact date and the exact place (name of hospital, clinic, office). No points are allocated if subject makes an error of one day for the day and date. TOTAL SCORE: Sum all subscores listed on the right-hand side. Add one point for an individual who has 12 years or fewer of formal education, for a possible maximum of 30 points. A final total score of 26 and above is considered normal.
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Clock Drawing A
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Clock Drawing Test
This test provides a quick screening test for cognitive dysfunction (frontal and temporo parietal functioning) secondary to dementia, delirium, or a range of neurological and psychiatric illnesses. It is a component of the minicog assessment, also serving the function of distracter for the threeword recall.
Clock Drawing Test
Link to Tool http://www.sagelink.ca/uploads/tools/ClockDrawingTest.pdf
Time to Administer
1 2 minutes
Type Standardized screening instrument.
Setting A variety of settings including primary care, acute care, community, outpatient/ rehab, and long term care. It is particularly useful in general practice.
Administration 1. Provide individual with a piece of paper with a predrawn circle of approximately 10 cm in diameter.
2. Indicate that the circle represents the face of a clock and ask the individual to put in the numbers so that it looks like a clock
3. Ask the individual to add arms so that the clock indicates the time “ten minutes after eleven”
These instructions can be repeated but no additional instructions should be given. Give the individual as much time as needed to complete the task.
Interpretation NORMAL ABNORMAL Mild Moderate Severe
Mild irregularities of number placement are acceptable as normal
Commonly, early dementia is associated with drawing hands towards the 11 and 10; this perseveration towards 10 is an example of problems with executive function
Abnormalities of number and hand placement
Severe abnormalities
*The odds ratio for cognitive impairment with abnormal clock drawing is 24X
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The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands display the requested time with one shorter and one longer hand. There is some variation in scoring methodology.
Clock errors may be divided into categories including visuospatial, perseveration, and gross disorganization. Common errors in Alzheimer's disease include perseveration, counter clockwise numbering, absence of numbers and irrelevant spatial arrangement. Errors following stroke may reflect spatial neglect, hemianopsia and sensory loss, in addition to errors suggestive of cognitive dysfunction. A variety of psychiatric conditions such as depression and schizophrenia contribute potentially to abnormal clockdrawing.
Reference Borson, S, Scanlan, J., Brush, M., Vitaliano, P., Dokmak, A., The minicog: a cognitive “vital signs” measure for dementia screening in multilingual elderly. Int J Geriatric Psychiatry 2000; 15 (11): 10211027.
Siu, AL. Screening for dementia and investigating its causes. Ann Intern Med 1991; 115: 122 132.
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Other Tools for Detecting Dementia / Cognitive Impairment
Mini Mental State Exam (MMSE)
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Folstein Mini-Mental State Examination (MMSE)
The Test
The MMSE was developed 30 years ago as a rapid screening test for cognitive function. It emphasizes the typical changes seen in Alzheimer’s disease (memory/orientation) as opposed to the early changes seen in the non-Alzheimer’s dementias (vascular, Lewy body, frontotemporal which are: executive function problems - frontal lobe: putting the hands on the clock, animal naming, Trails A and B which test SOAP—Strategizing, Organizing, Abstract thinking, Planning).
Strengths:
• Widely used, short (7 minutes), tests memory, orientation, naming, visuospatial, and attention.
Weaknesses:
• Focuses on few domains (little visuospatial, no executive function) • Poor at upper end of cognitive ability (ie, poor discrimination of normal vs MCI vs early
dementia) • Cut-off norms require adjustments based on the patient’s age and especially education—
particularly with a less than grade nine education • The MMSE is much more suitable to assess domains affected by Alzheimer’s disease than
by non-Alzheimer’s dementias Interpretation
• A score < 24 is suggestive of cognitive impairment/dementia. • Serial 7s vs spelling “world” backwards: The instructions call for the use of serial 7s
unless the person refuses, in which case spelling “world” backwards is a substitute. Alternatively, both tests can be done and recorded separately. Typically, patients score 1 to 2 points better with spelling “world” backwards.
• Based on the person’s history and functional issues, you may expect a certain MMSE (e.g. 17 to 18), but if the person scores much higher (e.g, 22 to 23 or more), suspect non-Alzheimer’s dementia. This is because the MMSE does not test the common problem areas seen in the non-Alzheimer’s dementias (executive function / visuospatial). In this situation, the MOCA is a much superior test.
Mean MMSE Scores
Years of Education Age
0-4 5-8 9-12 ∫College 65-69 22 26 28 29
70-74 22 26 27 28
75-79 21 25 27 28
80-84 20 25 25 27
85 19 23 26 27
A
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The Mini Mental State Examination (MMSE)
The Mini Mental State Examination (MMSE) is a tool that can be used to systematically and thoroughly assess mental status. It is an 11-question measure that tests five areas of cognitive function: Orientation, registration, attention and calculation, recall, and language. Permission to use tool and training is required. The Mini Mental State Examination (MMSE)
Link to Tool The tool: http://www.chcr.brown.edu/MMSE.PDF * Permission is hereby granted to reproduce this material for not-for-profit educational purposes only, provided The Hartford Institute for Geriatric Nursing, Division of Nursing, New York University is cited as the source. Available on the internet at www.hartfordign.org. E-mail notification of usage to: [email protected]. Instructions on administering the MMSE: http://www.palliative.org/PC/ClinicalInfo/AssessmentTools/instruct%20for%20admin%20mmse.pdf
Time to Administer
10 minutes
Type Standardized Screening Tool.
Setting Mental status screen for community dwelling, hospitalized and institutionalized elderly adults.
Administration 11-item measure administered by interview.
Interpretation Maximum score is 30. Scores of 23 or lower indicate cognitive impairment.
References Folstein, M., Folstein, S.E., McHugh, P.R. (1975). “Mini-Mental State” a Practical Method for Grading the Cognitive State of Patients for the Clinician. Journal of Psychiatric Research, 12(3), 189-198.
The Hartford Institute for Geriatric Nursing, Division of Nursing, New York,
www.hartfordign.org
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Tools for Determining Type of Dementia
Types of Dementia
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Types of Dementia
(Clinical features which should suggest a diagnosis other than Alzheimer’s)
Focal neurological symptoms Vascular Dementia Focal neurological signs Cognitive decline within 3 months of SVA/ TIA Abrupt onset/ stepwise decline Previous CVA or TIA
Visual hallucinations: detailed/ recurrent Lewy Body Dementia Pronounced fluctuation in cognition over hours/ days Parkinsonism (especially rigidity)/ bradykinesia Executive function worse than memory Neuroleptic sensitivity Unexplained falls / loss of consciousness
Impulsivity / poor judgment Frontotemporal Dementia Behavioural changes: disinhibition / apathy Self-neglect / socially inappropriate Executive function worse than memory Language problems
Abnormal gait (magnetic apraxia) Normal Pressure Incontinence early in course of dementia Hydrocephalus (NPH) Rapidly progressing dementia
B
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Types of Dementia
Definition: A template to indicate differences in presentation and symptoms of dementias other than Alzheimer’s Disease.
Types of Dementia
Link to Tool No Link Available
Time to Administer 5 mins
Type Non Standardized Assessment Tool
Setting Primary Care
Administration Use the checklist to assess symptoms and presentation
Reference
Adapted from: Patterson CJ, Gauthier S, Bergman H, et al.(1999). The recognition, assessment and management of dementing disorders: conclusions from the Canadian Consensus Conference on Dementia. CMAJ 160 (12 suppl): S1-S15
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Tools for Determining Staging of Dementia
Functional Assessment Staging (FAST)
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Functional Assessment Staging (FAST) Patient Name:________________________________________________________ Health card # ___________________ Date:____________ Period:______________ Physician Name: _______________________________________ Information gathered from: Patient OR Other: please specify relationship to patient ______________________________________ (If an Item is assessed as being due to other causes apart from dementia (paralysis, arthritis, etc.), please check “No” and note these other causes next to the item. Yes Months1 No1. No difficulties, either subjectively or objectively 2. Complaints of forgetting location of objects; subjective work
difficulties
3. Decreased job functioning evident to coworkers; difficulty in traveling to new locations
4. Decreased ability to perform complex tasks 5. Requires assistance in choosing proper clothing 6. a. Difficulty putting clothing on properly b. Unable to bathe properly; may develop fear of bathing
c. Inability to handle mechanics of toileting (i.e. forgets to flush, doesn’t wipe properly)
d. Urinary incontinence e. Fecal incontinence 7. a. Ability to speak limited (1 to 5 words a day) b. All intelligible vocabulary lost c. Non-ambulatory d. Unable to sit up independently e. Unable to smile f. Unable to hold head up Tester: ________________________________________________________________ Comments: ____________________________________________________________ ______________________________________________________________________ Note: Functional staging score = Highest ordinal value 1 Number of months FAST stage deficit has been noted
.
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Diagnosing Severe AD: Functional Assessment Staging
FAST Scale Stage
Characteristics
1. Normal adult No functional decline.
2. Normal older adult
Personal awareness of functional decline.
3. Early AD
Noticeable deficits in demanding job situations.
4. Mild AD
Requires assistance in complicated tasks such as handling finances, planning parties, etc. (IADL’S*)
5. Moderate AD
Requires assistance in choosing proper attire. (ADL’S*)
6. Moderate-Severe AD
Requires assistance dressing, bathing, and toileting. Experiences urinary and fecal incontinence.
7. Severe AD
Speech ability declines to about a half-dozen intelligible words. Progressive loss of abilities to walk, sit up, smile, and hold head up.
IADL’S (SHAFT-M) ADL’S (DEATH) S Shopping D Dressing H Household E Eating A Accounting A Ambulation F Food Preparation T Toiliting T Transportation H Hygeine M Medication
Seve
rity
A
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Functional Assessment Staging [FAST]
This “staging” tool evaluates functional deterioration in individuals living with Alzheimer’s Disease (AD) throughout the entire course of the illness. Functional Assessment Staging (FAST)
Link to Tool http://www.acsu.buffalo.edu/~drstall/fast.html
Time to Administer
1 - 5 minutes (estimate)
Type Standardized assessment tool.
Setting Can be used in any practice setting as a staging tool for individuals living with AD. Also, as the elements of functional capacity used in FAST are relatively universal, and characteristic of the course of AD, the tool can serve as a strong diagnostic and differential diagnostic aid for clinicians.
Administration 16-item questionnaire completed by clinician primarily on the basis of information obtained from a knowledgeable informant and/or caregiver. Results allow classification of individual’s disability into one of seven possible stages:
Stage 1 – Normal Stage 2 – Normal with mild memory loss Stage 3 – Early AD Stage 4 – Mild AD Stage 5 – Moderate AD Stage 6 – Moderately Severe AD Stage 7 – Severe AD
Interpretation Descriptive behaviours/symptoms are given for each of the seven stages.
Scorer selects highest consecutive level of disability.
Reference Reisburg, B. (1988). Functional assessment staging (FAST). Psychopharmacology Bulletin, 24, 653-659.
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Lawton-Brody
he Physical Self-Maintenance Scale T
A. Toilet 1. Cares for self at toilet completely, no incontinence. 2. Needs to be reminded, or needs help in cleaning self, or has rare (weekly at
most) accidents. 3. Soiling or wetting while asleep more than once a week. 4. Soiling or wetting while awake more than once a week. 5. No control of bowels or bladder.
B. Feeding 1. Eats without assistance. 2. Eats with minor assistance at meal times and/or with special preparation of food,
or help in cleaning up after meals. 3. Feeds self with moderate assistance and us untidy. 4. Requires extensive assistance for all meals. 5. Does not feed self at all and resists efforts of others to feed him.
C. Dressing 1. Dresses, undresses and selects clothes from own wardrobe. 2. Dresses and undresses self, with minor assistance. 3. Needs moderate assistance in dressing or selection of clothes. 4. Needs major assistance in dressing, but cooperates with efforts of others to help. 5. Completely unable to dress self and resists efforts of others to help.
D. Grooming 1. Always neatly dressed, well-groomed, without assistance. 2. Grooms self adequately with occasional minor assistance (e.g. shaving). 3. Needs moderate and regular assistance or supervision in grooming. 4. Needs total grooming care, but can remain well-groomed after help from others. 5. Activity negates all efforts of others to maintain grooming.
E. Physical Ambulation 1. Goes about grounds or city. 2. Ambulates within residence or about one block distant. 3. Ambulates with assistance of (check one) a. ( ) another person b. ( ) railing c. ( )
cane d. ( ) walker e. ( ) wheelchair 4. Sits unsupported in chair or wheelchair, but cannot propel self without help. 5. Bedridden more than half the time.
F. Bathing 1. Bathes self (tub, shower, sponge bath) without help. 2. Bathes self with help in getting in and out of the tub. 3. Washes face and hands only, but cannot bathe rest of body. 4. Does not wash self but is cooperative with those who bathe him. 5. Does not try to wash self and resists efforts to keep him clean.
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Activities of Daily Living Scale
A. Ability to use Telephone 1. Operates telephone on own initiative – looks up and dials numbers, etc. 2. Dials a few well-known numbers. 3. Answers telephone but does not dial. 4
. Does not use telephone at all.
B. Shopping 1. Takes care of all shopping needs independently. 2. Shops independently for small purchases. 3. Needs to be accompanied on any shopping trip. 4 . Completely unable to shop.
C. Food Preparation 1. Plans, prepares and serves adequate meals independently. 2. Prepares adequate meals if supplies with ingredients. 3. Heats and serves prepared meals, or prepares meals but does not maintain
adequate diet. 4
. Needs to have meals prepared and served.
D. Housekeeping 1. Maintains house alone or with occasional assistance (e.g. “heavy work-domestic
help”) 2. Performs light daily tasks such as dish washing, bed making. 3. Performs light daily tasks but cannot maintain acceptable level of cleanliness. 4. Needs help with all home maintenance tasks. 5
. Does not participate in any housekeeping tasks.
E. Laundry 1. Does personal laundry completely. 2. Launders small items – rinses socks, stockings, etc. 3
. All laundry must be done by others.
F. Mode of Transportation 1. Travels independently on public transportation or drives own car. 2. Arranges own travel via taxi, but does not otherwise use public transportation. 3. Travels on public transportation when assisted or accompanied by another. 4. Travel to limited to taxi or automobile with assistance of another. 5
. Does not travel at all.
G. Responsibility for own Medication 1. Is responsible for taking medication in correct dosages at correct time. 2. Takes responsibility if medication is prepared in advance in separate dosages. 3. Is not capable of dispensing own medication.
H. Ability to Handle Finances 1. Manages financial matters independently (budgets, writes checks, pays rent,
bills, goes to bank), collects and keeps track of income. 2. Manages day-to-day purchases, but needs help with banking, major purchases,
etc. 3. Incapable of handling money.
Date:__________________________ Signature :_____________________________
A
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Lawton-Brody
Definition: The Lawton Brody was developed in 1988 in Philadelphia at the Philadelphia Geriatric Center as part of their multilevel Assessment Instrument. This tool is primarily used to assist in assessing Functional status or the ability to perform self-care, self-maintenance and physical activities. There are several tools utilized to assess functional status that are very similar to the Lawton-Brody including the Independent Activities of Daily Living Scale and the Functional Activities Scale.
Lawton-Brody
Link to Tool IADLS Version: http://headford.com.au/hcc/materials/IADLlawtonbrody.pdf
Time to Administer N/A
Type Non Standardized Assessment Tool
Setting Primary Care
Administration
• Self-administered by the client/resident or administered by the caregiver
• Each category is reviewed and the highest level of function is circled • Scale is signed and dated
Reference Lawton MP, Brody EM. (1969) Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 9(3):179–86.
