reducing use of antipsychotic medications in long …...objective •describe the burdens and risks...

Reducing Use of Antipsychotic medications in Long-Term Care Residents with Dementia:

Ten Best Practices

Abhilash K. Desai, MDGeriatric Psychiatrist

Idaho Memory & Aging Center, PLLCAdjunct Associate Professor

University of Washington School of [email protected]

Disclosure Information• I will receive royalties for a book I co-authored with Dr. George

Grossberg (a nationally and internationally renowned Geriatric Psychiatrist and Alzheimer’s Expert) from Cambridge University Press for the 2nd edition of our book titled Psychiatric Consultation in Long-Term Care: A Guide for Healthcare Professionals; 2017.

• I have no other financial relationships with commercial interests to disclose.

• I do intend to discuss off-label uses of antipsychotics, antidepressants, and dextromethorphan-quinidine for management of behavioral and psychological symptoms of dementia.

Objective• Describe the burdens and risks of using antipsychotics in

long-term care populations.

• Using real-life cases, discuss Ten Best Practices to reduce antipsychotic use in long-term care residents with dementia.

• Discuss barriers to overcome so that the routine use of best practices becomes a norm in caring for long-term care residents.

Bottom Line• “We seek to work towards transforming our culture

to one honoring human dignity...Let’s be companions together on this journey.”

– Friedell and Bryden, Talk given at the Australian National Conference April 2001.

Key Burdens and Risks of Antipsychotics

• Black Box Warnings in individuals with dementia: stroke and death• Other serious and life-threatening risks:

• Aspiration pneumonia• Hospitalization• Falls and fracture, head injury and other injuries• Dysphagia• Delirium• Extrapyramidal syndrome (Parkinsonism, Akathisia)• Tardive Dyskinesias

• Adverse effects• Sedation, agitation, insomnia, fatigue, dysphoria, loss of appetite,

weight gain

– American Psychiatric Association 2016 Practice Guideline for the use of antipsychotics in the treatment of agitation or psychosis in patients with dementia. www.psychiatryonline.org/guidelines

Key Burdens and Risks of Antipsychotics

• New evidence indicates that for many patients with Alzheimer’s disease, antipsychotics can be tapered and discontinued without significant signs of withdrawal or return of behavioral symptoms.

– Rabins et al. Guideline Watch. Practice Guidelines for the treatment of patients with Alzheimer’s disease and other dementias. 2014. American Psychiatric Association www.psychiatryonline.org/guideilnes

Ten Best Practices

• 1: DICE Model and STAR Model (with nurses leading the way)

• 2: Accurate routine measurement of outcomes

• 3: Rational Deprescribing (with Primary Care Providers leading the way,

preferably in collaboration with consultant pharmacists)

• 4: Pain Management: ATMAN Approach (with Primary Care Providers leading

the way)

• 5: Identification and treatment of reversible physical health conditions (with

Primary Care Providers leading the way)

Ten Best Practices• 6: SPPEICE (with recreational therapists, activity therapists and social workers

leading the way)

• 7: STEPS (with nurses and social workers leading the way)

• 8: Rational Non-Prescribing (Medications to avoid for treatment of insomnia and agitation) (with PCPs leading the way) and Rational Prescribing: (with PCPs leading the way)

• 9: Consult Specialists (e.g., recreational therapists, geriatric psychiatrists, music therapists, art therapists).

• 10: Spiritual care (with Chaplains leading)

DICE Model• Proposed by Dr. Helen Kales, Director, Center for Positive Aging, University

of Michigan School of Medicine and her team.

• Describe (neuropsychiatric symptoms)

• Investigate (causes, triggers, contributing factors)

• Create (intervention care plan)

• Evaluate (response to interventions)

– Kales et al. Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel. Journal of

American Geriatrics Society 2014;62:762-769.– http://www.programforpositiveaging.org/diceapproach/

STAR Model• Safety • Team assessment• Action Plan• Response to treatment

– Desai and Grossberg. Chapter 2. The Assessment Process. Book: Psychiatric Consultation in Long-Term Care: A Guide for Healthcare Professionals. 2nd

edition. Cambridge University Press 2017.

Perspectives of Persons with Dementia

• Every effort should be made to understand the experiences and perspectives of persons with dementia.

– Desai, Grossberg and McFadden. Book chapter. Understanding experiences and perspectives of persons with dementia Dementia Care: An evidence-based approach. Marie Boltz and James E. Galvin, Eds. Springer, NY. 2016.

