understanding and treating difﬁ cult dementia behaviors…understanding and treating difﬁ cult...

Understanding and Treating Diffi cult Dementia Behaviors…

and How to Talk About It with Your Physician

Speaker: Terri Huh, Ph.D.University of California San Francisco

Sponsored by California’s Caregiver Resource Centers (CRCs) and the Department of Health Services, Alzheimer’s Disease Research Centers of California (ARCCs). Funded by the California Department of Mental Health and a Bristol-Myers Squibb Foundation grant to Family Caregiver Alliance.

www.californiacrc.org© 2006 Family Caregiver Alliance

180 Montgomery Street, Suite 1100San Francisco, CA 94104

© UCSF Over-60 Program 1

• What is dementia?

• Why do we see so many behavior problems in dementia?


DSM IV CriteriaDSM IV Criteria• Memory Problems

Speaking

AND

One or more of the following:

Recognizing things

Planning and Organizing

Motor Planning (Dressing)

1


DSMDSM--IV Criteria Cont.IV Criteria Cont.

Problems interfere with:Relationships (family and friends)

And

At Work


Common Causes of Cognitive Common Causes of Cognitive and Psychiatric Problems or and Psychiatric Problems or

Dementia in the ElderlyDementia in the Elderly

2


Irreversible DementiasIrreversible Dementias

• Alzheimer’s disease• Multi-infarct or

vascular dementia• Parkinson’s disease• Lewy Body disease• Korsakoff’s

dementia

• Creutzfeldt-Jakob disease

• FTLD• Huntington’s disease• AIDS dementia

complex


AD Is the Most Prevalent Type of AD Is the Most Prevalent Type of Irreversible DementiaIrreversible Dementia

Guttman R et al. Arch Fam Med. 1999;8:347-353.McKeith IG et al. Neurology. 1996;47:1113-1124.

Cherrier MM et al. J Am Geriatr Soc. 1997;45:579-583.

VaD, vascular dementia;DLB, dementia with Lewy bodies;FTD, frontotemporal dementia.

, reflects difficulties diagnosing/reporting dementias; only estimations of prevalence can be made.

0

20

40

60

80

100

AD VaD DLB FTD Other

Irrev

ersi

ble

dem

entia

s (%

)

3


Why do you see so many psychiatric, Why do you see so many psychiatric, behavior and thinking problems in behavior and thinking problems in

DementiaDementia??


Planning and Organizing

Visuospatial

FRONTAL

TEMPORAL

OCCIPITAL

PARIETAL

Verbal MemoryandLanguage

Speech

Seeing

Arithmetic

Nonverbal Memory

RelationshipsDepression

4


Brain Atrophy with ADBrain Atrophy with AD

Normal AD

Compare


HEALTHY OLDER ADULT PATIENT WITH ADHEALTHY OLDER ADULT PATIENT WITH AD

5


NFPAFTD SD

3 VARIANTS OF FTLDBehavioral and Cognitive Profile with Brain Atrophy

Disinhibited, Socially inappropropriate, Disorganized,Difficulty with planning

Difficulty with producing but able to understand speech

Repetitive behaviors and intense compulsions Fluent speech but unable to understand language, loss of semantics (meaning of words)

FTD- Frontal Variant FTD; NFPA- Non-fluent Progressive Aphasia; SD-Temporal Variant FTD


Can damaged brain tissue in Can damaged brain tissue in dementia heal?dementia heal?

• No, unlike a broken hip, for example, brain tissue cannot heal.

• With dementia, neurons are dying and the tissue is dead.

• Problems are permanent.• Problems are “progressive” because they

get worse over time.

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Reversible Causes of Reversible Causes of Cognitive and Psychiatric Cognitive and Psychiatric

ProblemsProblems• Intoxications• Infections• Major depression

• Brain tumors• Head injuries • Metabolic

disorders


What are some common What are some common thinking, behavior and thinking, behavior and psychiatric problems that psychiatric problems that persons with dementia have?persons with dementia have?

7


Common challenging behaviorsCommon challenging behaviorsAverage person with dementiaAverage person with dementia

develops about 3 of these:develops about 3 of these:

• Wandering - Becoming lost in familiar places; being unable to follow directions.