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Investigations and Labs
Investigations and Labs
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Name:__________________ Date: ____________
Investigation & Labs for Screening Dementia Basic laboratory tests Results
Complete blood count
TSH
Serum electrolytes BUN, Creatine
Serum calcium
Serum glucose levels
Vitamin B12
Neuroimaging in dementia Results
Consider CT scan (see below)
CT Scan Checklist
*Note: CT scan recommended if 1 or more of the following criteria are present age at dementia onset < 60 focal neurological signs rapid progression of dementia recent head trauma use of anticoagulants history of urinary incontinence and gait disorder early in course short duration of dementia (less than 2 years) unexplained neurological symptoms history of cancer (especially in sites and types that metastasize the brain) any new localizing sign (e.g. hemiparesis or a Babinski reflex) unusual or atypical cognitive symptoms or presentation (e.g. progressive aphasia)
Neuroimaging also recommended to evaluate for concomitant cerebrovascular disease as this may affect subsequent management
(see reverse for additional tests)
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Optional additional tests that may be helpful to diagnose specific causes of dementia
Test (measurement of…) Results
Amonia
Blood gases
Drug levels
Erythrocyte sedimentation rate
Folic acid
Heavy metal levels
Serum cortisol
Serum lipids
Urea nitrogen/ creatine
Water soluble vitamins
Carotid Doppler studies
Chest radiography
Electrocardiography
Electroencephalography
Lumbar puncture
Mammography
Serologic tests for syphilis
Test for HIV PET Scan SPECT Scan
B
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Investigations and Labs
Definition: Based on literature, the Third Annual Canadian Consensus Conference on Diagnosis and Treatment of Dementia and expert opinion, this checklist is for physicians to compile a comprehensive and thorough chart of medical testing and results throughout the screening of dementia.
Investigations and Labs
Link to Tool No Link Available
Time to Administer N/A
Type Non Standardized Screening Checklist
Setting Primary Care
Administration 1.If a dementia is suspected, the indicated tests are recommended. 2.Record results on checklist
Reference
Bergman et al. (2006) Third canadian consensus conference on diagnosis and treatment of dementia. Retrieved August 26th 2008 from <http://www.cccdtd.ca/cccdtd/pdfs/Final_Recommendations_CCCDTD_2007.pdf>
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Dementia Collaborative Care Tools
Three-Question Template & Summary of U-FIRST / P.I.E.C.E.S.
P.I.E.C.E.S Aid for Family Physicians Kingston Standardized Behavioural Assessment (KSBA) Is It Alzheimer’s Disease? 10 Warning Signs Dementia Observation System (DOS) Dementia Observation System (DOS) for Families 7 D’s to Define Severity: Monitoring Response for
Behaviour and Psychosis U-FIRST Wheel
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The P.I.E.C.E.S. Three-Question Template
Q. 1 What has changed? Q. 2 What are the RISKS and possible causes? Q. 3 What is the action ?
Question Approach, Guidelines and Tools
What has changed?
Avoid assumptions; Think atypical!
Avoid assumptions Always ask, what has changed? Determine if the problem/behaviour represents a change • Is the problem/behaviour new? If so, in what way and when did the change emerge? • Did the problem/behaviour already exist? If so, is it worse or different, and when did the change emerge? • Is the problem/behaviour long-standing and unchanged? If so, what else could have changed, for example,
caregiver stress?
Remember to think atypical! Atypical presentations are very common in older persons.
What are the RISKS and
possible causes?
Think P.I.E.C.E.S.
Remember! Almost always
multiple reasons for behaviour.
1. Identify the RISKS and avoid assumptions! • Is there a risk? And if so for whom? Person, other individuals, staff, family, visitors • What is the risk? Remember the types of risks by using the acronym RISKS:
R I S K
S
Roaming (wandering) Imminent physical; risk of harm - frailty (e.g. delirium), falls, fire, firearms Suicide Ideation Kinship Relationships (risk of harm by the older person or to the older person by others that includes avoidance of the person) Self-neglect, safe driving, and substance abuse
• What is the degree of risk? How imminent is the risk? Is the risk increasing? • Remember! For any intervention, consider both the potential risks and potential benefits. Be vigilant and
carefully observe and assess the individual’s capacity to understand. 2. Remember, consider atypical presentation! Use P.I.E.C.E.S. to identify possible causes:
Physical Intellectual Emotional Capabilities Environment Social
5 D’s: Delirium, Disease, Drugs, Discomfort, Disability 7 A’s: Amnesia, Aphasia, Apathy, Agnosia, Apraxia, Anosognosia, Altered Perception 4D’s: Disorder Adjustment, Disorders of Mood, Delusional, Disorders of Personality ADL’s, IADL’s Consider: over/under stimulation, relocation, change in routine, noise, lighting, colours Consider: social network, life story, cultural heritage
3. Remember, all behaviour has meaning! Use “P.I.E.C.E.S.” to help you remember!
What is the Action?
1. Use the 3 “I”s – Interventions, Interactions, and Information to guide action.
Intervention: What therapeutic approach, both nonpharmacological and pharmacological, may best address the person’s needs? What other investigations need to be undertaken? Use P.I.E.C.E.S.! Interaction: Using what has changed and understanding of causes for interaction at bedside.
Information: Think P.I.E.C.E.S.! What information should be shared with other team members, family, if the person is moved or requires transfer? How is the information shared? What are RISKS Factors?
2. Use U-First!/P.I.E.C.E.S. Collaborative Care Tool to promote dialogue and shared team solution finding.
P
I
E
C
S
E
Understand Flag Interact Report Support Team
Collaborative Care (Shared Care)
Algorithm and Tools
Remember! Almost always multiple reasons for behaviour.
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P.I.E.C.E.S.TM
What is P.I.E.C.E.S.? P.I.E.C.E.S. is an acronym that conveys the individuality and importance of the various factors in the well-being, self-determination, and quality of life for older people. The first three letters P-I-E, represent an individual's Physical, Intellectual, and Emotional health. The C can be seen as the centerpiece or focus in care, i.e., maximizing Capabilities which promotes the achievement of the highest quality of life possible. The E-S represents the Environment that an individual interacts with (physical as well as the emotional environment) and the person’s Social self (cultural, spiritual, “life story”). P.I.E.C.E.S. represents Physical, Intellectual, Emotional, Capabilities, Environment, Social and are the cornerstones of the approach.
Delirium! Think 4 M’s 1. Medicine: prescription, OCD, substance misuse 2. Microbials 3. Metabolic 4. Myocardial/Respiratory and other Medical disorders Causes of Delirium: I Watch Death I Infections W Withdrawal A Acute Metabolic T Toxins, drugs C CNS Pathology H Hypoxia D Deficiencies E Endocrine A Acute Vascular T Trauma H Heavy Metals Wise MG, Hilty DM, Cerda GM, Trzepacz PT. (2002) Delirium (confusional states). In: Wise MG, Rundell JR, editors. Textbook of consultation-liaison psychiatry: psychiatry in the medically ill. 2nd ed. Washington: American Psychiatric Publishing; 2002. pp. 257-272. Confusion Assessment Method (CAM) – to help detect possible delirium
1. Acute onset 2. Inattention 3. Disorganized Thinking 4. Altered Level of Consciousness 5. Disorientation 6. Memory Impairment 7. Perceptual Disturbances 8. Psychomotor Agitation and Retardation 9. Sleep/Wake Cycle Disturbance
Consider delirium if 1 & 2 and either 3 or 4 are present Inouye, S.K., van Dyck, C.H., Alessi, C. A., et al. (1990). Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Annals of Internal Medicine, 113: 941-948.
Identify & Assess Discomfort or Pain Flags: • Emotional/behaviour changes: increased intensity of dementia,
depression or delirium • Physical changes: gait, posture, appetite, and sleep patterns,
elevated BP, increased respirations, diaphoresis, pupil changes Assessment: • 0-10 Rating. Faces Pain Rating Scale.
Detecting Cognitive Impairment (Mini Cog) Flags: near misses excuses confabulation • Repeat 3 words and remember them House Tree Car • Name as many four legged animals in one minute (average 15) • Recall the three words • DRAW A CLOCK Hand on for 10 after 11 Adapted from S.Borson http://www.cmecorner.com/macmcm/AAGP/aagp2003_07.htm Also consider the MoCA© a cognitive screening test designed to assist Health Professionals for detection of mild cognitive impairment. http://www.mocatest.org/
Psychoses/Behavioural challenges monitor, observe, record 7 Ds. 1. Dangerous - dangerousness/how threatening 2. Distressing - how distressing to self 3. Disturbing - disturbing quality/disturbing to others 4. Direct Action - whether the resident is acting on them 5. Jeopardizing Independence or social interactions 6. Distant vs Present - occurring in the past or present 7. Definite (fixed) - full or partial insight; are they fixed vs. insight The Do’s & Don’ts for Psychosis/Behaviour:
Do ensure the persons and your safety Do understand this is a response to a “real” perception of the
individual Do focus on the effects on the person not the content (i.e. validate) Do distract Don’t confront the false beliefs
Remember the delusions may not emerge until a period of time has elapsed – it may take time to “organize” the delusion Signs of Depression. SIG: E CAPS
• Sleep disturbed • Interest decreased • Guilt feelings • Energy lower • Concentration poor • Appetite disturbed • Psychomotor retardation or agitation • Suicidal ideation Dr. Carey Cross and reported in Jenike, M. (1989). Geriatric Psychiatry and Psychopharmacology: A clinical approach.p.36.Chicago:Yearbook Medical Publishers Inc
DOS – Dementia Observation System 1. Helps determine the % of time over 24-hr cycle that the person
displayed a behaviour(s) of concern; helps team determine if behaviour(s) have responded to interventions and/or side effects to medications
2. Replaces opinion with measurable data by establishing the: • Occurrence of specific behaviours of interest • Frequency with which target behaviours occur • Duration the target behaviours are displayed • Frequency with which the target behaviours of greatest risk are
displayed, in comparison with those behaviours that should be accommodated
Guidelines for Selection and Monitoring the Use, Risk, and Benefits of Psychotropics
• Why is the psychotropic being used or considered? • How do I select the right medication? • How do I monitor the response and side effects?
High Risk Elderly Where Competency May Be an Issue 6 Key Areas for Assessment:
1. Clinical 2. Capacity 3. Values & Preferences of Individual 4. Legal & least restrictive legal option, alternatives 5. Influences on our decision-making 6. Plan and reassessment; with specific indicators/triggers when to review
© P.I.E.C.E.S. Consult Group. January, 2009.
Physical Often Urgent Emotional Behaviour Depression/Psychosis
Key to Diagnosis Change (short time) Communication Capabilities
Intellectual
Risk Factors for Delirium 1. Cognitive Impairment 2. Sleep Deprivation 3. Immobility 4. Visual Impairment 5. Hearing Impairment 6. Dehydration
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Kingston Standardized Behavioural Assessment
Name:_____________________________________ Case #:__________Sex: M___ F___ Age_______ Education______ Years of Illness______Date:____________________ Informant:_____________________
Lives in Community__ or Lives in Care Facility __
Please check all of the following behaviours that have occurred in the last month or are presently occurring, andthat are a change from your spouse/relative/client’s earlier behaviour (prior to illness). Indicate whether they applyby marking the box beside the appropriate statement. The Total Score equals number of boxes checked.
1 Daily Activities
1 No longer takes part in favourite pastimes (orgreatly reduced).
2 Reduced personal hygiene . (e.g. Would nottake a bath unless told to do so, or wears thesame clothes for days unless made tochange).
3 If left on his/her own, doesn't eat properly.
4 Unsafe in daily activities, if left unsupervised.
5 No longer uses some common objectsproperly. (e.g. telephone)
6 Unable to handle personal finances.
7 Is unable to perform usual household tasks.
8 Gets confused in places other than home.
9 Overly dependent, wants more guidance thanusual.
10 Trouble appreciating subtleties inconversations (e.g. recognizing humor).
11 Difficulty judging the passing of time.
12 Wanders aimlessly.
13 Hides things.
14 Hoards objects.
15 Fails to recognize family or friends.
16 Incontinence of urine/faeces in clothes indaytime.
17 Voids in non-toilet areas.
< Total Daily Activities
2 Attention/Concentration/Memory
18 Can't concentrate, pay attention for long.
19 Misplaces things more than usual.
20Has difficulty organizing his/her time or dailyactivities.
21Forgets activities, conversations of only ashort time before.
22 Forgets important everyday information.
< Total Attention/Concentration/Memory
3 Emotional Behaviour
23 Shows little or no emotion.
24 Mood changes with no apparent reason.
25Expresses inappropriate emotions, either typeor intensity.
26 Makes uncharacteristically pessimisticstatements.
< Total Emotional Behaviour
4 Aggressive Behaviour
27 Verbally abusive at times.
28Uncharacteristically excitable, easy to upset;reacts catastrophically.
29 Attempts to hit/strike out at others.
< Total Aggressive Behaviour
5 Misperceptions/Misidentifications
30Claims an object/possession looks similar to,but is not the real one.
31Claims a family member looks similar but isnot the true one.
32Thinks present dwelling is not their place ofliving.
33 Thinks people are present who aren't.
< Total Misperception Behaviour
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6 Paranoid Behaviour
34 Suspicious of family and friends.
35 Suspicious about money issues.
36 Accuses others of stealing his or her things.
37 Accuses spouse of infidelity.
38Expresses suspicion around takingmedication.
< Total Paranoid Behaviour
7 Judgement/Insight
39 Shows poor judgement in social situations.
40 Shows poor judgement about driving.
41Shows uncharacteristic change in his or herconcern about money.
42
Poor choices in dressing. (e.g. wears clothesthat are inappropriate for season ortemperature, wears the same clothes fordays).
43 Makes inappropriate sexual advances.
44 Shows less self control than usual.
45 Unable to identify personal safety risks.
< Total Judgement/Insight
8 Perseveration
46 Repeats same actions over and over.
47 Repeats same words or phrases.
48 Repeatedly shouts or calls out.
< Total Perseveration
9 Motor Restlessness
49 Desire to pace or walk almost constantly.
50 Can't sit still, restless, fidgety.
51 Tries doors, windows.
< Total Motor Restlessness
10 Sleep/Activity/Sundowning
52 Falls asleep at uncharacteristic times.
53Gets up and wanders or awakens frequentlyat night, more than usual.
54 Sleeps more.
55Behaviour more agitated or impaired in lateafternoon.
< Total Sleep/Activity/Sundowning
11 Motor/Spatial Problems
56Poor coordination seen in limb/fingermovements.
57 Slowness of movement
58 Unsteadiness when walking.
59Has trouble dressing, especially with buttonsor shoelaces.
60Difficulty judging object sizes or how near anobject is from themselves.
< Total Motor Spatial Problems
12 Language Difficulties
61 Reads far less frequently than previously.
62 Substitutes some words for others.
63 Does not watch or follow television.
64Does not speak unless spoken to. (e.g. Doesnot participate in conversations.)
65 Often cannot find the right word.
66 Trouble pronouncing words.
67Does not understand simple commands,explanations.