Accurate Measurement of Outcomes• Identifying, measuring (frequency, severity) and tracking two or more most

distressing symptoms and or harmful behaviors.

– American Psychiatric Association 2016 Practice Guideline for the use of antipsychotics in the treatment of agitation or psychosis in patients with dementia. http://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426807.

http://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426807

Rational Deprescribing

• Identify and discontinue medications that are inappropriate in older adults in collaboration with the pharmacist based on the Beers Criteria and STOPP START criteria.

• Identify and discontinue medications that are causing adverse effects, are not in keeping with goals of care, or have not shown clear benefits.

– Desai and Grossberg. Chapter 12. Rational Deprescribing. Book: Psychiatric Consultation in Long-Term Care: A Guide for Healthcare Professionals. 2nd

edition. Cambridge University Press 2017.

Pain Management: ATMAN Approach• A: Acetaminophen, Anti-inflammatory medications (e.g., celecoxib)• T: Topical analgesics (including joint injections)• M: Migraine medications, Muscle relaxants • A: Anticonvulsants, Antidepressants (SNRIs)• N: Non-drug interventions for pain management (e.g., hot and cold

therapies, exercise therapy, massage therapy)

– Husebo et al. Efficacy of treating pain to reduce behavioral disturbances in residents of nursing homes with dementia: cluster randomized clinical trial. BMJ 2011.

– Desai and Grossberg. Chapter 11. Psychiatric aspects of pain and palliative care. Book: Psychiatric Consultation in Long-Term Care: A Guide for Healthcare Professionals. 2nd edition. Cambridge University Press 2017.

Rx of Reversible Physical Health Conditions

• Constipation• Urinary tract infection• Dehydration• GERD• Vitamin deficiencies (e.g., B12, Vitamin D)• Pressure ulcers• REM Sleep Behavior Disorder• Restless Leg Syndrome• Other conditions

– Desai and Grossberg. Chapter 3. Major Neurocognitive Disorders. Book: Psychiatric Consultation in Long-Term Care: A Guide for Healthcare Professionals. 2nd edition. Cambridge University Press 2017.

SPPEICE• Strengths-based Personalized Psychosocial sensory nutritional

Environmental Initiatives and Creative Engagement (aka Non-

pharmacological interventions)

– Desai and Grossberg. Chapter 13. Psychosocial Spiritual Wellness Care Plan.

Book: Psychiatric Consultation in Long-Term Care: A Guide for Healthcare Professionals. 2nd edition. Cambridge University Press 2017.

– Livingston et al. Dementia Prevention, Intervention, and Care.

2017;6736(17):31363-31366.

STEPS• Staff Training Empowerment Praise Support (e.g., therapeutic

communication / relationship building communication techniques)

– Desai and Grossberg. Chapter 13. Psychosocial Spiritual Wellness Care Plan. Book: Psychiatric Consultation in Long-Term Care: A Guide for Healthcare Professionals. 2nd edition. Cambridge University Press 2017.

American Association of Sleep Medicine 2017 Practice Guideline for Treatment of Chronic

Insomnia • The guideline suggests that we Do NOT use trazodone, diphenhydramine,

tiagabine, melatonin, tryptophan or valerian for treatment of chronic insomnia.

– Sateia et al. Clinical practice guideline for the pharmacological treatment of chronic insomnia in adults: An American Association of Sleep Medicine Clinical Practice Guideline. 2017;13(2):307-349.

National Institute of Clinical Excellence (NICE)• Valproate is no more effective than placebo for the treatment of agitation in

persons with dementia.

– NICE Evidence Summary March 2015 www.nice.org.uk/guidance/esuom41.

Citalopram• Citalopram was more effective in individuals with dementia who had less

severe agitation and less severe cognitive impairment.

– Porteinsson et al. Effects of citalopram on agitation in Alzheimer’s disease: the CiTAD randomized controlled trial. JAMA 2014;311:682- 691.

– Livingston et al. Dementia Prevention, Intervention, and Care. 2017;6736(17):31363-31366.

Dextromethorphan-Quinidine• Dextromethorphan-quinidine is approved for treatment of Pseudobulbar

Affect (PBA)

• A pilot RCT suggest benefit in the treatment of agitation in persons with dementia.