• Aggression – physical and or verbal• Repetitive questions or statements – perseveration• Disruptive vocalizations – screaming, moaning• Inappropriate sexual behavior• Paranoia


Additional challenging Additional challenging behaviors:behaviors:

• Throwing objects• Hitting• Scratching oneself• Banging• Pacing

• Severe restlessness• Repeatedly and

inappropriately interrupting others

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Cognitive enhancers and NPSCognitive enhancers and NPSMetaMeta--analysis indicated that treatment with analysis indicated that treatment with cholinesterase inhibitors (CI) decrease behavioral cholinesterase inhibitors (CI) decrease behavioral symptoms (Trinh et al, 2003)symptoms (Trinh et al, 2003)

16 studies16 studies10 show CI > placebo and 1 show placebo > CI 10 show CI > placebo and 1 show placebo > CI

More limited data on More limited data on MemantineMemantineModest improvement overallModest improvement overallUpshot: Upshot:

NPS may improve with cognitive enhancer treatment.NPS may improve with cognitive enhancer treatment.Initiate cognitive enhancer and monitor NPS.Initiate cognitive enhancer and monitor NPS.NPS should not be primary indication NPS should not be primary indication CI may worse NPS in FTDCI may worse NPS in FTD

AntipsychoticsAntipsychotics

Review of RCT shows that overall little Review of RCT shows that overall little significant impact on NPS significant impact on NPS Clinical experience suggests helpful in more Clinical experience suggests helpful in more acute situationsacute situationsGrowing concerns about side effectsGrowing concerns about side effects

Elderly at increased risk Elderly at increased risk tardivetardive dyskinesiadyskinesiaLBD more susceptible to side effectsLBD more susceptible to side effectsBlack box warning (Black box warning (cerebrovascularcerebrovascular events)events)Increased Increased mortailitymortaility risk of deathrisk of death

9


Sensory changes:Sensory changes:

• Persons with dementia have sensory problems that come with age. They may not be able to see or hear as well as before.

• Example: a shadow might be perceived as an uninvited “guest”. A radio in the next room may be perceived as “people living in the walls”. A change in taste might lead a person to believe that they are being “poisoned”.


Additional Features of Additional Features of DementiaDementia

• Delusion: a strongly held false belief (e.g. thinking someone is out to get you when this belief has been shown to be false). With dementia, delusions tend to be more vague and less bizarre.

• Examples of common paranoid delusions: the person believes that someone is stealing something from them; the person begins hiding or hoarding things possibly due to distrust of others and/or self-preservation.

• Examples of delusions related to disorientation to person/place: the person believes s/he is living in the 1940’s, that deceased spouse is still alive, mistaking care workers for family members, etc.

10


Check for medical causesCheck for medical causes• Be sure that the behavior is not because of a

medical problem or possible side effects of a new medication.

• Have care receiver examined by their physician.

• Some medications can cause symptoms of “agitation”.


What are they really trying to tell What are they really trying to tell us?us?

• These reactions are often labeled: “AGITATIONAGITATION””

• Does this label prevent us from thinking about the person with dementia’s experience?

• What might their behavior be telling us?

11


What is dementia likeWhat is dementia like……??

Imagine you no longer recognize things as you used to. You have difficulty remembering where you are and why you are there. The people around you are unfamiliar. They often approach you but you are confused about why…


Behavior as CommunicationBehavior as Communication• How do you feel when

you get confusedconfused?

• What if you had no way of expressing or understanding why you were afraid, confused, or in pain?

• What might you try to do?

• These reactions are often labeled: “AGITATIONAGITATION””

• Does this label prevent us from thinking about the person’s experience?

• What might their behavior be telling us?

12


AdaptiveAdaptive oror AgitatedAgitated??

• Some of these challenging behaviors are actually adaptive.

• They help the person communicate• Remember: dementia has taken away their

ability to communicate in other ways.• How can we try to figure out what they want, and

make changes in the environment to decrease the need for the behavior?


ExampleExample::How How AgitationAgitation can be can be

AdaptiveAdaptive

• Every time you try to bathe your loved one, she kicks and screams, and bites.• Why is she doing this? • Is she resisting care?• How may this be adaptive?

13


Resistance vs. Resistance vs. CommunicationCommunication

• Perhaps the person is communicatingFEAR because she does not remember her caregiver, does not know she is in her own home, or that she needs to be bathed

• Imagine a stranger comes into your room everyday, tries to disrobe and bathe you.

• How do you think you would respond?


ABCABC’’s of Behaviors of Behavior

• Antecedent: What happened right before your loved one became agitated?

• Behavior: What does the behavior look like?