68 Does not produce meaningful speech.
< Total Language Difficulties
TOTAL SCORE
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Kingston Standardized Behavioural Assessment - ANALYSIS FORM
BEHAVIOURAL PROFILE TOTAL SCORE ANALYSIS
1 2 3 4 5 6 7 8 9 10 11 12 COMM INST
CO
MP
AR
ISO
N S
CA
LE
Daily
Activ
ities
Atte
ntio
n/C
on
cen
tratio
n/M
em
ory
Em
otio
nal B
eh
avio
ur
Ag
gre
ssiv
e B
eh
avio
ur
Mis
perc
ep
tion
s
Para
no
id B
eh
avio
ur
Ju
dg
em
en
t/Insig
ht
Pers
evera
tion
Mo
tor R
estle
ssn
ess
Sle
ep
/Activ
ity/S
un
do
wn
ing
Mo
tor/S
patia
l Pro
ble
ms
Lan
gu
ag
e D
ifficu
lties
To
tal S
co
re
To
tal S
co
re D
escrip
tion
s
To
tal S
co
re
To
tal S
co
re D
escrip
tion
s
10 17 5 4 3 4 5 7 3 3 4 5 8 68 67
67
C
66
C
9.5 16 66
O
65
R
64
N
64
I
9 15 63
S
63
S
6 7 62
I
62
I
8.5 61
D
61
S
14 60
E
608 4 4 4 58
R
5813 56 56
7.5 3 3 5 3 6 54
P
5412 52
L
527 50
A
5011 2 2 2 48
C
486.5 46
E
4610 5 44
M
446 3 3 4 3 42
E
429 40
N
40
C
5.5 38
T
38
O
8 36 36
N
5 2 2 2 4 34 34
S
32 32
U
4.5 7 3 30
C
30
L
28
O
28
T
4 2 2 2 26
N
26
/
6 3 24
S
24
C
3.5 1 1 1 22
U
22
O
20
L
20
N
3 5 2 19
T
18
C
17
/
16
E
2.5 4 1 1 1 2 16
C
14
R
14
O
12
N
2 3 1 1 1 11
N
109
C
81.5 2 1 6
E
61 5
R
51 4
N
41 3 3
.5 2 21 1
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
To produce a behaviour profile, count the number of items checked for each behavioural group and circle that number on the abovechart in the appropriate column. To the right of the profile chart are columns for total score analysis. Select the appropriate column andcircle the number matching the total score. (COM = community living; INST = institutional living).
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KSBA Behavioural Analysis Procedures
1 2 3 4 5 6 7 8 9 10 11 12 COMM
CO
MP
AR
ISO
N S
CA
LE
Daily
Activ
ities
Atte
ntio
n/C
on
cen
tratio
n/M
em
ory
Em
otio
nal B
eh
avio
ur
Ag
gre
ssiv
e B
eh
avio
ur
Mis
pe
rce
ptio
ns
Para
no
id B
eh
avio
ur
Ju
dg
em
en
t/Insig
ht
Pers
evera
tion
Mo
tor R
estle
ssn
ess
Sle
ep
/Activ
ity/S
un
do
wn
ing
Mo
tor/S
patia
l Pro
ble
ms
Lan
gu
ag
e D
ifficu
lties
All Ite
ms
To
tal S
co
re D
escrip
tion
s
10 17 5 4 3 4 5 7 3 3 4 5 8 68
67
C
9.5 16 66
O
64
N
9 15 63
S
6 7 62
I
8.5 61
D
14 60
E
8 4 4 4 58
R
13 56
7.5 3 3 5 3 6 54
P
12 52
L
7 50
A
11 2 2 2 48
C
6.5 46
E
10 5 44
M
6 3 3 4 3 42
E
9 40
N
5.5 38
T
8 365 2 2 2 4 34
324.5 7 3 30
C
28
O
4 2 2 2 26
N
6 3 24
S
3.5 1 1 1 22
U
20
L
3 5 2 18
T
16
/
2.5 4 1 1 1 2 14
C
12
O
2 3 1 1 1 10
N
8
C
1.5 2 1 6
E
1 5
R
1 4
N
1 3.5 2
1
0 0 0 0 0 0 0 0 0 0 0 0 0 0
For explanations and samples as to how to use this form see KSBA Administration and Interpretation Manual, which can be
freely downloaded from www.providencecare.ca Clinical Services Geriatric Psychiatry Kingston Scales
or e mail: [email protected]
© Copyright 2007 R.W. Hopkins, L. Kilik, D. Day (Sep 2007)
STEP 2READ TOTAL
SCOREPERFORMANCECLASSIFICATIONIN COLUMN TO
RIGHT(See arrow)
STEP 1CIRCLE SUM
OF TOTALITEMS SCORED
(See arrow)
STEP 3CREATE
BEHAVIOURALPROFILE BY
CIRCLING SUM OFITEMS SCORED FOREACH BEHAVIOURALGROUP (See arrows). CONNECT CIRCLES,
IF DIESIRED.
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Kingston Standardized Behavioural Assessment (KSBA)
Definition: The Kingston Standardized Behavioural Assessment (KSBA) was designed to complement cognitive assessment tools by providing an indication of the number of behavioural symptoms associated with dementia which are currently affecting the individual. The KSBA also provides caregivers with comparative data to assist them in making difficult decisions about the required level of care.
Kingston Standardized Behavioural Assessment (KSBA)
Link to Tool http://www.providencecare.ca/cms/sitem.cfm/clinical_services/geriatric_psychiatry/kingston_scales/ksba_(behaviour)/
Time to Administer
Subjective to the person (caregiver) completing the scale and amount of time spent in dialogue with clinician. (Approximately 5-15 minutes)
Type Standardized Assessment Tool
Setting Primary Care and Long-Term Care
Administration
The informant (an individual who knows the person on a day-to-day basis) either completes the scale or has the items read to them by a physician. The informant is asked which of the 68 commonly observed behaviours in dementia have occurred in the last month and are a change from their spouse/relative/client’s earlier behaviour
Interpretation
1. The number of checked items on the scale is tallied and recorded on the Total Score Descriptions Column corresponding to that individual’s current living situation 2. Tally scores for the checked items in each group of behaviours on the KSBA and transfer this to the Behavioural Profile
Reference
Hopkins R, Kilik L, Day D, Bradford L, Rows C, (2006) “Kingston Standardized Behavioural Assessment” The American Journal of Alzheimer’s Disease and Other Dementias , 21: 339-346 Kilik L, Hopkins R, Day D, Prince C, Prince P, Rows C. (2008) “The progression of behaviour in dementia: An in-office guide for clinicians.” The American Journal of Alzheimer’s Disease and Other Dementias, 23: 242-249. (Originally Published online Feb 13th 2008)
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ADMINISTRATIONAND
INTERPRETATIONMANUAL
(INCLUDING LONG TERM CARE FORM)
Kingston
Standarized
Behavioural
Assessment
Geriatric Psychiatry Programme, Providence Care Mental Health Services, Kingston, Canada K7L 4X3
The Kingston Scales and Manuals can be freely downloaded from:www.providencecare.ca Clinical Services Geriatric Psychiatry Kingston Scales
e mail: [email protected]© Copyright 2007 R.W. Hopkins, L. Kilik
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KSBA Manual 2
Purpose:
Since progressive dementias such as Alzheimer’s disease are characterized by behavioural as wellas cognitive disturbances, the Kingston Standardized Behavioural Assessment (KSBA ) was designedto complement cognitive assessment tools such as the Kingston Standardized Cognitive Assessment -Revised (KSCA-R) by providing an indication of the number of behavioural symptoms associated withdementia which are currently affecting an individual.
The KSBA also provides validation for caregivers struggling with the issue of moving theirrelative into a long term care setting. This, in our experience, is often a difficult and stressful decisionfor many family members and they usually leave it too late, impairing their own health as well as that oftheir relative. By being able to provide an objective score that reflects behavioural issues, a decisionabout long term care can often be made more easily. This can help to alleviate the distress and sense ofguilt caregivers often experience. The information can also be used to facilitate the introduction of homesupport services. Likewise, for patients already in long term care settings, the KSBA allows staff tomonitor and assess the behavioural status of an individual and institute further professional assessmentsor consultations.
Since both the placement and introduction of home support services, not to mention caregiverstress, are almost always triggered by behavioural and not cognitive issues, a behavioural analysis of theindividual is of great importance and not something that can be gained easily from other sources.
The KSBA consists of two parts, the KSBA form which is a list of 68 commonly observed behaviours in dementia, broken into groups of related behaviours, and a second page, the AnalysisForm for summarizing and analysing the reported behaviours. On the reverse side of the Analysis Formpage is the Behaviour Analysis Procedures page; listing a brief set of instructions on how to use theAnalysis Form. This Analysis Form is used by the health care professional, not the informant. TheKSBA provides a powerful behavioural analysis that is normally only available to behaviourally trainedclinicians (e.g. psychologists, psychometrists, etc.).
Administration:
The informant is an individual, who knows the person on a day-to-day basis i.e. spouse or otherrelative, or in the case of an individual living in long term care, the staff member who knows him or herbest. The scale may be completed by the informant, or you can read the items to the informant and askfor a yes/no answer.
The instructions are: “Please check all of the following behaviours that have occurred in thelast month or are presently occurring, and that are a change from your spouse/relative/client’s earlierbehaviour (prior to illness). Indicate whether they apply by marking the box beside the appropriatestatement. The Total Score equals number of boxes checked.” That is, all the behaviours that now apply. Not those that were seen months ago but have since disappeared.
It should be noted that while many behaviours are discrete acts (like biting or hitting people), thatcan be fairly easily identified in both time and place, other behaviours like “unable to handle personalfinances” or “unsafe in daily activities, if left unsupervised” are ongoing. Usually, once an individual isdeemed incompetent to perform a task or is shown to be a risk for some behaviour, he or she is not given
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KSBA Manual 3
another chance to demonstrate his or her incompetence, but rather are kept away from such activities orclosely supervised while performing them. These ongoing behaviours are checked as if they hadrecently occurred, as it is assumed that once one is unable to perform a task, the individual will continueto be unable. This situation only pertains to progressive dementias and similar disorders where nosignificant improvement is expected. It is important to remember that one only checks behavioursthat are a recent change from the individual’s pre-illness pattern of behaviour.
To aid in the explanation of some behaviours to the informant, a glossary providing a moredetailed explanation of the behaviours listed on the KSBA form is found at the end of this manual.
Interpretation:
The Analysis Form is divided into two parts; Total Score Analysis and a Behaviour Profile.
TOTAL SCORE ANALYSIS
On the right side of the Analysis Form page is a group of columns marked “Total ScoreAnalysis”. The pair on the far right (marked INST) are for patients living in an institution and the two onthe left (marked COMM) are for community dwelling patients. One simply counts the number of tickeditems on the KSBA form and circles that number in the appropriate “All Items” column (COMM ifcommunity dwelling or INST if institutional dwelling). The “Total Score Descriptions” column providesthe corresponding description for scores in that range. (See Examples on pages 5 to 12.)
The “Consult / Concern” range for either community dwelling or institutional living patientsrepresents the lower part of the response range. Scores in the range of “Consider Placement” (or in thecase of institutional living patients “Crisis”), are at a level that may indicate some serious difficulties. Normally, we have found that when community dwelling patients score at or above 38, it becomesincreasingly difficult for family caregivers to continue to be able to provide care at home, or atleast without considerable help. In the middle ranges, additional services or supports may be requiredby caregivers.
Likewise, institutional living patients scoring above 58 might well benefit from a specialistconsult or other intervention. However, it is advised that such consults/interventions be considered longbefore the “Crisis” point is reached.
It must be remembered that these descriptive ranges are merely labels placed on a continuum ,and that there are no true, hard and fixed demarcation points. What caregivers, lay or professional, canhandle will vary between individuals and institutions. It must also be remembered, that there aredifferences between individual patients. If a patient scores only 1, yet that behaviour is related to violentphysical outbursts, there would be need for help.
At the present time the following statistics apply to the standard scale (NOT the LTC Form) andmay be used as a guide. Score refers to the number of behaviours checked. The maximum score is 68.
KSBA Score Summary COMMUNITY INSTITUTIONSn 103 n 38
Mean sd Min Max Mean sd Min MaxMean Score /68 20.88 11.58 0 56 31.32 12.62 10 60
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KSBA Manual 4
BEHAVIOUR PROFILE
The large chart on the left side of the Analysis Form page is the Behaviour Profile which lists the12 groups of related behaviours with one column for each. For each column the number of possiblebehaviours in that group is displayed, starting with 0 (zero) at the bottom and going up to the maximumnumber of behaviours in that group, at the top. To fill out the profile, simply count the number of tickeditems for each group of behaviours on the KSBA form and put that value in the Total box at the end ofeach group. Then transfer these values to the profile chart. If desired, these circled scores can be joinedup with a line to create a visual profile, unique to each patient. See Examples on pages 5 to 12. It isuseful to examine and compare individual groups of behaviours on the Analysis Form to assist inidentifying specific behaviours for intervention.
On the extreme left side of the Profile chart is a “Comparison Scale” column that is used to giveeach of the other column scores a relative value, allowing all groups to be compared to each other. Forexample, if the score on group 7 (Judgement/Insight) equals 5 and group 6 (Misperceptions) the scoreequals 3, then both can be said to have a relative score of 7.5. Or if the score on group 7(Judgement/Insight) equals 4 and group 12 (Paranoid Behaviour) the score equals 2, then the scoresrepresent relative values of 6 and 4 respectively. In this way, relative comparisons (i.e. degree ofimpairment or sparing) across the 12 groups of behaviours can be made.
EXAMPLES
On pages 5 to 12 are some sample Total Score Analyses and Profiles taken from actual cases. Examples 1 and 2 are community dwelling individuals but the first is an individual who has a relativelylow number of total responses (i.e.14). The second individual is someone at a more advanced stage ofdementia with a much larger number of total responses (i.e.49). In this later case, placement wasimminent. Due to space limitations on the “Analysis Form”, some numbers are skipped in the “AllItems” column. (See Example 2.) In these cases indicate the obtained score by placing a mark betweenthe two numbers nearest to the score. Patients who obtain the same total score (e.g. 19) can havedistinctly different profiles as can be seen in Examples 3 and 4.
REPEATED ADMINISTRATIONS
The KSBA is normally used to capture a current snapshot of an individual’s behaviour. Typically, “current” has been taken to mean behaviours that have occurred in the last month. However,the KSBA can also be used to track behaviour change over time including change attributable to specificinterventions. In such cases the KSBA may be administered repeatedly, and the interval may also beshorter than one month. When doing so, the reporting interval should match the repetition interval. Forexample, if you give it once a week to a patient, then only ask for behaviours that have been noted in thatpast week. One should also make sure that the chosen interval is clearly described when reportingchanges over time.
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KSBA Manual 5
THE LONG TERM CARE FORM
In addition to the standard (68 item community) form, there is a Long Term Care (LTC) form foruse in long term care facilities. The LTC form differs from the community form in that 25 new itemshave been added, while 19 items were removed from the original scale, yielding a total of 74 for the LTCform. The removed items were ones that were unlikely to be applicable to a person in a long term carefacility (e.g. .Shows poor judgement about driving, Is unable to perform usual household tasks). Thenew items are ones that are much more likely to be seen in long term care residents (e.g. Resistant tobathing, Repeatedly rearranges furniture). The LTC form is therefore better able to capture the essenceof the behavioural disturbances seen in long term care patients.
Administration and interpretation of the form is basically the same as with the standardcommunity form. The rater being the staff member (or members) who knows the patient best.