– Cummings et al. Effect of dextromethorphan-quinidine on agitation in patients with Alzheimer’s disease dementia: a randomized clinical trial. JAMA 2015;314:1242-54.

Methylphenidate for Apathy• A pilot RCT suggest benefit in the treatment of apathy in persons with

dementia.

– Padala et al. Methylphenidate for apathy in community dwelling older veterans with mild Alzheimer’s disease: a double-blind randomized placebo-controlled study. American Journal of Psychiatry 2018;175:159-168.

DeliriumMulticomponent Interventions: Prevention and Treatment of Delirium:

frequent reorientation, engagement in cognitively stimulating activities, promotion of sleep with sleep-inducing stimuli (e.g., relaxation tapes, warm milk) and a sleep-promoting environment (e.g. noise reduction), encouragement of physical activity, use of visual and auditory aids, early treatment of dehydration.

Use of antipsychotics does not reduce delirium scores. Individualized management of delirium precipitants and supportive strategies result in lower scores and shorter duration of target distressing delirium symptoms than when risperidone or haloperidol are added.

Agar et al: Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care. A randomized clinical trial. JAMA Internal Medicine 2017;177:34-42.

Major Depression Guidelines• Canadian Network for Mood and Anxiety Treatments (CANMAT)

Pharmacological Treatment of Late-Life Depression: Level 1 evidence:

mirtazapine, duloxetine, nortriptyline. Others Level 2 evidence.

– MacQueen et al. CANMAT 2016 Clinical Guidelines for the Management of Major

Depressive Disorder. Section 6: Special Populations: Youth, Women and the

Elderly. Canadian Journal of Psychiatry 2016;61(9):588-603.

Generalized Anxiety Disorders Guidelines

• Escitalopram, paroxetine, venlafaxine, duloxetine, buspirone.

– Katzman et al. Canadian Clinical Practice Guidelines for the management of anxiety, post-traumatic stress and obsessive compulsive disorders. BMC Psychiatry 2014;Suppl 1.

PTSD Guidelines• Sertraline, Fluoxetine, Paroxetine and Venlafaxine recommended (Va

Guidelines); SSRIs (Australian Guidelines).

– VA / DoD Guidelines for the treatment of PTSD 2010 https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGClinicianSummaryFinal.pdf

– Australian PTSD Guidelines 2013 http://phoenixaustralia.org/wp-content/uploads/2015/03/Phoenix-ASD-PTSD-Guidelines-Summary.pdf

Parkinson’s Disease Psychosis• Pimavanserin approved by the FDA for the treatment of

PDP.

Cholinesterase inhibitors and memantine

• New studies indicate that cholinesterase inhibitors (donepezil, rivastigmine, galantamine) and memantine have no clinically significant effects on disruptive behaviors.

• Rabins et al. Guideline Watch. Practice Guidelines for the treatment of patients with Alzheimer’s disease and other dementias. 2014. American Psychiatric Association www.psychiatryonline.org/guideilnes

Consult Specialists• Recreational therapists• Geriatric Psychiatrists• Geriatricians• Music therapists• Art therapists• Occupational therapists• Speech and Language therapists (Cognitive Communication Specialists)• Other specialists


Spiritual Care• Chaplains• Dignity therapy• Meaningful rituals• Gratitude jar


Seven Key Barriers to Overcome• Lack of Joy at work

• Lack of Knowledge and Skills

• Knowledge and Skills not put into routine Practice

• Institutional inertia

• Lack of access to psychiatrists with expertise in long-term care psychiatry

• Lack of access to geriatricians and geriatric psychiatrists

• Lack of home based dementia care (HBDC)

– Desai and Grossberg. Chapter 14. Person-Centered Long-Term Care

Communities: A Road Map. 2nd edition. Cambridge University Press 2017.

Seven Key Strategies to Barriers to Overcome

• Institute for Healthcare Improvement Framework for Improving Joy in Work (http://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Improving-Joy-in-Work.aspx)

• HBDC• Technology (includes telepsychiatry; electronic decision support; ECHO

project)• Continuous case-based education and training of prescribers (on Practice

Guidelines and Best Practices) and caregivers (family and professional)• Hands on training of staff in therapeutic communication skills• Quality improvement measures targeting reduction in antipsychotic use• Culture change practices by the institution

– Desai and Grossberg. Chapter 14. Person-Centered Long-Term Care Communities: A Road Map. Psychiatric Consultation in Long-Term Care: A Guide for Healthcare Professionals, 2nd edition. Cambridge University Press 2017.