• Consequence: What happened right after the behavior?

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Motivations behind behaviorsMotivations behind behaviors

• Attention: Do they want you to pay more attention to them?

• Stimulation: Are they understimulated? Bored? Is there too much stimulation? Too much noise?

• Escape: Are they trying to get away from something or someone because they are afraid?

• Tangible: Are they trying to gain something, e.g. food or a favorite object?


How Can You Help?How Can You Help?

• Be flexible• Be open• Be curious• Be patient

15


More Communication More Communication StrategiesStrategies

• Use short, simple words and sentences

• Use a soothing voice• Speak slowly• Provide ample time to

respond


Communication styles to avoidCommunication styles to avoid• Do not talk loud or in a patronizing manner:

• Even those people with severe impairment still have some sense of how adults are supposed to talk to one another.

• Do not command or use a commanding tone:• “Get out of bed!”

• Do not ask questions that rely on memory: • This can cause extreme anxiety in your loved one.

• Do not focus on logic or explaining yourself:• Arguing with your loved one only leads to more

confusion.• Do not view behavior problems as intentional

• The disease is the cause of these behaviors.

16


FINAL WORDS ON DEMENTIAFINAL WORDS ON DEMENTIA

• Dementia is not a normal part of aging.• Dementia results in slow deterioration of

brain regions.• Dementia affects cognition and behavior.• Difficult behaviors in dementia may be their

way of communicating their needs• You need to also take care of yourself


ResourcesResources

• Family Caregiver Alliance:http://www.caregiver.org/caregiver/jsp/publications.jsp?nodeid=345&expandnodeid=384

• Communicating with someone who has Alzheimer’s Disease:http://healthresources.caremark.com/topic/alzcomm

• Memory and Aging Center at the University of California, San Francisco School of Medicine Resources Guide for Caregivers:http://www.memory.ucsf.edu/resources.html#caregiving

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Pharmacological treatment of non-cognitive symptoms in AD

Speaker: Ladson Hinton MDAssociate Professor, Department of Psychiatry

Education Core Director, ADCUC Davis

[email protected]

www.californiacrc.org© 2006 Family Caregiver Alliance

180 Montgomery Street, Suite 1100San Francisco, CA 94104

Sponsored by California’s Caregiver Resource Centers (CRCs) and the Department of Health Services, Alzheimer’s Disease Research Centers of California (ARCCs). Funded by the California Department of Mental Health and a Bristol-Myers Squibb Foundation grant to Family Caregiver Alliance.

Overview of talkOverview of talk

Prevalence, etiological factors, & Prevalence, etiological factors, & consequencesconsequencesGeneral issues in assessment and General issues in assessment and management management Role of medicationsRole of medications

NeuropsychiatricNeuropsychiatric symptom frequency in symptom frequency in populationpopulation--based studiesbased studies

0

10

20

30

40

50

60

70

%

Dep Irr Anx Agg Apa Dis Hal Del Mot Ela

Individual neuropsychiatric symptoms

SALSA CHS Cache County

1

NeuropsychiatricNeuropsychiatric symptoms (NPS)symptoms (NPS)Signs and symptoms of disturbed perceptions, Signs and symptoms of disturbed perceptions, thoughts, mood, behavior in persons with dementiathoughts, mood, behavior in persons with dementiaClusters of nonClusters of non--cognitive symptomscognitive symptoms

Mood/apathy: depression, apathy, sleep, appetiteMood/apathy: depression, apathy, sleep, appetiteHyperactivity: agitation, irritability, euphoria, motorHyperactivity: agitation, irritability, euphoria, motorPsychosis: delusions, hallucinationsPsychosis: delusions, hallucinationsAnxietyAnxiety

May underpin common behavior May underpin common behavior ““problemsproblems”” and help and help to guide pharmacotherapy approachesto guide pharmacotherapy approachesCommon and recurrent: 50Common and recurrent: 50--95% with ADRD95% with ADRDMeasured with standard instruments Measured with standard instruments

e.g., e.g., NeuropsychiatricNeuropsychiatric Inventory (NPI)Inventory (NPI)

BiopsychosocialBiopsychosocial model of NPSmodel of NPS

PSYCHOLOGICAL

BIOLOGICAL: ENVIRONMENT

2

Consequences of untreated NPS Consequences of untreated NPS

Excess disabilityExcess disabilityElevated caregiver depression and burdenElevated caregiver depression and burdenRisk of harm to person or othersRisk of harm to person or othersIncreased service utilizationIncreased service utilizationIncreased risk of institutionalization Increased risk of institutionalization Lower quality of lifeLower quality of life