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KSBA Manual 6
Example 1
BEHAVIOURAL PROFILE TOTAL SCORE ANALYSIS1 2 3 4 5 6 7 8 9 10 11 12 COMM INST
CO
MPA
RISO
N SC
ALE
Daily A
ctivities
Attention/C
oncentration/Mem
ory
Emotional B
ehaviour
Aggressive B
ehaviour
Misperceptions
Paranoid Behaviour
Judgement/Insight
Perseveration
Motor R
estlessness
Sleep/Activity/Sundow
ning
Motor/Spatial Problem
s
Language Difficulties
Total Score
Total Score Descriptions
Total Score
Total Score Descriptions
10 17 5 4 3 4 5 7 3 3 4 5 8 68 6767
C
66
C
9.5 16 66
O
65
R
64
N
64
I
9 15 63
S
63
S
6 7 62
I
62
I
8.5 61
D
61
S
14 60
E
608 4 4 4 58
R
5813 56 56
7.5 3 3 5 3 6 54
P
5412 52
L
527 50
A
5011 2 2 2 48
C
486.5 46
E
4610 5 44
M
446 3 3 4 3 42
E
429 40
N
40
C
5.5 38
T
38
O
8 36 36
N
5 2 2 2 4 34 34 32 32
U
4.5 7 3 30
C
30
L
28
O
28
T
4 2 2 2 26
N
26 /
6 3 24
S
24
C
3.5 1 1 1 22
U
22
O
20
L
20
N
3 5 2 19
T
18
C
17 / 16
E
2.5 4 1 1 1 2 16
C
14
R
14
O
12
N
2 3 1 1 1 11
N
109
C
81.5 2 1 6
E
61 5
R
51 4
N
41 3 3
0.5 2 21 1
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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Example 2
BEHAVIOURAL PROFILE TOTAL SCORE ANALYSIS1 2 3 4 5 6 7 8 9 10 11 12 COMM INST
CO
MPA
RISO
N SC
ALE
Daily A
ctivities
Attention/C
oncentration/Mem
ory
Emotional B
ehaviour
Aggressive B
ehaviour
Misperceptions
Paranoid Behaviour
Judgement/Insight
Perseveration
Motor R
estlessness
Sleep/Activity/Sundow
ning
Motor/Spatial Problem
s
Language Difficulties
Total Score
Total Score Descriptions
Total Score
Total Score Descriptions
10 17 5 4 3 4 5 7 3 3 4 5 8 68 6767
C
66
C
9.5 16 66
O
65
R
64
N
64
I
9 15 63
S
63
S
6 7 62
I
62
I
8.5 61
D
61
S
14 60
E
608 4 4 4 58
R
5813 56 56
7.5 3 3 5 3 6 54
P
5412 52
L
527 50
A
5011 2 2 2 48
C
486.5 46
E
4610 5 44
M
446 3 3 4 3 42
E
429 40
N
40
C
5.5 38
T
38
O
8 36 36
N
5 2 2 2 4 34 34
S
32 32
U
4.5 7 3 30
C
30
L
28
O
28
T
4 2 2 2 26
N
26 /
6 3 24
S
24
C
3.5 1 1 1 22
U
22
O
20
L
20
N
3 5 2 19
T
18
C
17 / 16
E
2.5 4 1 1 1 2 16
C
14
R
14
O
12
N
2 3 1 1 1 11
N
109
C
81.5 2 1 6
E
61 5
R
51 4
N
41 3 3
0.5 2 21 1
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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KSBA Manual 8
Kingston Standardized Behavioural Assessment
Name:___Example 3_______________________ Case #:__12345________Date:___Nov 17 2004_________________ Informant:__Daughter___________________Lives in:Community_X__ or HFTA __ NH __ Rest Hm __ Hosp __ Other __
Below are listed some behaviours that your spouse/relative/client may show. Please check all of the followingbehaviours that have occurred in the last month or are presently occurring. Indicate whether they apply bymarking the box beside the appropriate statement. The Total Score equals number of boxes checked.
1 Daily Activities
X 1 No longer takes part in favourite pastimes (orgreatly reduced).
X2 Reduced personal hygiene . (e.g. Would not
take a bath unless told to do so, or wears thesame clothes for days unless made tochange).
3 If left on his/her own, doesn't eat properly.
X 4 Unsafe in daily activities, if left unsupervised.
5 No longer uses some common objectsproperly. (e.g. telephone)
X 6 Unable to handle personal finances.
X 7 Is unable to perform usual household tasks.
8 Gets confused in places other than home.
9 Overly dependent, wants more guidance thanusual.
10 Trouble appreciating subtleties inconversations (e.g. recognizing humor).
11 Difficulty judging the passing of time.
12 Wanders aimlessly.
13 Hides things.
14 Hoards objects.
15 Fails to recognize family or friends.
16 Incontinence of urine/faeces in clothes indaytime.
17 Voids in non-toilet areas.
5 < Total Daily Activities
2 Attention/Concentration/Memory18 Can't concentrate, pay attention for long.
19 Misplaces things more than usual.
X 20 Has difficulty organizing his/her time or dailyactivities.
X 21 Forgets activities, conversations of only ashort time before.
X 22 Forgets important everyday information.
3 < Total Attention/Concentration/Memory
3 Emotional Behaviour23 Shows little or no emotion.
X 24 Mood changes with no apparent reason.
25 Expresses inappropriate emotions, either typeor intensity.
26 Makes uncharacteristically pessimisticstatements.
1 < Total Emotional Behaviour
4 Aggressive Behaviour
27 Verbally abusive at times.
28 Uncharacteristically excitable, easy to upset;reacts catastrophically.
29 Attempts to hit/strike out at others.
0 < Total Aggressive Behaviour
5 Misperceptions/Misidentifications
30 Claims an object/possession looks similar to,but is not the real one.
31 Claims a family member looks similar but isnot the true one.
32 Thinks present dwelling is not their place ofliving.
33 Thinks people are present who aren't.
0 < Total Misperception Behaviour
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KSBA Manual 9
6 Paranoid Behaviour34 Suspicious of family and friends.
35 Suspicious about money issues.
36 Accuses others of stealing his or her things.
37 Accuses spouse of infidelity.
38 Expresses suspicion around takingmedication.
0 < Total Paranoid Behaviour
7 Judgement/Insight39 Shows poor judgement in social situations.
40 Shows poor judgement about driving.
41 Shows uncharacteristic change in his or herconcern about money.
42
Poor choices in dressing. (e.g. wears clothesthat are inappropriate for season ortemperature, wears the same clothes fordays).
43 Makes inappropriate sexual advances.
44 Shows less self control than usual.
45 Unable to identify personal safety risks.
0 < Total Judgement/Insight
8 Perseveration46 Repeats same actions over and over.
47 Repeats same words or phrases.
48 Repeatedly shouts or calls out.
0 < Total Perseveration
9 Motor Restlessness49 Desire to pace or walk almost constantly.
50 Can't sit still, restless, fidgety.
51 Tries doors, windows.
0 < Total Motor Restlessness
10 Sleep/Activity/Sundowning52 Falls asleep at uncharacteristic times.
53 Gets up and wanders or awakens frequentlyat night, more than usual.
X 54 Sleeps more.
55 Behaviour more agitated or impaired in lateafternoon.
1 < Total Sleep/Activity/Sundowning
11 Motor/Spatial Problems
X 56 Poor coordination seen in limb/fingermovements.
X 57 Slowness of movement
X 58 Unsteadiness when walking.
X 59 Has trouble dressing, especially with buttonsor shoelaces.
X 60 Difficulty judging object sizes or how near anobject is from themselves.
5 < Total Motor Spatial Problems
12 Language Difficulties
X 61 Reads far less frequently than previously.
X 62 Substitutes some words for others.
63 Does not watch or follow television.
64 Does not speak unless spoken to. (e.g. Doesnot participate in conversations.)
65 Often cannot find the right word.
X 66 Trouble pronouncing words.
X 67 Does not understand simple commands,explanations.
68 Does not produce meaningful speech.
4 < Total Language Difficulties
19 TOTAL SCORE
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KSBA Manual 10
Example 3
BEHAVIOURAL PROFILE TOTAL SCORE ANALYSIS1 2 3 4 5 6 7 8 9 10 11 12 COMM INST
CO
MPA
RISO
N SC
ALE
Daily A
ctivities
Attention/C
oncentration/Mem
ory
Emotional B
ehaviour
Aggressive B
ehaviour
Misperceptions
Paranoid Behaviour
Judgement/Insight
Perseveration
Motor R
estlessness
Sleep/Activity/Sundow
ning
Motor/Spatial Problem
s
Language Difficulties
Total Score
Total Score Descriptions
Total Score
Total Score Descriptions
10 17 5 4 3 4 5 7 3 3 4 5 8 68 6767
C
66
C
9.5 16 66
O
65
R
64
N
64 I
9 15 63
S
63
S
6 7 62 I 62 I
8.5 61
D
61
S
14 60
E
608 4 4 4 58
R
5813 56 56
7.5 3 3 5 3 6 54
P
5412 52
L
527 50
A
5011 2 2 2 48
C
486.5 46
E
4610 5 44
M
446 3 3 4 3 42
E
429 40
N
40
C
5.5 38
T
38
O
8 36 36
N
5 2 2 2 4 34 34
S
32 32
U
4.5 7 3 30
C
30
L
28
O
28
T
4 2 2 2 26
N
26 /
6 3 24
S
24
C
3.5 1 1 1 22
U
22
O
20
L
20
N
3 5 2 19
T
18
C
17 / 16
E
2.5 4 1 1 1 2 16
C
14
R
14
O
12
N
2 3 1 1 1 11
N
109
C
81.5 2 1 6
E
61 5
R
51 4
N
41 3 3
0.5 2 21 1
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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KSBA Manual 11
Kingston Standardized Behavioural Assessment
Name:_Example 4___________________________ Case #:___54321___Date:___Nov 17 2004_________ Informant:____Spouse______________Lives in:Community_X__ or HFTA __ NH __ Rest Hm __ Hosp __ Other __
Below are listed some behaviours that your spouse/relative/client may show. Please check all of the followingbehaviours that have occurred in the last month or are presently occurring. Indicate whether they apply bymarking the box beside the appropriate statement. The Total Score equals number of boxes checked.
1 Daily Activities
X 1 No longer takes part in favourite pastimes (orgreatly reduced).
2 Reduced personal hygiene . (e.g. Would nottake a bath unless told to do so, or wears thesame clothes for days unless made tochange).
X 3 If left on his/her own, doesn't eat properly.
4 Unsafe in daily activities, if left unsupervised.
5 No longer uses some common objectsproperly. (e.g. telephone)
X 6 Unable to handle personal finances.
X 7 Is unable to perform usual household tasks.
X 8 Gets confused in places other than home.
X 9 Overly dependent, wants more guidance thanusual.
10 Trouble appreciating subtleties inconversations (e.g. recognizing humor).
X 11 Difficulty judging the passing of time.
X 12 Wanders aimlessly.
X 13 Hides things.
14 Hoards objects.
15 Fails to recognize family or friends.
16 Incontinence of urine/faeces in clothes indaytime.
17 Voids in non-toilet areas.
9 < Total Daily Activities
2 Attention/Concentration/Memory18 Can't concentrate, pay attention for long.
X 19 Misplaces things more than usual.
20 Has difficulty organizing his/her time or dailyactivities.
X 21 Forgets activities, conversations of only ashort time before.
X 22 Forgets important everyday information.
3 < Total Attention/Concentration/Memory
3 Emotional Behaviour23 Shows little or no emotion.
24 Mood changes with no apparent reason.
25 Expresses inappropriate emotions, either typeor intensity.
26 Makes uncharacteristically pessimisticstatements.
0 < Total Emotional Behaviour
4 Aggressive Behaviour
27 Verbally abusive at times.
28 Uncharacteristically excitable, easy to upset;reacts catastrophically.
29 Attempts to hit/strike out at others.
0 < Total Aggressive Behaviour
5 Misperceptions/Misidentifications
30 Claims an object/possession looks similar to,but is not the real one.
31 Claims a family member looks similar but isnot the true one.
32 Thinks present dwelling is not their place ofliving.
33 Thinks people are present who aren't.
0 < Total Misperception Behaviour
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KSBA Manual 12
6 Paranoid Behaviour34 Suspicious of family and friends.
X 35 Suspicious about money issues.
36 Accuses others of stealing his or her things.
37 Accuses spouse of infidelity.
38 Expresses suspicion around takingmedication.
1 < Total Paranoid Behaviour
7 Judgement/Insight
X 39 Shows poor judgement in social situations.
X 40 Shows poor judgement about driving.
X 41 Shows uncharacteristic change in his or herconcern about money.
42
Poor choices in dressing. (e.g. wears clothesthat are inappropriate for season ortemperature, wears the same clothes fordays).
43 Makes inappropriate sexual advances.
44 Shows less self control than usual.
45 Unable to identify personal safety risks.
3 < Total Judgement/Insight
8 Perseveration46 Repeats same actions over and over.
47 Repeats same words or phrases.
48 Repeatedly shouts or calls out.
0 < Total Perseveration
9 Motor Restlessness49 Desire to pace or walk almost constantly.
50 Can't sit still, restless, fidgety.
51 Tries doors, windows.
0 < Total Motor Restlessness
10 Sleep/Activity/Sundowning52 Falls asleep at uncharacteristic times.
X 53 Gets up and wanders or awakens frequentlyat night, more than usual.
54 Sleeps more.
55 Behaviour more agitated or impaired in lateafternoon.
1 < Total Sleep/Activity/Sundowning
11 Motor/Spatial Problems
56 Poor coordination seen in limb/fingermovements.
57 Slowness of movement
58 Unsteadiness when walking.
59 Has trouble dressing, especially with buttonsor shoelaces.
60 Difficulty judging object sizes or how near anobject is from themselves.
0 < Total Motor Spatial Problems
12 Language Difficulties
61 Reads far less frequently than previously.
62 Substitutes some words for others.
X 63 Does not watch or follow television.
64 Does not speak unless spoken to. (e.g. Doesnot participate in conversations.)
X 65 Often cannot find the right word.
66 Trouble pronouncing words.
67 Does not understand simple commands,explanations.
68 Does not produce meaningful speech.
2 < Total Language Difficulties
19 TOTAL SCORE
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KSBA Manual 13
Example 4
BEHAVIOURAL PROFILE TOTAL SCORE ANALYSIS1 2 3 4 5 6 7 8 9 10 11 12 COMM INST
CO
MPA
RISO
N SC
ALE
Daily A
ctivities
Attention/C
oncentration/Mem
ory
Emotional B
ehaviour
Aggressive B
ehaviour
Misperceptions
Paranoid Behaviour
Judgement/Insight
Perseveration
Motor R
estlessness
Sleep/Activity/Sundow
ning
Motor/Spatial Problem
s
Language Difficulties
Total Score
Total Score Descriptions
Total Score
Total Score Descriptions
10 17 5 4 3 4 5 7 3 3 4 5 8 68 6767
C
66
C
9.5 16 66
O
65
R
64
N
64 I
9 15 63
S
63
S
6 7 62 I 62 I
8.5 61
D
61
S
14 60
E
608 4 4 4 58
R
5813 56 56
7.5 3 3 5 3 6 54
P
5412 52
L
527 50
A
5011 2 2 2 48
C
486.5 46
E
4610 5 44
M
446 3 3 4 3 42
E
429 40
N
40
C
5.5 38
T
38
O
8 36 36
N
5 2 2 2 4 34 34
S
32 32
U
4.5 7 3 30
C
30
L
28
O
28
T
4 2 2 2 26
N
26 /
6 3 24
S
24
C
3.5 1 1 1 22
U
22
O
20
L
20
N
3 5 2 19
T
18
C
17 / 16
E
2.5 4 1 1 1 2 16
C
14
R
14
O
12
N
2 3 1 1 1 11
N
109
C
81.5 2 1 6
E
61 5
R
51 4
N
41 3 3
0.5 2 21 1
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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KSBA Manual 14
Description of Behaviours
1 Daily Activities
1 - No longer takes part in favourite pastimes (or greatly reduced). - no longer participates in hobbies or previously preferred activities like playing the piano, or cardgames- reduction in self-directed leisure activities
2 - Reduced personal hygiene.- would not take a bath unless told to do so, or wears the same clothes for days unless prompted tochange- reduction in individual’s normal self-directed hygiene - care done by nursing staff
3 - If left on his/her own, doesn't eat properly. - will not independently eat adequate meals or will miss meals, even if provided- weight loss may be apparent
4 - Unsafe in daily activities, if left unsupervised.- may leave stove on, water running, choking, unsafe with hot liquids, unsafe getting into bath, etc.