Strategies to Barriers to Overcome

GRADE• Many guidelines (e.g., the American Psychiatric

Association Practice Guidelines on the use of antipsychotics for the treatment of agitation and psychosis in persons with dementia) are rated according to GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) which is used by multiple professional organizations around the world to develop practice guideline recommendations.

– Guyatt et al 2013.

Terms• Grade A: High confidence that evidence reflects true effect and

further research unlikely to change the confidence level

• Grade B: Moderate confidence and further research may change the confidence level

• Grade C: Low confidence and further research is likely to change the confidence level

– Agency for Healthcare Research and Quality 2014.

15 Recommendations• 1. Assess type, frequency, severity of symptoms (C)

• 2. Assess for pain, subtype of dementia, other modifiable contributors (C)

• 3. Assess response to treatment with a quantitative measure (C)

– APA 2016 Guidelines.

15 Recommendations• 4. Comprehensive treatment plan with appropriate person centered

nonpharmacological and pharmacological interventions (C)

• 5. Non-emergency use of antipsychotics used only when symptoms are severe, are dangerous, and or causing significant distress (B)

• 6. Reviewing clinical response to nonpharmacological interventions prior to starting antipsychotics (C)


15 Recommendations• 7. Risks and benefits discussed prior to starting antipsychotics (C)

• 8. If benefits outweigh risks, start low and use minimum effective dose (B)

• 9. If adverse effects occur, review risks and benefits again regarding discontinuing antipsychotics (C)


15 Recommendations• 10. If response not clinically significant with adequate dose for 4

weeks, taper and discontinue the antipsychotic (B)

• 11. If positive response, discuss criteria for tapering, past trials, and continued risks with family (C)

• 12. If positive response, attempt to taper and discontinue within 4 months unless past failure of taper (C)


15 Recommendations• 13. Assess for recurrence once a month during taper and for 4

months after discontinuation (C)

• 14. Haloperidol should not be used as first line except for delirium related severe agitation (B)

• 15. Long-acting injectable antipsychotic medication should not be used (B)


Quantitative Measures• Neuropsychiatric Inventory Questionnaire (NPI-Q)

• Section E of Minimum Data Set (MDS)

• Cohen Mansfield Agitation Inventory (CMAI)

• Rating of behaviors on a Likert scale (never, rarely, sometimes,

often, always)


Doses of antipsychotics and monitoring

• One third to one half the starting doses used for younger adults or the smallest tablet strength available; May titrate upwards if partial response and no adverse effects.

• Abnormal Involuntary movement scale (AIMS) done every six months to monitor emergence of Tardive Dyskinesias.

• Baseline BMI, HbA1c, lipid profile and 12 weeks later and periodically (q3-6 months) after that.


Antipsychotics• Second Generation Antipsychotics preferred over First Generation

Antipsychotics (e.g., haloperidol)

• Risperidone found effective against psychotic symptoms

• Risperidone, olanzapine and aripiprazole effective against agitation

• Insufficient evidence with quetiapine for psychotic symptoms or agitation


Second Generation Antipsychotics• In patients with dementia with Lewy bodies and Parkinson’s disease

dementia, quetiapine and clozapine are preferred over other SGAs.


Improving appropriate use of antipsychotics

• Educational activities.

• Electronic clinical decision support


Definitions / Understanding of various terms

• Adequate dose: dose tested in clinical trials that has been found to be effective. Dose may need to be adjusted based on liver and kidney functions, etc.

• Adequate response: 50% or more reduction in symptoms


Definitions / Understanding of various terms

• Agitation: A state of excessive motor activity, verbal aggression or physical aggression to oneself or others that is accompanied by observed or inferred emotional distress

– Cummings et al 2015.

Evidence regarding Aripiprazole• Three randomized controlled trials.• 1. For BPSD (behavioral and psychological symptoms of dementia):

Confidence moderate. Effect: small.

• 2. For agitation: Confidence low. Effect: small.

• 3. For psychosis: Confidence low. Effect: nonsignificant


Evidence regarding Olanzapine• Three randomized controlled trials.

• 1. For BPSD: Confidence low. Effect: very small.

• 2. For agitation: Confidence moderate. Effect: very small.