Barriers to medical care for NPSBarriers to medical care for NPSFamily factorsFamily factors

Presentation of symptoms, knowledgePresentation of symptoms, knowledge

Physician factors Physician factors UnderUnder--detectiondetectionReactive careReactive careLack of trainingLack of trainingCompeting medical concernsCompeting medical concerns

Structural constraintsStructural constraintsTime, reimbursement, access to mental health Time, reimbursement, access to mental health specialistsspecialists

Scientific: criteria and robust treatmentsScientific: criteria and robust treatments

3

Symptom presentation: Symptom presentation: The many faces of depressionThe many faces of depression

Agitation and aggressionAgitation and aggressionIrritabilityIrritabilitySomatic symptomsSomatic symptomsParanoia and psychosisParanoia and psychosisDelayed rehabilitationDelayed rehabilitationConflicts with caregiverConflicts with caregiverRefusal to eatRefusal to eatExcessive functional impairmentExcessive functional impairmentAlcohol or other substance abuse Alcohol or other substance abuse

To treat or not to treat? To treat or not to treat?

Mild <Mild <------------------------Moderate Moderate --------------------------> Severe> Severe

Low CR/CG distressLow CR/CG distress High CR/CG distressHigh CR/CG distressLow risk of harm Low risk of harm High risk of harmHigh risk of harmLow environment impact Low environment impact High disruptionHigh disruptionLow impact CR QOL Low impact CR QOL High impact CR QOLHigh impact CR QOL

Treatment considerations:Treatment considerations:Underlying medication/drug cause Underlying medication/drug cause treattreatMildMild: monitor or : monitor or nonpharmnonpharm rxrx, cog enhancer trial, cog enhancer trialModerateModerate: : nonpharmnonpharm, possible drug or referral, possible drug or referralSevereSevere: : nonpharmnonpharm + drug, referral, in+ drug, referral, in--patient, ECTpatient, ECT

4

Common medical triggersCommon medical triggersDeliriumDeliriumMedication side effectMedication side effectMetabolic imbalanceMetabolic imbalance

e.g. hypoglycemiae.g. hypoglycemia

PainPainInfection Infection

e.g. UTI, pneumoniae.g. UTI, pneumonia

StrokeStroke

Overview of treatment modalitiesOverview of treatment modalities

Family Family psychoeducationpsychoeducationNonNon--pharmacological interventionspharmacological interventions

Identify unmet needs, environmental triggers, Identify unmet needs, environmental triggers, ABC patternsABC patterns

Pharmacological approachesPharmacological approachesData best for depressionData best for depressionNew data shows higher mortality risk with New data shows higher mortality risk with antipsychoticsantipsychotics

Emerging data suggests multiEmerging data suggests multi--modal modal interventions may be more effectiveinterventions may be more effective

5

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Implications for Implications for antipsychoticsantipsychoticsReRe--assess risk/benefit ratioassess risk/benefit ratioInform patient and proxy of risks/benefits and Inform patient and proxy of risks/benefits and involve in decisioninvolve in decision--makingmakingConsider alternative (nonConsider alternative (non--pharmacological) pharmacological) treatments firsttreatments firstLimit use to situations where symptoms pose Limit use to situations where symptoms pose significant risk of harm or reduced quality of life significant risk of harm or reduced quality of life Taper off after 3Taper off after 3--4 weeks in non4 weeks in non--respondersrespondersGive responders a Give responders a ““holidayholiday”” and reand re--evaluate needevaluate needStay tuned! ? cause of increased mortalityStay tuned! ? cause of increased mortality

AntidepressantsAntidepressants

12 double12 double--blind drug trials (1989blind drug trials (1989--2003)2003)Antidepressants include Antidepressants include TCAsTCAs and SSRIand SSRIDuration 4Duration 4--12 weeks12 weeksDepressive symptoms or MDDDepressive symptoms or MDDIn 10 doubleIn 10 double--blind placebo controlled, 6 blind placebo controlled, 6 favored active drug and none PBOfavored active drug and none PBOHigh placebo response High placebo response