5 - No longer uses some common objects properly. - now seems to have difficultly handling common household objects such as telephones, microwaves,etc.- difficulty with kitchen utensils - knowing what to use
6 - Unable to handle personal finances.- gets confused paying bills - may not pay at all, or pays twice- now someone else has to handle finances
7 - Is unable to perform usual household tasks- such as cleaning, minor repairs, or prepare meals.- gets confused while trying to fix something, - or unable to organize oneself to prepare meals
8 - Gets confused in places other than home. - gets confused in other people’s homes or other familiar places such as shopping centres,neighbourhood, etc.- if taken off unit for activities/appointments could not find their way back to unit alone.
9 - Overly dependent, wants more guidance than usual.- asks for more help, or approval from caregiver than in past; relies on caregiver to initiate activities- often described as “shadowing”
10 - Trouble appreciating subtleties in conversations - now has trouble recognizing humour - does not get jokes
11 - Difficulty judging the passing of time.- may keep asking time of day, etc.- may prepare for appointments etc., several hours before necessary
12 - Wanders aimlessly.- walks around looking lost- not rapid pacing as in motor restlessness
13 - Hides things.- hides things away that do not need to be hidden, e.g. dentures- stores things in inappropriate places such putting a purse or wallet in freezer
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KSBA Manual 15
14 - Hoards objects.- more extreme version of hiding; collecting excessive quantity of things
15 - Fails to recognize family or friends. - does not know them or thinks they are someone else
16 - Incontinence of urine/faeces in clothes in daytime.- clothes includes “Depends” etc.
17 - Voids in non-toilet areas.- plant pots, hall corners, etc.- not the same as incontinence in clothes or incontinence briefs
2 Attention/Concentration/Memory18 - Can't concentrate, pay attention for as long as they used to.
- attention span reduced, thinking is more muddled, often slower19 - Misplaces things more than usual.
- like normal failures of memory/forgetfulness, only much more frequent- forgets where they put something down e.g. book, glasses, etc.
20 - Has difficulty organizing his/her time or daily activities.- seems to be busy but accomplishes very little- activities are organized by someone else
21 - Forgets activities, conversations of only a short time before.- within that day
22 - Forgets important everyday information.- such as scheduled appointments and activities, phone numbers, addresses, etc.
3 Emotional Behaviour23 - Shows little or no emotion.
- reduction of normal emotional range24 - Mood changes for no apparent reason.25 - Expresses inappropriate emotions, either type or intensity.
- e.g. laughing at news of a death, or crying at mild disappointment26 - Makes uncharacteristically pessimistic statements.
4 Aggressive Behaviour27 - Verbally abusive at times.
- must be directed at someone or something28 - Uncharacteristically excitable, easy to upset; reacts catastrophically.
- reactions to change are exaggerated - intensity of emotional reaction is excessive for the situation
29 - Physically aggressive.- hitting, biting, pinching, spitting, pushing, hair pulling, etc.
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KSBA Manual 16
5 Misperceptions/Misidentifications Behaviour30 - Claims an object or possession looks similar to, but is not the real one.
- e.g. the family car in driveway is not recognized as own car, or a piece of jewellery/glasses isidentified as looking similar to but not their own
31 - Claims a family member looks similar (to that person) but is not the true one. 32 - Thinks present dwelling is not their place of living.
- e.g. the person in the nursing home does not recognize that they live in that facility- or, the person who lives in their own home but states they want to or is packing to “go home”
33 - Thinks people are present who aren't.- thinks people are present in the room or somewhere in the house when in fact they are not e.g. believesthat people on TV are real and in the room, a deceased family member is living elsewhere in the house,misinterprets own image in mirror as another person
6 Paranoid Behaviour34 - Suspicious of family and friends.
- accuses family or staff of putting poison in food or drinks35 - Suspicious about money issues.
- suspects people around them are trying to steal their money- suspects people around them are taking unusual interest in their financial affairs
36 - Accuses others of stealing his or her things. 37 - Accuses spouse of infidelity.- refers to current behaviour not some incident from long past.
38 - Expresses suspicion around taking medication. - suggests that the contents of the medicine bottle is not what it says on the label- believes that the medicine is poison- NOT questions re the value of the medication
7 Judgement/Insight39 - Shows poor judgement in social situations.
- e.g. Making inappropriate comments - off-coloured jokes - no longer respects the social decorum required in a given situation e.g. unwanted comments onphysical appearance
40 - Shows poor judgement about driving. - wants to drive when he or she should not- believes he or she could safely drive despite evidence to the contrary
41 - Shows uncharacteristic change in his or her concern about money.- e.g. very reluctant to pay bills, or may give away money to strangers
42 - Poor choices in dressing. - e.g. wears clothes that are inappropriate for season or temperature.- nursing staff picks out clothing
43 - Makes inappropriate sexual advances. - behaviour should be explicit and not vague references that could be interpreted in many ways
44 - Shows less self control than usual.- problems controlling eating, drinking, etc. (not just memory problem)- e.g. eating a whole pot of chili at one sitting- difficulty denying impulses
45 - Unable to identify personal safety risks.- unable to foresee obviously dangerous outcomes to certain actions
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KSBA Manual 17
- unable to take personal safety into account in decision making- will eat food even if clearly spoiled
8 Perseveration46 - Repeats same actions over and over.
- such as tapping or rocking in a chair47 - Repeats same words or phrases.
- includes repetition of syllables or sounds48 - Repeatedly shouts or calls out.
9 Motor Restlessness49 - Desire to pace or walk almost constantly.
- different from aimless wandering, i.e. faster50 - Can't sit still; restless; fidgety.
- e.g. restlessly moving from chair to chair (or in wheel chair, etc.)51 - Tries doors, windows.
- seems unable to inhibit the tendency to use handles and knobs on things- exit seeking behaviour
10 Sleep/Activity/Sundowning52 - Falls asleep at uncharacteristic times.
- during conversations or during meals, or increased daytime sleep53 - Gets up and wanders or awakens frequently at night more than usual. 54 - Sleeps more.
- more than usual55 - Behaviour more agitated or impaired in late afternoon.
- ADL is more impaired in late afternoon or early evening; exacerbation of already problematicbehaviours
11 Motor/Spatial ProblemsScore even if due to physical problems e.g. arthritis, vision, etc.
56 - Poor coordination seen in limb/finger movements. - e.g. difficulty using pens or pencils, or moving a cup to one’s mouth- includes tremor
57 - Slowness of movement.58 - Unsteadiness when walking.59 - Has trouble dressing, especially with buttons or shoelaces.
- struggles to put on clothes the right way - lefts and rights frequently mixed up or clothes sometimes onbackwards
60 - Difficulty judging object sizes or how near an object is from themselves.- may make exaggerated steps to step over something quite low, such as a crack in the floor, change incarpet colour
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KSBA Manual 18
12 Language Difficulties61 - Reads far less frequently than they used to.62 - Substitutes some words for others.
- substitutes an incorrect term for an object or uses a nonsensical word- makes substitutions usually without knowing it
63 - Does not watch or follow television. 64 - Does not speak unless spoken to. (e.g. Does not participate in conversations.) 65 - Often cannot find the right word.
- halted speech while struggling to find the right word66 - Trouble pronouncing words. 67 - Does not understand simple commands, explanations. 68 - Does not produce meaningful speech.
- caregiver cannot reliably understand person’s requests or responses.
Items Found Only in the Long Term Care Form
1 Daily Activities2 - Resistant to bathing.3 - Refuses to leave own room.5 - Does not like being touched.6 - Combines foods not usually eaten together. i.e. mixes food on plate7 - Refuses to eat.8 - Drools on self, clothing.10 - Eats other’s food at meal time.18 - Smears faeces.
2 Attention/Concentration/Memory21 - Easily distracted by surrounding noises.22 - Places things in inappropriate places.
3 Emotional Behaviour27 - Expresses suicidal feelings, threatens to hurt him/herself
4 Aggressive Behaviour30 - Throws things at, or pinches others.
5 Misperceptions/Misidentifications36 - Sees or hears things that are not there.37 - Talks to pictures or mirrors.
7 Judgement/Insight43 - Seeks constant attention.44 - Eats non-food items.45 - Grabs others nearby.46 - Shows increased sexual drive, interest.48 - Accident prone, gets hurt a lot.50 - Invades personal space.
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KSBA Manual 19
8 Perseveration53 - Talks about same topic over and over again.55 - Clapping/noise making.
9 Motor Restlessness59 - Repeatedly rearranges furniture.60 - Bangs head deliberately.12 Language Difficulties74 - Speaks in meaningless phrases, or unintelligible language.
© Copyright 2008 [Jan 2008]
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Is It Alzheimer’s Disease? 10 Warning Signs Checklist for Individual/ Family
www.alzheimer.ca Memory loss that affects day-to-day function
It’s normal to occasionally forget appointments, colleagues’ names or a friend’s phone number and remember them later. A person with Alzheimer’s disease may forget things more often and not remember them later, especially things that have happened more recently.
Difficulty performing familiar tasks Busy people can be so distracted from time to time that they may leave the carrots on the stove and only remember to serve them at the end of a meal. A person with Alzheimer’s disease may have trouble with tasks that have been familiar to them all their lives, such as preparing a meal.
Problems with language Everyone has trouble finding the right word sometimes, but a person with Alzheimer’s disease may forget simple words or substitute words, making her sentences difficult to understand.
Disorientation of time and place It’s normal to forget the day of the week or your destination-for a moment. But a person with Alzheimer’s disease can become lost on their own street, not knowing how they got there or how to get home.
Poor or decreased judgment People may sometimes put off going to a doctor if they have an infection, but eventually seek medical attention. A person with Alzheimer’s disease may have decreased judgment, for example, not recognizing a medical problem that needs attention or wearing heavy clothing on fa hot day
Problems with abstract thinking From time to time, people may have difficulty with tasks that require abstract thinking, such as a balancing a cheque book. Someone with Alzheimer’s disease may have significant difficulties with such tasks, for example not recognizing what the numbers in the cheque book mean.
Misplacing things Anyone can temporarily misplace a wallet or keys. A person with Alzheimer’s disease may put things in inappropriate places: an iron in the freezer or a wristwatch in the sugar bowl.
Changes in mood or behaviour Everyone becomes sad or moody from time to time. Someone with Alzheimer’s disease can exhibit varied mood swings-from calm to tears to anger- for no apparent reason.
Changes in personality People’s personalities can change somewhat with age. But a person with Alzheimer’s disease can become confused, suspicious or withdrawn. Changes may also include apathy, fearfulness or acting out of character.
Loss of initiative It’s normal to tire of housework, business activities or social obligations, but most people regain their initiative. A person with Alzheimer’s disease may become very passive, and require cues and prompting to become involved.
B
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Use corresponding numbers to record in ½ intervals. 1. Sleeping in Bed 5. Restless, Pacing 2. Sleeping in Chair 6. Exit Seeking 3. Awake/Calm 7. Aggressive –verbal 4. Noisy 8. Aggressive – physical
YMD
Time 0730 0800 0830 0900 0930 1000 1030 1100 1130 1200 1230 1300 1330 1400 1430 1500 1530 1600 1630 1700 1730 1800 1830 1900 1930 2000 2030 2100 2130 2200 2230 2300 2330 2400 0030 0100 0130 0200 0230 0300 0330 0400 0430 0500 0530 0600 0630 0700 Schindel Martin, L. (1998). The dementia observational system: A useful tool for discovering the person behind the illness. Long Term Care, 8(4), 19-22.
Dementia Observation System
B
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YMD 07/01/08 07/01/09 07/01/10 07/01/11 07/01/12 07/01/13 07/01/14
Time 0730 3 3 3 4, 7 3 3 3 Buspar 5mg 0800 3 3 3 4, 7 3 3 3 0830 2 3 3 4, 7 4, 5 3 3 0900 3 2 3 4, 7 2 4, 6 2 0930 4 4, 5 3 2 4, 5 4, 6 3 1000 4, 5 5, 6 2 3 4, 7 2 3 1030 3 4 5, 6 3 2 4, 6 3 1100 3 3 4 3 3 4, 6 4, 5 1130 3 3 4, 5 3 3 3 4, 5, 6 1200 3 3 4, 5 3 3 3 4, 5, 6 1230 3 3 4, 5 3 3 3 3 1300 3 3 3 4, 5 3 3 3 1330 3 3 3 3 3 3 3 1400 3 3 3 3 3 3 3 1430 3 3 3 3 3 3 3 1500 3 4, 5 3 4, 5 4, 7 3 3 1530 3 4, 5 3 3 4, 7 3, 4 4, 7 1600 3 4 3 4 4, 7 3, 4 4, 7 1630 3 3 3 3 4, 7 3 4, 7 1700 3 3 3 3 4, 7 3 4, 7 1730 3 3 3 3 4 3 4 1800 4, 5 3 4 7 3 3 4 1830 4, 5 3 4 7 3 3 4 1900 4, 5 5, 7 1 3 3 3 4 1930 4, 5 5, 6, 7 1 3 3 3 4 Buspar 2.5mg 2000 4, 5 5, 6, 7 1 3 4, 5 3 4 2030 4 5, 6, 7 1 3 4, 5 3 3 2100 1 5, 6, 7 1 3 4, 5 3 3 2130 1 5, 6, 7 1 3 4, 5 3 3, 4, 6 2200 1 3, 7 1 1 4, 5 3 3, 4, 6 2230 1 7, 3, 6 1 1 4, 5 1 3, 4, 6 2300 1 6, 7, 6, 4 1 1 4, 5 1 3, 6 2330 1 6, 7 1 1 4, 5 1 3, 6 2400 1 6, 4, 1 1 1 4, 7 1 3, 6 0030 1 4, 7, 4 1 1 6, 4, 3 1 3, 6 0100 1 4, 7 1 1 3, 4, 6 1 3, 6 0130 1 4, 7, 4 1 1 6, 4 1 3, 6 0200 1 4, 6 1 1 4, 1 3, 6 0230 1 3, 4, 3 1 1 4, 6 1 1 0300 1, 3 4 1 1 4, 6 1 1 0330 1 4, 6, 7 1 3, 4 4 1 1 0400 1, 3 4 1 4, 5 4 1 1 0430 1, 3 4 1 5, 4, 7 4 1 4 0500 3 4 1 4, 6, 5 4 1 4 0530 3 4 1 4 3 1 1 0600 3 4 1 4, 5 4 1 4 0630 3 4 1 4 3 1, 3 3 0700 3 4 1 3 3 3 3
Dementia Observation System Use corresponding numbers to record in ½ hr intervals 1. Sleeping in Bed 3. Awake/Calm 5. Restless, Pacing 7. Aggressive -verbal 2. Sleeping in Chair 4. Noisy 6. Exit Seeking 8. Aggressive - physical
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Dementia Observational System (D.O.S) Schindel Martin, L. (1998). The dementia observational system: A useful tool for discovering the person behind the illness. Long Term Care, 8(4), 19-22. Why do we use the D.O.S.? The D.O.S. is used to assess the person’s activities over the course of a 24 hour cycle; it is an attempt to answer the clinical question “What is the rhythm of this person’s day?”