• 3. For psychosis: Confidence insufficient. Effect: nonsignificant


Evidence regarding Quetiapine• Three randomized controlled trials.

• 1. For BPSD: Confidence low. Effect: nonsignificant.

• 2. For agitation: Confidence insufficient. Effect: nonsignificant.

• 3. For psychosis: Confidence insufficient. Effect: nonsignificant


Evidence regarding Risperidone• Three randomized controlled trials.

• 1. For BPSD: Confidence moderate. Effect: very small.

• 2. For agitation: Confidence moderate. Effect: small.

• 3. For psychosis: Confidence moderate. Effect: small


Average, Maximum Doses, and Dose Range of Aripiprazole in RCTs

• Average: 10 mg / day

• Maximum: 15 mg / day

• Dose range: 2-15 mg / day


Average, Maximum Doses, and Dose Range of Olanzapine in RCTs





Average, Maximum Doses, and Dose Range of Quetiapine in RCTs





Average, Maximum Doses, and Dose Range of Risperidone in RCTs

• Average: 1mg / day

• Maximum: 2mg / day

• Dose range: 0.5-2 mg / day


Average, Maximum Doses, and Dose Range of Haloperidol in RCTs

• Average: 1.5 mg / day


• Dose range: 0.5-4 mg / day


Strength of Evidence (confidence level) for Adverse effects: Mortality

• Grade A (high): SGAs > placebo

• Grade A (high): FGAs > SGAs

• Grade B (moderate): Haloperidol > Risperidone > Quetiapine


Confidence level: Adverse effects• Grade C (low): Stroke

• Grade C (low): Myocardial infarction and other CVS events

• Grade C (low): Pulmonary events

• Grade C (low): Cognitive changes


Adverse effects• Grade C (low): Falls and hip fracture

• Grade C (low): Diabetes

• Grade C (low): Urinary symptoms


Adverse effects• Grade B (moderate): Sedation / fatigue

• Grade B (moderate): Extrapyramidal signs and symptoms

• Grade B (moderate): Weight gain


Appropriateness of antipsychotics: Level 1-5 (1=highly inappropriate; 5=highly

appropriate)• Dangerous Agitation: New agitation and assessment finds a short-

term reversible cause (e.g., acute delirium, medication-induced, environmental causes)– Aripiprazole : 3– Haloperidol: 4– Olanzapine: 3– Quetiapine: 4– Risperidone: 4– Ziprasidone: 2



appropriate)• Dangerous Agitation: New agitation and assessment does not find a

short-term reversible cause – Aripiprazole : 3– Haloperidol: 3– Olanzapine: 4– Quetiapine: 4– Risperidone: 4– Ziprasidone: 3



appropriate)• Persistent Dangerous Agitation and assessment does not find a




appropriate)• Are there other antipsychotics (FGAs or SGAs) that are highly

appropriate for management of Dangerous Agitation?

• 86% said No (N=170)

• 14% said Yes (N=28). Perphenazine and to a lesser extent

fluphenazine were considered appropriate



appropriate)• New Non-Dangerous Agitation and assessment does find a short-

term reversible cause – Aripiprazole : 2– Haloperidol: 2– Olanzapine: 2– Quetiapine: 2– Risperidone: 3– Ziprasidone: 1



appropriate)• New Non-Dangerous Agitation and assessment does not find a




appropriate)• Persistent Non-Dangerous Agitation and assessment does not find a




appropriate)• Are there other antipsychotics appropriate for non-dangerous

agitation?

• 92% said No.

• 8% said Yes. Perphenazine



appropriate)• New Dangerous Psychosis: New agitation and assessment finds a




appropriate)• New Dangerous Psychosis: New agitation and assessment does not

find a short-term reversible cause – Aripiprazole : 3– Haloperidol: 4– Olanzapine: 4– Quetiapine: 4– Risperidone: 5– Ziprasidone: 3



appropriate)• Persistent Dangerous Psychosis: New agitation and assessment

does not find a short-term reversible cause – Aripiprazole : 4– Haloperidol: 3– Olanzapine: 4– Quetiapine: 4– Risperidone: 5– Ziprasidone: 3



appropriate)• New Non- Dangerous Psychosis and assessment does find a short-

term reversible cause – Aripiprazole : 2– Haloperidol: 2– Olanzapine: 3– Quetiapine: 3– Risperidone: 3– Ziprasidone: 1



appropriate)• New Non- Dangerous Psychosis and assessment does not find a




appropriate)• Persistent Non- Dangerous Psychosis and assessment does not

find a short-term reversible cause – Aripiprazole : 3– Haloperidol: 2– Olanzapine: 3– Quetiapine: 3– Risperidone: 3– Ziprasidone: 2



appropriate)• Are other antipsychotics appropriate for non-dangerous psychotic

symptoms

• 88% said No.