This tool provides the clinical team with information that will replace opinion with measurable data and helps to determine if there is evidence to support a behavioural diagnosis such as a sleep pattern disturbance.
The D.O.S. also helps to determine the % of time over the 24 hour cycle that the person displayed a behaviour of concern, such as the vocally disruptive; it helps the team to determine if interventions are helping to reduce the frequency of any behaviour of interest; this tool is most helpful because it replaces opinion with measurable data by establishing the:
• Occurrence of a distinct behavioural entity • Frequency with which target behaviours occur • Duration the target behaviour is displayed • Frequency with which the target behaviours of the GREATEST risk are display in comparison
with those behaviours that should be ACCOMODATED
General Information The D.O.S. is a caregivers’ descriptive worksheet that comes in two versions:
1. Standardized
• Has behavioural key that tracks sleep, calm/awake noise, restlessness, exit-seeking, verbal aggression, and physical aggression
• Most useful for the person who is newly admitted and has a scant behavioural history; use this to determine what behaviours the person is likely to display that might require an intervention plan
2. Individualized
• Has behavioural key that describes up to eight behaviours; these target behaviours can be well-
defined and written on the form to capture the unique characteristics of the person’s profile • Designed so that the lower the number assigned to the behaviour, the lower the associated risk • The higher the number, the higher the associated risk with that behaviour
Note: for both versions it is very important to include positive behaviour labeled, as “awake/calm”.
If behavioural key does not include these anchors, portions of the 24 hours map will either be left blank or staff will write descriptors into the squares, resulting in inconsistencies. It is recommended for both versions that the first three anchors remain the same i.e. “sleeping in bed, sleeping in chair, awake and calm.
This is important because if you are evaluating a behavioural or psychopharmacological intervention, you will need to know if the target behaviour reduces in frequency simply because the person is sleeping a good deal of the time as a side effect of medications that are either introduced or titrated to higher doses.
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When do you use the D.O.S.? • Upon admission for the first 7 – 14 days, using the standardized version to establish a baseline for
behavioural profile • Whenever there is a change or concern in the person’s typical behavioural profile • Whenever the team needs an outcome measure to determine if the target behaviour has changed in
frequency and duration How do we administer the D.O.S.?
• Select the corresponding number from the behavioural key that best describes the person’s behaviour within the time period and record that in the slot provided under the appropriate date.
• Record the behaviour in 30 minute intervals for the duration of 7 –14 days or as directed by the
clinical leader.
It is important to keep the following principles in mind: • Consult with the health care aides when designing the individualized behavioural key so that it is
representative of the behaviours they are observing and a “team approach” to care.
• Review the observational record as frequently as possible and give staff positive feedback for completing it, so the recorders see that it is a useful tool.
• Don’t worry if pieces of time are missing from the record, you will still likely be able to get a better picture of what is going on in a 24 hour cycle over 7-14 days than you would if you only had the progress records available to you.
How do we interpret the results? Using coloured highlighter pens, assign colours to each of the numbers on the behavioural rating key;
collapse categories using one colour. For e.g., on both versions of the record, categories 1 and 2 represent sleep pattern, therefore a single colour can be used for numbers 1 and 2. If you have the following colours available, it is most helpful to assign them in the following fashion:
BLUE: sleep GREEN: calm/awake (or any other category that represent neutral behaviour) YELLOW: restlessness, low level agitation ORANGE/PINK: higher level agitation and verbal aggression RED: physical aggression • Using the coloured markers, colour each 30 minute square, for each 24 hour cycle with the
appropriate colour. • For each 24-hour column, calculate the number of hours spent in sleep, calmness, restlessness, verbal
aggression/agitation, and physical aggression • Summarize your analysis in the person’s progress record with a note that describes the total number
of days of the record, ranges of hours spent in each category of behaviour, and any significant negatives. E.g., “There is no evidence on the Dementia Observational Record of any periods of physical aggression during the 7-day period of observation”; “The periods of noisemaking are episodic and time-limited, ranging from 1-3.5 hours in length, usually occurring between 1700 –1900 hours.”
• Communicate your findings to the appropriate team members, e.g., the physician who may be using it as one piece of data to consider in making a decision to start or change a medication.
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Using the DOS as a Tool to Assist You in Working With Your Family Health Team
(adapted from P.I.E.C.E.S. Dementia Observation System) Included below are some tips to assist you to use the Behavioural/Dementia Observation System to gather and communicate important information about new and distressing behaviors. This information will help you and your family doctor and other members of the care team to determine the best approach to care.
In conversation with your healthcare team decide what behaviors are of greatest concern or risk.
Some of the changes in behavior most often reported by families are listed below:
− suspiciousness − accusing others − physically threatening − rapid emotional changes − threatening to harm self − tearfulness
− agitation − verbally threatening − sleeping during the day − awake at night − repetitive actions that are disruptive
This list may help you and your healthcare team to identify the behaviors of greatest concern. Have a look at the list as this may help you and the health care team describe and identify what you are seeing. Because everyone is different there may be something that you and your family member may be experiencing that is not on the list.
Together with the team choose only a couple of behaviors to monitor at one time.
Complete the Behavioural/Dementia Observation System as best as you can for 3-4 days.
Each behavior you have identified is given a number and is written at the top left hand
corner of the page. For example: 1. Pacing
2. Awake at night
Over the course of the 3 days when the identified behavior occurs mark the corresponding number/s in the appropriate time slot – if more than one of the identified behaviours occur at the same time include the corresponding numbers in the same time slot.
It is not necessary to get up at night to record night-time behaviors. It is sufficient to record these behaviors the next morning.
EXAMPLE 1. Pacing 2. Awake at night
Date → Monday Tuesday Wednesday Thursday Friday COMMENTS 3:00am 1 2 1 4:00 am 2 2 1
B
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BEHAVIOURAL/DEMENTIA OBSERVATION SYSTEM NAME
1.
2.
3.
Date →
COMMENTS
7:00 am
8:00 am
9:00 am
10:00 am
11:00 am
12:00 pm
1:00 pm
2:00 pm
3:00 pm
4:00 pm
5:00 pm
6:00 pm
7:00 pm
8:00 pm
9:00 pm
10:00 pm
11:00 pm
12:00 am
1:00 am
2:00 am
3:00 am
4:00 am
5:00 am
6:00 am
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The 7 D’s to Define Severity: Monitoring Response for Behaviour and Psychosis
P.I.E.C.E.S.
Patient’s Name: Date:
A// DANGEROUS 1. Dangerousness
Yes No Immediate High Risk
Potential High Risk
Intermediate Low
To Self To Others Residents Caregivers Staff
B// DISTRESS AND INDEPENDENCE 2. Distress (Psychological/ Social) High Intermediate Low Expressed Distress Objective observed (ie agitation)
3. Directing Action 4. Disturbing relationships and defining place of residence
C// DISABILITY 5. Disability (Medical/Functional) Yes No Comments A. Medical
• Affecting physical health & nutrition
• Affecting medical treatment, medical illness (ie.e drug Rx)
B. Functional • Dressing • Eating • Ambulation • Transferring • Hygiene
Other 2 D’s that are useful additional characteristics for monitoring:
1. Distant vs. Present 2. Definitive vs. Fixed
B
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Using the 7 D’s
1) Determining the risk and need for immediate action
2) Defining the disability and need for treatment and what type of treatment (non pharmacological, atypical, dementia drugs)
3) Monitoring response to treatment
4) As a vehicle to assist in collaborative care
*NOTE* The first things to respond to are the:
1) Distress and disturbing characteristics 2) Individual may identify these are occurring more in the
past 3) Then the delusion itself (if ever)
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CONDITIONS EITHER ASSOCIATED WITH AND / OR RESPONSIBLE FOR
COGNITIVE IMPAIRMENT Delirium
Periodic Health Exam Tools for Screening and Identification
Red Flags for Potential Delirium
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Red Flags for Potential Delirium
Over 75 years old Post surgical Chronic illness Previous delirium episode Diagnosis of dementia/cognitive impairment Drugs (polypharmacy, psychoactives anticholinergics,
alcohol abuse) Poor nutritional status (dehydration, malnutrition)
Contributing factors
Sensory losses (sight, hearing) Environmental change Social losses
B
If there is a positive flag consider prevention… 1. Maximizing health 2. Maintaining brain health 3. Educating individual/family about maintaining brain health 4. Consider potential for possible delirium before surgery or
medications or medications
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Red Flags for Potential Delirium
Definition: Collection of red flags for potential delirium from the VIHA website as well as expert opinion.
Red Flags for Potential Delirium
Link to Tool No link available
Time to Administer 5 minutes
Type Non-Standardized Screening Tool
Setting Primary Care
Administration Checklist
Interpretation Red flags for clinical consideration
Reference
Vancouver Island Health Authority (2006). Delirium in the older person: A medical emergency. Retrieved May 20th 2009 from<<http://www.viha.ca/NR/rdonlyres/4DB9F6C8-1105-4B8B-8924-95E3200F2D71/0/decision_tree_09.pdf>>
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Tools for Delirium Assessment and Management
The Confusion Assessment Method (CAM) (see http://www.rnao.org)
Algorithm for Diagnosing Delirium Causes for Delirium Checklist Causes of Delirium: “DELIRIUMS” CHAOS
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Confusion Assessment Method Instrument (CAM)
Definition: The Confusions Assessment Method (CAM) was originally developed to identify delirium quickly and accurately. The full CAM or shortened version can be used to detect the presence of delirium in individuals.
Confusion Assessment Method Instrument (CAM)
Link to Tool
Form only: http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/confusion_assessment.pdf Form, administration and scoring manual: http://www.viha.ca/NR/rdonlyres/0AC07A64-FF24-41E3-BDC5-41CFE4E44F33/0/cam_training_pkg.pdf
Time to Administer 5-10 minutes
Type Standardized Screening Tool
Setting Primary Care
Administration Information is gathered from an interview with the individual and from discussions with caregivers and family members, a review of the individual’s chart, as well as observations by the interviewer.
Interpretation A delirium should be suspected if features 1 and 2 and either 3 or 4 are present. If so, further investigation is warranted to confirm a diagnosis of delirium
Reference
Cole, M. (2004). Delirium in elderly patients. American Journal of Geriatric Psychiatry, 12, 7-21. Dolan, M., Hawkes, W., Zimmerman, S., & Morrison, R. (2000). Delirium on hospital admissionin aged hip fracture patients: Prediction of mortality and 2 year functional outcomes. Journal of Gerontology: Medical Sciences 55A, M527-M534. Inouye, S.K. (2008). The Confusion Assessment Method (CAM): Training manual and coding guide. New Haven: Yale University, accessed, May 2, 2008, from http://elderlife.med.yale.edu/pdf/The_Confusion_Assessment_Method.pdf Inouye, S.K., van Dyck, C.H., Alessi, C.A., Balkin, S., Siegal, A.P. and Horowitz, R.I. (1990). Clrifying confusion: The confusion assessment method: A new method for detection of delirium. Annals of Internal Medicine, 113, 941-948. Milisen, K., Foreman, M.D., Abraham, I.L., De Geest, S., Gooderis, J., Vandermeulen, E., et al. (2001). A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients. The Journal of the American Geriatrics Society, 49, 523-532. Marcantonion, E.R., Flacker, J.M., Wright, R.J., & Resnick, N.M. (2001). Reducing delirium after hip fracture: A randomized trial. The Journal of the American Geriatrics Society, 49, 516-522.
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Algorithm for Diagnosing Delirium
Determining Diagnosis
Key Question
• Has there been a significant change in last few weeks? • Has the family/friends noted an acute change in their ability to communicate? • Has there been an acute change in capabilities?
Think 3 C’s
hange
ommunicate
apabilities
C
C
C
If Delirium, What’s the Cause? Think 4 Ms
4 M’s
edicine; over the counter, prescription starting, stopping and drug interactions, substances (alcohol) edical illness;
(1) Particularly cardiac or respiratory (2) Re-emergence of past or chronic illness (3) New acute illness, i.e., UTI, pneumonia, etc.
icrobials; infections etabolic (hemalogical)
M
M
M
M
B
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Causes for Delirium Checklist
MEDICINES Prescribed Medication : New Ones Yes No : Withdrawn recently Yes No : Syndrome of sudden compliance Yes No :Adherence problems (mixing up meds) Yes No Over-the-Counter Medication Yes No (Remember over the fence) Substance Misuse :Alcohol Yes No :Other Yes No MEDICAL ILLNESS Myocardial Infarction Yes No Respiratory Yes No Hypoxia Yes No Relapse or new medical illness Yes No MICROBIALS Infection, Particularly UTI or pneumonia Yes No METABOLIC Hydration Yes No Others Yes No
Remember! Usually multiple causes.
Remember! One cause may be found as initial reason followed by another cause causing a relapse or responsible for lack of recovery
Remember! Many times, it is delirium and no cause is found
B
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Causes of Delirium: “DELIRIUMS”
D Drugs: (Prescription, OTC, Herbal, Alcohol) Minimize anticholinergic load
E Emotional: (Depressed, Mania/ Depression) and Environment
L Low O2 States (MI, CHF, COPD, Pulmonary Embolus)
I Infection: Pulmonary / Urinary / Abdominal / Skin: Deep Decubitus
R Retention: Urinary and Feces
I Ictal: Seizures
U Under: Hydration, Nutrition, Sleep
M Metabolic Changes: Blood Sugar, Calcium & Sodium
S System Failure: Stroke, Subdural and Stress
A useful acronym when looking for underlying cause(s) of a delirium is the acronym "DELIRIUMS" (see above). There are many potential causes of delirium but the big “4” cause of delirium are drugs, infection, system failure and metabolic. It is important to appreciate that in many cases there are multiple predisposing and precipitating factors present.
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CHAOS Treatment Checklist With permission from author Jean Nelson
CHAOS Treatment Checklist C Eliminate cause, calm gentle approach (Think 4M’s) H Hydrate, nourish A Ambulate (Ensure mobility is maintained) O
Orientate, increase observation • Ensure consistent environment, people (family
and staff), good lighting etc • Remember, do not challenge misperceptions but
address fears, provide structure and reassurance S Set free, address safety, sleep, sensory needs,
stimulation and socialization • Avoid unnecessary sedation and restraints
Reminder: 4 M’s (Causes of Delirium)
1. Medicine 2. Medical 3. Metabolic 4. Microbials (infections) B
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Depression Office and Primary Care Checklists
Signs of Depression: SIG E CAPS
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Name of Resident/Client: Date:
Signs of Depression: “SIG E CAPS”
S Sleep is disrupted
I Interest is decreased
G Guilt (feelings of guilt, having regrets, etc)
E Energy is lower than usual
C Concentration is poor and memory problems may occur
A Appetite is disturbed, usually a loss of appetite accompanied by weight loss
P Psychomotor retardation or agitation
S Suicidal ideation, at leas a passive wish to die, is frequently present
B
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SIG E CAPS
Definition: An acronym which reflects the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV, American Psychiatric PR, 4th Edition, June 15, 2000 criteria for major depression
SIG E CAPS
Link to Tool No Link Available
Time to Administer 1 Minute
Type Non Standardized Assessment Tool
Setting
Administration Observe the patient for the listed criteria
Interpretation If 5 symptoms are present, the patient likely suffers from a major depressive episode which will require active treatment.