• 12% said Yes. Perphenazine and clozapine


Taper and Discontinue• 50% recommended taper and discontinuation over around 4 months

for dangerous persistent agitation management

• 60% recommended taper and discontinuation over around 4 months for dangerous persistent psychotic symptoms


Disciplines / focus of research: researchers and clinicians

• 70% psychiatrists• 40% geriatrics• 20% neurology• 15% nursing• 5% internal medicine• 4% family medicine


How long in practice? researchers and clinicians (n=185)

• >20 years: 54%

• 11-20 years: 21%

• 5-10 years: 12.5%

• < 5 years: 12.5%


Degree of clinical experience? researchers and clinicians (n=185)

• Substantial 75%

• Moderate 25%


Antipsychotics you would refuse to prescribe

• None: 86• Ziprasidone: 34• Haloperidol: 28• Olanzapine: 17• Aripiprazole: 10• Quetiapine: 4• Risperidone: 3


Grades of Recommendation• A: consistent level 1 studies

• B: consistent level 2 or 3 studies or extrapolations from level 1 studies

• C: level 4 studies or extrapolations from level 2 or 3 studies

• D: level 5 evidence or troublingly inconsistent or inconclusive studies of any level

Oxford Centre for Evidence-Based Medicine. Levels of Evidence. March 2009. http://www.cebm.net/index.aspx?o=1025. Accessed February 24, 2013.

Levels of Evidence• Level 1a: systematic review (SR) (with homogeneity) of randomized

controlled trials (RCTs) OR level 1b: individual RCT (with narrow confidence interval)

• Level 2a: SR (with homogeneity) of cohort studies OR level 2b: individual low-quality RCT

• Level 3a: SR (with homogeneity) of case-control studies OR level 3b: one case-control study

• Level 4: case series

• Level 5: expert opinion without explicit critical appraisal

Limitations of Traditional Medical Model of Care

-Traditional model will not address distress due to unmet psychosocial, environmental and spiritual needs.

-Traditional model does not focus on prevention of behavioral and psychological symptoms of dementia / Bio-Psycho-Social Distress (BPSD)

- Traditional model does not focus on promoting wellbeing (fostering happiness and psychological and spiritual growth)

Person Centered Approach- “it is not possible to achieve person-centered outcomes solely with

traditional medical approaches.”

- Living With Dementia: Changing The Status Quo. 2016. White Paper, Dementia Action Alliance.

Health Care Professionals and Persons Having Dementia (PHD)

• “We’ve been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being.” ~ Atul Gawande (2014,p.259)

• Gawande, A. (2014). Being Mortal: Medicine and What Matters in the End. New York: Henry Holt and Company, LLC.

Person Centered Approach“A person-centered approach embraces

a holistic bio-psychosocial-environmental-spiritual model of care. A person-centered approach considers what is most important to the person, including his or her goals and preferences and seeks to actively promote well-being.”

- Living With Dementia: Changing The Status Quo. 2016. White Paper, Dementia Action Alliance.

Person Centered ApproachThe most disabling effects of cognitive impairment

were found to be the threat to one’s personhood - more than the actual functional impairment.

- Tom Kitwood, geriatric psychologist and father of Person Centered Approaches.

Person Centered Approach• “We’re caught in a transitional phase. However miserable the old

system has been, we are all experts at it. We know the dance moves. With this new way, in which we together try to figure out how to face mortality and preserve the fiber of a meaningful life with its loyalties and individuality, we are plodding novices. We are going through a societal learning curve, one person at a time.”

– Atul Gawande. Being Mortal: Medicine and What Matters in the End. New York: Henry Holt and Company LLC; 2014, p. 193)

Person Centered Approaches• Exercise (e.g., walking program, chair yoga, Tai Chi)• Meaningful activities - continuous activity programming (e.g.,

therapeutic coloring, TimeSlips, cognitive stimulation therapy, humor-based activities, cooking, gardening)

• Sensory approaches (touch, music, aroma, Snoezelen [multisensory room])

• High tech (e.g., simulated presence therapy, personalized music)• Environmental (e.g., safe wandering path, bright light therapy, Eden

alternative, lots of natural light, access to nature)• Spiritual (e.g., prayers, religious rituals and songs)• Mixed (e.g., animal assisted therapy)

Caregiver Education and Training- CMS Hand in Hand: A training series for Nursing Homes Toolkit

- DVD: Bathing Without a Battle (University of North Carolina)

- Alive Inside Movie

- Cognitive Stimulation Therapy (http://www.cstdementia.com)

.

Caregiver Education and Training- TimeSlips (http://www.timeslips.org)

- Onsite Training by Teepa Snow, occupational therapist (http://teepasnow.com)

- It’s Never 2 Late: Dignity through Technology (http://in2l.com)

- DVD: Mouth Care Without a Battle (UNC)

- Dementia Care Mapping (University of Bradford School of Dementia studies https://www.bradford.ac.uk/health/dementia/dementia-care-mapping/)

.

Other Key References- American Psychiatric Association 2016 Practice Guideline for the

use of antipsychotics in the treatment of agitation or psychosis in patients with dementia. http://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426807

- Desai AK, Grossberg GT. Psychiatric aspects of long-term care, In Kaplan & Sadock’s Comprehensive Textbook of Psychiatry, 10e, eds. Sadock, BJ, Sadock VA, Ruiz, P. Philadelphia: Wolters Kluwer 2017; pp. 4221-4232.

.

http://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426807

Other Recommended Resources- American Geriatrics Society 2011 Guide to the management of psychotic

disorders and neuropsychiatric symptoms of dementia in older adults. www.americangeriatrics.org

- American Geriatrics Society. 2015. 2015 Updated Beers Criteria For Potentially Inappropriate Medication Use in Older Adults. American Geriatrics Society Beers Criteria Update Expert Panel. Journal of the American Geriatrics Society 63:2227-2246.

.

http://www.americangeriatrics.org

Recommended Reading- Aging Together: Dementia, Friendship and Flourishing

Communities. Susan H. McFadden and John T. McFadden. 2011. Johns Hopkins Press.

.

Recommended Reading- American Geriatrics Society Expert Panel on Person-Centered Care.

(2015b). Person-centered care: A definition and essential elements. Journal of the American Geriatrics Society, retrieved online on January 4, 2016 at http://onlinelibrary.wiley.com/doi/10.1111/jgs.13866/pdf.

• Dementia Care: An evidence-based approach. Marie Boltz and James E. Galvin, Eds. Springer, NY. 2016.

• Memory: Your Annual Guide to Prevention, Diagnosis, and Treatment. Peter V. Rabins, Johns Hopkins University 2017 White Papers.

.

Recommended Reading- Neuropsychiatric symptoms as predictors of progression of progression to

severe Alzheimer’s dementia and death: The Cache county dementia progression study. American Journal of Psychiatry, May 2015.

- Brasure, M. E. Jutkowitz, E. Fuchs, et al. 2016. Nonpharmacologic interventions for agitation and aggression in dementia. Comparative Effectiveness Review No. 177. AHRQ Publication No. 16-EHC019-EF. Rockville, MD: Agency for Healthcare Research and Quality. www.effectivehealthcare.ahrq.gov/reports/final.cfm

- Kales HC, Gitlin LN, Lyketsos CG, Detroit Expert Panel on Assessment and Management of Neuropsychiatric Symptoms of Dementia. 2014. Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel. Journal of the American Geriatric Society 62(4): 762-769.

.

http://www.effectivehealthcare.ahrq.gov/reports/final.cfm

Local Resources- Alzheimer’s Idaho www.alzid.org

- Alzheimer’s Association Greater Idaho Chapter www.alz.org/Idaho

- Fun Deficit Disorder: The Problems of Loneliness and Boredom in Long-term Care. By Abhilash K. Desai and Faith Galliano Desai. Contact Dr. Desai via email ([email protected]) for pdf.

.

http://www.alzid.org/

http://www.alz.org/Idaho

Bottom Line• “We seek to work towards transforming our culture

to one honoring human dignity...Let’s be companions together on this journey.”

– Friedell and Bryden, Talk given at the Australian National Conference April 2001.

Thank you for your attention

reducing use of antipsychotic medications in long …...objective •describe the burdens and risks...

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