Reference
References: Dr. Carey Cross Jenike, M. (1989). Geriatric Psychiatry and Psychopharmacology: A clinical approach. p. 36. Chicago: Yearbook Medical Publishers Inc.
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Tools for Mood / Anxiety Assessment and Management
Cornell Scale for Depression NICE Job Aid for Depression
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Cornell Scale for Depression Person Name: _________________________ Administered: _____________Date:____________ Administered at (check one) Assessment ________ By: _______________ Discharge _________ Mood-related Signs 1. Anxiety………………………………….……. _____ anxious expression, ruminations, worrying 2. Sadness……………………………….………. _____ sad expression, sad voice, tearfulness
3. Lack of reactivity to pleasant events………. _____ 4. Irritability………………………………………______ Easily annoyed, short tempered
Cyclic Functions 12. Diurnal variation of mood symptoms worse in the morning .................................. ____ 13. Difficulty falling asleep later than usual for this person ................... ____ 14. Multiple awakenings during sleep................ ____ 15. Early morning awakening earlier than usual for this person ................. ____
Behavioural Disturbance 5. Agitation………………………………... …… _____ restlessness, handwringing, hairpulling 6. Retardation…………………………………… _____ slow movements, slow speech, slow reactions 7. Multiple physical complaints (score 0 if GI symptoms only)..................... _____ 8. Loss of interest less involved in usual activities (score only if change occurred acutely, i.e. less than 1 month) ....................................... ___
Ideational Disturbance 16. Suicide
feels life is not worth living, has suicidal wishes, or makes suicide attempt................ ____
17. Poor self-esteem
self-blame, self-depreciation, feelings of failure.............. ............................................ ____
18. Pessimism
anticipation of the worst............................... ____ 19. Mood-congruent delusions delusions of
poverty, illness, or loss ....................... ____
Physical Signs 9. Appetite loss eating less than usual................................ ___ 10. Weight loss (score 2 if greater than 5 lbs. in 1 month) ................. ............................................ ___ 11. Lack of energy fatigues easily, unable to sustain activities (score only if change occurred acutely, i.e. in less than 1 month)………………….. ____
Scoring System Ratings should be based on symptoms and signs occurring during the week prior to interview. No score should be given if symptoms result from physical disability or illness. 0 = absent 1 = mild or intermittent 2 = severe N/A = unable to evaluate
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Cornell Scale for Depression in Dementia
Definition: The Cornell Scale for Depression in Dementia was designed to assess signs and symptoms of major depression in people with cognitive impairment.
Cornell Scale for Depression in Dementia
Link to Tool Tool: www.emoryhealthcare.org/departments/fuqua/CornellScale.pdf
Time to Administer
30-40 minutes
Type Standardized assessment tool
Relevance For use in community, hospital and long term care facilities
Administration
Scores are determined by a combination of prior observation and two interviews: 20 minutes with the caregiver and 10 minutes with the patient. All symptoms (occurring on a regular, persistent basis only) are rated for severity in three grades;
0= absent 1= mild or intermittent 2= severe
No score is given if the interviewer is unable to evaluate the symptom. The administration and scoring guidelines should be read and the assessor should be familiar with the instrument before attempting the Cornell. The guidelines provide detailed information about how to ask each question and the meaning of the questions. The answers should be based on symptoms from the week prior to the interview.
Interpretation Depressive symptoms are suggested by a total score of 8 or more.
Reference Alexopoulos, G.S. (1988) Cornell Scale for Depression in Dementia. Biological Psychiatry, 23(3), p.271-284.
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The Cornell Scale for Depression 77B
Why do we use the Cornell?
The Cornell provides a quantitative rating of depression in persons with or without dementia. The scale was designed to utilize information obtained from caregivers, as well as an interview with a person. Frequent coexistence of depression and dementia in older people suggested the need for a depression-rating instrument designed specifically for use in this group.
The Cornell is found to be reliable, sensitive and valid in rating depression in a population of demented subjects with various degrees of depression. Scoring is based on both observation and verbal feedback. The scale is designed as screening tool and is not diagnostic (Alexopoulous, Abrams, Young, Shamoian, 1988). .
How do we administer the Cornell?
Administration requires two separate interviews. The clinician first interviews the person's caregiver:
• During the caregiver interview, the clinician inquires about the signs and symptoms of
depression as they appear on the scale.
• Additional descriptions can be used to clarify to the caregiver the meaning of an item.
• The clinician assigns preliminary scores to each item of the scale on the basis of the caregiver's report.
Next, the clinician briefly examines the person using the Cornell scale items as a guide. • If there is disagreement between the clinician's impression and the caregiver's report,
the caregiver is interviewed again in order to clarify the source of discrepancy. • Finally, the clinician scores the Cornell scale based on his/her judgement formed
during this process. Please note: Two items, “loss of interest” and “lack of energy” require both a disturbance occurring during the week prior to interview and relatively acute changes in these areas occurring over less than one month.
The Scale
• 19 questions distributed within five major headings (mood-related signs, behavioural disturbance, physical signs, cyclic functions and ideational disturbance).
• Each question is scored on a three-point scale: 0 = absent; 1 = mild or intermittent; 2
= severe; n/a = unable to evaluate.
• The item "suicide" is rated with a score of “1” if the person has passive suicidal ideation, e.g. feels like life is not worth living.
• A score of “2” is given to subjects who have active suicidal wishes, or have made a
recent suicide attempt. • History of a suicide attempt in a subject with no passive or active suicidal ideation
does not in itself justify a score. • The clinician is to mark an “n/a” when an item cannot be evaluated.
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• Older persons often have disabilities or medical illnesses with symptoms and signs
similar to those of depression. Scoring of the Cornell scale on such items as "multiple physical complaints", "appetite loss", "weight loss", "lack of energy" and possibly others may be confounded by disability or physical disorder.
• To minimize assignment of falsely high Cornell scale scores in disabled or medically
ill persons, raters are instructed to assign a score of "0" for symptoms and signs associated with these conditions. In many cases the relationship between symptomatology and physical disability or illness is obvious. In some persons, however, this determination cannot be made reliably.
• There is a maximum score of 38. The ratings are based on behaviours observed or
reported the previous week. • The five categories (mood-related signs, behavioural disturbance , physical signs,
cyclic functions, and ideational disturbance) provide a format to assist the interviewer in organizing his/her assessment interviews and observation. The total time for administration and rating of the Cornell Scale is approximately 30 minutes.
How do we interpret the results? (adapted from: Alexopoulous et al., 1988, p. 232, Table 2)*:
Caution must be used when interpreting the score. It is important for the clinician to note the exact responses. This will allow a more consistent interpretation of the scores in each area when the tool is used.
Average Cornell Ratings
No psychiatric diagnosis
1.4
Non-depressive psychiatric disorders 4.8 Minor or probable major depressive disorder 12.3 Definite major depressive disorder 24.8
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Are my older patients at higher risk of depression?
Risk factors socially isolated
persistent complaints of memory difficulties
chronic disabling illness
major physical illness within the last 3 months
persistent sleep difficulties
somatic concerns or recent-onset anxiety
refusal to eat or neglect of personal care
recurrent or prolonged hospitalization
diagnosis of dementia, Parkinson’s disease, or stroke
recent placement in a nursing/LTC home
Available depression assessment tools for elderly persons without significant cognitive impairment:
• Geriatic Depression Scale (GDS) • the SELFCARE self-rating scale • the Brief Assessment Schedule Depression Cards (BASDEC)
Available depression assessment tools for elderly persons with moderate to severe cognitive impairment:
• Cornell Scale for Depression in Dementia
Further Assessment:
A complete biopsychosocial assessment should be
conducted following a positive screen for depression.
Details for this assessment are listed on the reverse.
If your patient is recently bereaved active suicidal ideation
guilt not related to the deceased
psychomotor retardation
mood congruent delusions
marked functional impairment (2 months after loss)
reaction that seems out of proportion to the loss
CANADIAN COALITION FORSENIORS’ MENTAL HEALTH
To promote seniors’ mental health by connecting people, ideas and resources
COALITION CANADIENNE POUR LA SANTÉMENTALE DES PERSONNES ÂGÉES
Promouvoir la santé mentale des personnes agées enreliant les personnes, les idées et les ressource
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PHARMACOLOGICAL / NON PHARMACOLOGICAL APPROACHES
Pharmacological Approaches
Behavioural and Psychological Symptoms of Dementia (BPSD) Algorithm
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Behavioural and Psychological Symptoms of Dementia (BPSD) The Right Medication, at the Right Time, for the Right Reason
Tools
• 7 D’s• DOS
Strategies
• Consider Atypical Antipsychotics• Environmental/ Interaction Strategies
• Algorithm for Diagnosing Delirium
• Treat the 4M’s• CHAOS
• Consider Type of Dementia•Dementia Staging (FAST)
Is it an Emotional
Disturbance?
• SIG E CAPS• Cornell• The A’s of Dementia
• Consider Antidepressant (Mood stabilizer)
Is it Due to Brain/
Behaviour?• 7A’s
• Consider Cholinergics/ Memantine
PreventionLooking Back
Looking Forward
Is it a Delirium?
Is it Dangerous/ High Risk?
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Psychotropic Job Aids
Psychotropic Job Aid for the Physician Psychotropic Job Aid for the Collaborator Cognitive Enhancers: Monitoring Side Effects
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Antipsychotic medications for 1. Persistent and distressing psychotic symptoms or agitation that is not responsive to non-pharmacological interventions or 2.
Continuation of treatment of schizophrenia and delusional disorders that preceded dementia.
Preferred (first line) choices & anticholinergic activity -/+ to ++
Usual starting
dose
Average (A) & Maximum (M) recommended
doses
Monitoring response and side effects All atypical antipsychotics can cause side effects. However, side effects more common
with specific medications are outlined below.
All have been noted to have increased associated mortality but may also prevent
serious injury. Discuss risk/benefits for informed decision and consent.
Quetiapine + 25-50 mg undetermined (A) (M) Hypotension and oversedation, mild anticholinergic properties at
higher doses, some weight gain. Sedation may occur early but full antipsychotic effect usually takes several weeks.
Wide titration range. If no effect within 150 mg daily, may consider changing medication.
Risperidone +/- 0.5 mg
1 mg daily (A) 2-3 mg daily (M)
Hypotension and extrapyramidal side effects.
Olanzapine ++ 2.5 mg 5-7.5 mg (A) 10 mg (M) Weight gain and increased vascular risk factors (lipid profile,
diabetes). Hypotension, anticholinergic side effects (dry mouth, constipation, etc.).
Beyond 10 mg daily, anticholinergic activity may worsen dementia and cause delirium.
Haloperidol -USED IF ACUTE DELIRIUM SHORT-TERM
0.5mg 1-2 mg (A) 5 mg/day (M)
Extrapyramidal symptoms (rigidity, Pisa syndrome, shuffling gait, tremors, etc.) if used more than a few days.
Used mostly in acute management of delirium when no Lewy Body Dementia. If possible LBD, consider quetiapine or trazodone for short-term
sedation.
Usually not first line treatment: Chlorpromazine is very anticholinergic and hypotensive. Continuation of older neuroleptics may however be warranted in some patients with schizophrenia, particularly when switching to newer (atypical) antipsychotic medication has failed to control schizophrenia. May consider Loxapine or Perphenazine if atypicals fail.
Pharmacological treatment of delirium: Use haloperidol unless Lewy Body Dementia (see above notes) or withdrawal delirium from alcohol or benzodiazepines, when we recommend using a benzodiazeopine such as Lorazepam 1- 2 mg Q 2 hours initially until symptoms improve or sedation occurs. Re-assess Q 6-8 hours on the first day to adjust dosage, provide symptom
control without oversedation and estimate daily dose to taper from. Take more than twice the time to taper the benzodiazepine than with younger patients.
Treatment of dementia: cognitive enhancers (donepezil, rivastigmine, galantamine and glutaminergic agents (memantine)
Choices Risk evaluation and possible contra-indications
Usual starting dose Maximum recommended dose
Monitoring and side effects.
Donepezil (Aricept)
5 mg daily for 4 to 6 weeks
10 mg daily
Rivastigmine (Exelon)
1.5 mg BID for 4 weeks, increase by 1.5
mg BID Q 4 weeks
6 mg BID with meals
Galantamine (Reminyl)
Breathing problems (asthma, COPD) Peptic ulcers (esp. if ASA or NSAID is
also taken) Seizures Syncope, bradycardia and second degree block on ECG (B-blockers) Heart disease
(CHF, CAD) Drug interactions (anticholinergics decrease efficacy and some SSRIs can increase blood levels:
e.g. paroxetine, fluoxetine and fluvoxamine
ER 8 mg AM for 4 weeks then, 16 mg in
AM for 4 weeks and 24 mg if no SE
ER 24 mg Q AM
May improve cognition, socialization, prevent decline in ADLs. May save caregiver time. Watch for “MIND”: • Muscle cramps; • Insomnia and
agitation • Nausea & vomiting (if titration too rapid); (consider propantheline 7.5-15 mg or domperidone 10 mg TID if severe) • Diarrhea •
Weight loss with longer term use.
May improve cognition, socialization, ADLS and decrease BPSD in moderate to severe Alzheimer Disease and vascular dementia Most
common side effects: Confusion, Headaches, Agitation, Insomnia and Dizziness Urinary incontinence and UTIs can occur. Hallucinations if dose
too high.
10 mg BID * 5 mg BID if CrCl less than 60
5 mg daily X 1 week 5 mg BID X 1 week 10
mg AM and 5 mg in PM X 1 week 10 mg BID
Not recommended if severe renal impairment Antacids may increase
blood levels
Memantine (Ebixa)
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Antidepressants: Indicated when there is a depressive or anxiety disorder appearing or continuing during the course of dementia: to prevent relapse in recurrent or persistent mood and anxiety disorders.
Preferred (first line) choices & anticholinergic activity - /+ to ++
Usual starting dose
Average (A) & Maximum (M) recommended doses
Monitoring response and side effects Notes
Citalopram (SSRI) +
10 mg 20-30 mg (A) 40 mg/day (M)
Escitalopram (SSRI) +
5 mg 10 mg (A) 20 mg (M)
Sertraline (SSRI) ++
25 mg 100 mg (A) 200 mg (M)
• Headache, Hyponatremia • Agitation • Nausea • Diarrhea • Sweating • Somnolence • Initially watch for increased agitation, sleeplessness,
suicidal ideation and excessive drowsiness. Monitor serum sodium levels at baseline and in first month of treatment. Sertraline: mild anticholinergic activity
• Individuals usually do not feel subjectively better for 6-8 weeks
Other SSRIs: Paroxetine, fluoxetine, fluvoxamine have more common or severe drug interactions; prolonged side effects (weeks) with fluoxetine due to long elimination half-life
Venlafaxine (SNRI) -
37.5 mg 150 mg (A) 225 mg (new Max dose, 300 mg previously
Headaches, nausea, elevated BP with higher doses, may also cause hypo-natremia
Watch for suicidal risk when “energy” increased but still despondent.
Mirtazapine(NASA) ++
15 mg 30 mg (A) 45 mg (M)
Dry mouth, Drowsiness, weight gain, dizziness, mild anticholinergic activity
Bupropion (NDRI) -/+
100 mg Wellbutrin SR (M=150mg) XL: M=150 BID
Seizures, Headaches, Agitation, Rash, Emesis, Sleep disturbance and possible increase in blood pressure
Advanced dementia also associated with increased seizure risk.
Moclobemide (RIMA) -
150 mg 450 mg (A) 600 mg (M)
Monitor for hypotension. When combined with MAO-B (Eldepryl), MAOI diet/full precautions needed. Interactions: Carbamazepine, narcotics, Sympathomimetic
In doses up to 600 mg/day, no dietary precautions needed.
Trazodone (SARI) is currently used mostly for HS sedation rather than its antidepressant properties. Initial dose 25-50 mg HS. May need to be repeated as short duration of sedation. Occasionally used during the day in severe BPSD.
Watch for hypotension
Usually not first line treatment: Tricyclics since they have more anticholinergic activity and are more likely to cause hypotension. SSRI: Selective Serotonin Reuptake Inhibitor, SNRI: Serotonin, Norepinephrine Reuptake Inhibitor, NASA: NorAdrenergic and specific Serotoninergic Antidepressant; SARI: Serotonin-2 Antagonist/Reuptake Inhibitor; RIMA: Reversible Inhibitor of Monoamine Oxydase of type A
Revised August 8, 2007. J. Kenneth LeClair, MD. Marie France Rivard, MD.
“H.A.N.D.S.”
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Three-Question Framework for Selection and the Detection, Monitoring the Use, Risk, and Benefits of Psychotropics
1. When should a psychotropic be used or considered? 2. How do I select the right medication? 3. How do I monitor the response and side effects (with person, family, providers)?
Are the benefits outweighing the risks and side effects (to this treatment vs. other treatments)??
How long is the medication to be used, and when is it to be reviewed? What are the indicators for increasing or decreasing the medication? If no response, consider non-adherence, wrong diagnosis, wrong dose, or not enough time.
CLASS Preferred choices, starting doses
Side Effects
Notes & max. recomm. doses SSRI Citalopram (10 mg), Escitalopram
(5-10 mg), Setraline (25 mg): preferred
Paroxetine, fluoxetine, fluvoxamine: more common or severe drug interactions; prolonged side effects with fluoxetine
Headache, Agitation, Nausea, Diarrhea,
Sweating, Somnolence
Monitor for hyponatremia. Anticholinergic effects: paroxetine
Initially, watch for increased agitation,
sleeplessness, increased suicidality or
excessive drowsiness. Monitor sodium in
first month of Rx. Individuals usually do
not feel subjectively better for 6-8 weeks
SNRI Venlafaxine (37.5 mg)
Headache, nausea, elevated BP in higher doses. Watch for suicidal risk when “energy” increased but still despondent. Max. recommended dose: 300 mg daily
NASA Mirtazapine (15 mg)
Dry mouth, drowsiness, weight gain, dizziness: mild anticholinergic activity
Weight gain can be substantial. Maximum recomm. Dose: 45 mg
NDRI Bupropion (100 mg)
Seizures, Headache, Agitation, Rash, Emesis, Sleep disturbance
Maximum recommended dose: 150 mg BID
SARI Trazodone (25-50 mg)
Drowsiness and orthostatic hypotension Used more for sedation than for antidepressant effect. Effects last approx. 4 hours
RIMA Moclobemide (150 mg) Monitor for hypotension. When combined with MAO-B (Eldepryl), MAOI diet/full precautions needed
In doses up to 600 mg per day, no dietary precautions required. Given BID from 300 mg to 600 mg daily
STIMULANT Methylphenidate (5 mg in morning) Cardiovascular risks: high BP, agitation, sleeplessness Usually not a first line treatment
TRICYCLIC Avoid most TCAs, Nortriptyline or Deipramine may be considered in treatment resistant depression
(C)ardiovascular: Orthostatic hypotension
(dizziness), falls, pulse rate Anti(C)holinergic: Urinary retention constipation, dry mouth, blurred vision (C)onfusion: Monitor with the C.A.M.
Usually not a first line treatment
Important Note: • Withdrawal symptoms are associated with many
psychoactives, including SSRIs (flu-like symptoms). The dose must be reduced slowly and the status monitored closely.
HANDS
SHARES
3 C’s
P.I.E.C.E.S. Psychotropic Template-Collaborative Care August 2009
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Later
Initial
Atypical Antipsychotics Newer Antipsychotics – Side Effects to Monitor Clinical Response
Common Olanzapine
Risperidone Quetiapine
Advantages of New Antipsychotics • Less EPS • Less risk of developing tardive dyskinesia • Less cognitive effects • May stabilize mood
Dizziness, Agitation (early), Somnolence, Hypotension May cause weight gain May cause tachycardia, with higher doses – EPS Watch for sedation
Cautions: • Lipid increases • Insulin resistance (glucose changes) • Weight gain • Potential cardiovascular events
The clinical factors to monitor include the 7 parameters of delusion: 1. Dangerous, threatening 2. Distressing to self 3. Disturbing to others 4. Direct Action, if acting on them 5. JeoparDizing independence 6. Distant or present 7. Definite (fixed) vs insight Tranquilizing effect usually occurs early; however, resolution of psychosis may take 1-2 months
Traditional antipsychotics or neuroloeptics Traditional Antipsychotics - Side Effects to Monitor Mainly used if delirium High potency Haloperidol
• Constriction: EPS: rigidity, tremors, showed movements, drooling, leaning
to one side, parkinsonian gait and falls
Mid potency Loxapine, Perphenazine
• Less EPS but more anti-cholinergic than haloperidol
Low potency Chlorpromazine • Anti-Cholinergic side effects, Confusion, Cardiovascular side effects In general, should be avoided
If it is an anxiolytic, what class is it? Side Effects to Monitor Response Benzodiazepine Lorazepam, Oxazepam,
Alprazolam, Temazepam, Clonazepam
Confusion and memory problems, ataxia (poor balance) and falls, disinhibition leading to inappropriate or aggressive behaviour
• decreased agitation and anxiety • Rapid response within 1-2 hours • Best in panic attacks or catastrophic reactions
Mood stabilizers Side Effects to Monitor Response Lithium Carbonate
Ataxia and falls, confusion, weakness, diarrhea usually when serum level is greater than 0.8 mmol/L some GI upset in early treatment. Polyuria, tremor may occur at therapeutic doses. Maintain serum levels between 0.4 to 0.7 mMol/L
• stabilization of mood and behaviour within 2-4 weeks at therapeutic dose/level
• Mostly used when previous recurrent mood disorder, particularly bipolar illness
Antiepileptic Na Valproate, Carbamazepine, Lamotrigine
Sedation, ataxia, nausea; if there is bruising or bleeding of any type, call physician. Check if drug levels and blood work done regularly (liver, hematology). Watch for rashes particularly with Lamotrigine.
• May be considered in lability of mood and behavioural problems in dementia
Drugs to treat Dementia
Side Effects to Monitor Response
Cholinesterase
inhibitors
Donepezil, Rivastigmine, Galantamine
Muscle cramp, Insomnia, Nausea, Diarrhea and weight loss Slow pulse, heart block, peptic
• Improve or prevent decline in ADLs, Behaviour, Cognition, and Decrease caregiver time (ABCD)
Cognitive Enhancers (Potential Problems)
© P.I.E.C.E.S.TM Consultation Team & Associates Sept 2007
Breathing Problem Seizures Nausea and peptic ulcer Low pulse (bradycardia)
Pam Hamilton BA Curriculum and Education Consultant. Joanne Collins. RSW. Curriculum and Education Consultant Diane Harris R.N. MSc CHRD, CPT. Performance & Learning Consultant, Project Coordinator J. Kenneth LeClair MD, FRCP(C). Clinical Advisor, Curriculum & Education Consultant Marie France Rivard MD, FRCPC(C). Chair, Steering Committee for P.I.E.C.E.S. for Family Physicians
Glutaminergic agent
Side Effects to Monitor Response
Memantine
• Indicated for moderate to severe dementia
Confusion, Headache, Equilibrium, Constipation,
Kidney function
• Cognition - improved • Socialization – improvements • Household tasks • ADLs - improved function • Persecutory thoughts decreased • Excessive activity/irritability decreased • Caregiver time saved
DASH
MIND
4C’s
CHECK C-SHAPES
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Cognitive Enhancers – Monitoring Side Effects Date: _____________________ Name: _____________________________________
Medication & Dose: ______________________ Time on Medication: ________________ A. Common Side Effects
B. MINDFUL (Relative Risk to Cholinergic Enhancer)
Tools/
Score Better Stable Worse Comments
C Cognition Person, Partner, Practitioner
S Socialization Apathy, Communication
H Household Tasks Telephone, Table, Tasks (identify for individual)
A ADL Toilet, Washing (identify for individual) P Persecutory Ideation
(Delusions) Delusions (7 D’s)
E Excessive Activity Agitation, Cohen/DOS S Saving Caregiver Time
(1) ECG results: _________________________________________________________________________ ___ (2) Psychotropics and medical drugs of relevance:_______________________________________________
(3) Other issues: _________________________________________________________________________
Memantine Cholinergics: Donepezil, Rivastigmine, Galantamine
CHECK
Absent Mild Moderate Severe MIND
Absent Mild Moderate Severe
C Confusion (with dose )
H Headache Muscle cramps
E Equilibrium Insomnia
C Constipation Nausea
K Kidney Function
Diarrhea
MINDFUL
Seizures (anesthesia)
Cardiac (conduction bradycardia)
Respiratory (Asthma)
GI (ulcer NSAIDS)
seizures cardiac bradycardia
asthma (RAD)
history of ulcers NSAIDS use
C. MONITORING Memantine Response
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Tools and Tailoring to the Individual
For Memantine and Cognitive Enhancers in Moderate Dementia Cognition
• Consider Global Impression of person, partner and practitioner along with standardized tools. • Consider unique cognition of “importance” to the person/partner.
(What could they do 3 months ago?) • Tools such as Folstein have basement effect. Use of analogues, KSCA, SIB components.
Socialization
• Communication may be the first sign “an awakening” may be described apathy may improve as well as involvement in groups usually seen at 1 month (may be later or earlier).
Household Tasks
• In studies, measured use of telephone, watching television, disposal of garbage, clearing dishes from table, finding his or her belongings (make it person-relevant).
ADL
• Toilet use, washing, motility, drinking/eating. Persecutory Ideation (Delusions)
• Noted to prevent emergence, may improve, not an acute treatment (takes time—months). Excessive Activity (Agitation)
• Although improved or prevented in some people, can be a side effect Saving Caregiver Time (Studies have shown over 1 hour/day)
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Non Pharmacological Approaches
Crisis Intervention: Non Pharmacological Approaches Top 8 Non Pharmacological Approaches
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Crisis Intervention: Non Pharmacological Checklist Phaneuf, M. Le viellissement perturbé: la maladie d’Alzheimer. 2nd ed; (2007)
Voyer, P. Soins infirmiers aux aines en perte d’autonomie: Une approche adapée au CHSLD. A// SAFETY
Secure the environment Remove ongoing triggers Remove potentially dangerous objects Move other individuals away Make sure you are safe (exit available) B// SETTING THE TONE
Stay Calm: The patient will be receptive to your mood and mirror it
Be compassionate and affectionate: Ask the person “What would you like to happen?” C// INTERVENTION (Also see Non Pharmacological Approaches Sheet)
Establish visual contact
Approach slowly, head on. Be aware of zone of comfort
If fear for safety put a chair between you and patient
Recognize how patient is feeling
Get on the patient’s side ie. “you will help”
Distract patient. If you know the person’s greatest achievement or what made him/her proud or was important to them, “steer” the conversation in that direction
DO’S AND DON’TS OF DELUSION/HALLUCINATION INTERACTIONS
Do ensure the person’s and your safety
Do understand this is a response to their reality
Do focus your efforts on how patient feels, not the content
Do offer distraction
Do enquire how this is affecting the person
Don’t confront the false belief
B
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8 Non-Pharmacological Approaches to Dementia
Thank you to Pam Hamilton for content contributions
1. Life Story~ Getting to know the person (artful distraction)
2. Stigma~ Getting your own house in order
3. Communication~ What you are saying
4. Interaction & Space~ How you are saying it
5. Errorless Learning
6. Control to Patient
7. Validate Feelings
8. Environment
B
Remember ERRORS Environment Reception (Vision, hearing, non verbal) Regulation (Balance capabilities, stimulation) Organization (7A’s) Reality (PIECES) Support caregivers
Remember the dementia changes, the Thinking, Emotional and Instinctual Brain
Remember behaviour needs to be understood before it can be managed
• Thinking Brain; Remember the 7 A’s of dementia and how they alter the way the person understands and reacts to the world
• Emotional/Instinctual Brain; As dementia progresses or under stress, the instinctual brain and emotional brain responses are seen
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APPROACH HOW WHY
LIFE STORY
Getting to know the person (Artful Distraction)
• Know, use, share • Use info you know from the past to meaningfully
distract, reassure, validate (Amnesia) • Know mountaintop experience (proud, positive
emotions) • Know traumatic (abuse, stressful times, war, negative
emotions)
Most emotionally powerful memories are easiest to trigger~ Can use mountaintop experiences to help distract and knowledge of Traumatic experiences will help avoid problems
STIGMA
Get your own house in
order
• Address and dismiss negative attitudes or myths you may believe about the aging process and dementia in particular
• Work to understand the disease and how it uniquely affects individuals. The better your understanding, the better able to help.
• Negative attitudes lead to failure of diagnosis, lack of treatment, medical, surgical conditions, involving people in decisions, premature placement
• Understand that “No” might not mean they do not want to do something, just that they don’t know how (Apraxia)
COMMUNICATION What you are saying
• Use primary positive meaning (Front loading, the positive, avoid No, don’t, stop, wait in your sentences)
• Think of what you are asking (ie. if Habitual Memory could cuing work better?)
INTERACTION AND
SPACE How you are saying it
Nonverbal communication
• Think 4 comfort zones (crowd, stranger, friend, whisper)
• Think non verbal (sorry, smile, calm) • eye contact, introduce, go slowly, use past memories,
validate, non confrontational, pitch, allow time for response, speak to them as adult, respect personal space, respond to emotion when words don’t make sense
• Only 20% of communication is verbal
• Emotional Brain—person responding emotionally and words (thinking brain) may not make sense
ERRORLESS LEARNING AND
COMMUNICATION BRIDGES
• Supportive communication strategies aligned with strengths and deficits
• Conversations are often not equal; need to provide bridges, cues, to dialogue
CONTROL TO PATIENT
• Always ask what you would like to happen • Often, patient is feeling overwhelmed, out of control
VALIDATE FEELINGS
• Person with dementia lives in moment but may only has access to info from the past (Amnesia)
• With Anosognosia has no knowledge of illness, therefore their reality is as real as yours
• Their reality often is what was their reality between age 3-30
ENVIRONMENT A// Consider the “A’s” and what they influence • Cover mirrors if no longer able to recognize
self/others (Agnosia) • Do not have doors and walls the same colour (Altered
perception) • Dark tiles and carpet look like holes (Altered
perception) B// Consider the cues that will orient the person to the task C// Consider the time of day and routine D// Consider modeling the behaviour or providing prompts
• Time warp delusions • Altered perception leads to
Hallucinations OR illusion (misperceiving what is there)
• Sundowning (Altered Perception) with changing light
• Loss depth perception
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