8

Dementia in AlzheimerDementia in Alzheimer’’s Disease Studys Disease Study

0

10

20

30

40

50

60

70

No response Partial response Full response

PlaceboSertrline

Lyketsos et al, Archives Gen Psych 2003

Antidepressant treatment algorithm Antidepressant treatment algorithm

Initiate SSRI and titrate to target doseInitiate SSRI and titrate to target dose44--6 weeks6 weeks

If some improvement, increase If some improvement, increase If no improvement, switch class (e.g. If no improvement, switch class (e.g. buproprionbuproprion, , mirtazapinemirtazapine))

1010--12 weeks12 weeksIf remission, continueIf remission, continueIf some improvement, augmentIf some improvement, augment

Treatment resistant: Treatment resistant: venlafaxinevenlafaxine, , remeronremeron, , wellbutrinwellbutrin, , nortriptylinenortriptyline, MAOI, stimulants, ECT, MAOI, stimulants, ECT

Mulsant et al, Int J Ger Psychiatry 2001

9

SummarySummary

NPS are common and costlyNPS are common and costlyNonpharmacologicalNonpharmacological rxrx underusedunderusedDrugsDrugs

Data best for depression in AlzheimerData best for depression in Alzheimer’’ssCognitive enhancers may lower NPS as secondary Cognitive enhancers may lower NPS as secondary benefit benefit Need to reNeed to re--examine risk/benefit ratio of antiexamine risk/benefit ratio of anti--psychotics psychotics in light of emerging datain light of emerging data

Drugs most effective in multiDrugs most effective in multi--modal approachmodal approachexamination of underlying medical/drug causesexamination of underlying medical/drug causesfamily education and support family education and support social service referral social service referral nonnon--pharmacological treatmentpharmacological treatment

Selected referencesSelected references

Hinton L et al (2003) Hinton L et al (2003) NeuropsychiatricNeuropsychiatric symptoms in demented and symptoms in demented and cognitively impaired but not demented Latino elderly and factorscognitively impaired but not demented Latino elderly and factorsthat modify their association with caregiver depression. The that modify their association with caregiver depression. The Gerontologist, 43 (5), 669Gerontologist, 43 (5), 669--677.677.Katz IR. (1998) Diagnosis and treatment of depression in patientKatz IR. (1998) Diagnosis and treatment of depression in patients s with Alzheimerwith Alzheimer’’s disease and other dementia. J s disease and other dementia. J ClinClin Psychiatry Psychiatry 59[suppl 9]:3859[suppl 9]:38--44.44.LyketsosLyketsos et al. (2003) Treating depression in Alzheimeret al. (2003) Treating depression in Alzheimer’’s disease: s disease: Efficacy and safety of Efficacy and safety of sertralinesertraline therapy, and the benefits of therapy, and the benefits of depression reduction: The DIADS. Archives of General Psychiatry.depression reduction: The DIADS. Archives of General Psychiatry.60:73760:737--746.746.MulsantMulsant BH et al. (2001) Pharmacological treatment of depression BH et al. (2001) Pharmacological treatment of depression in older primary care patients: the PROSPECT algorithm.in older primary care patients: the PROSPECT algorithm.IntInt J J GeriatrGeriatr Psychiatry. 2001 Jun;16(6):585Psychiatry. 2001 Jun;16(6):585--92. 92. Schneider LS et al (2005)Risk of death Schneider LS et al (2005)Risk of death witihwitih atypical antipsychotic atypical antipsychotic drug treatment for dementia. 294;1934drug treatment for dementia. 294;1934--19431943Teri L. et al (1997) Behavioral treatment of depression in demenTeri L. et al (1997) Behavioral treatment of depression in dementia tia patients: a controlled clinical trial. J patients: a controlled clinical trial. J GerontolGerontol B B PsycholPsychol SciSci Soc Soc SciSci4:1594:159--166.166.Trinh et al (2003). Efficacy of Cholinesterase Inhibitors in theTrinh et al (2003). Efficacy of Cholinesterase Inhibitors in thetreatment of treatment of neuropsychiatricneuropsychiatric symptoms and functional impairment symptoms and functional impairment in Alzheimerin Alzheimer’’s disease: A metas disease: A meta--analysis. JAMA 289:210analysis. JAMA 289:210--216216

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Alzheimer’s Disease Research Centers of California (ARCCs)

Fresno University of California, San Francisco(559) 227-4810Email: [email protected]: http://fserve.fresno.ucsf.edu/alzheimer/

Irvine University of California, Irvine(949) 824-5847Website: http://www.alz.uci.edu/

Los Angeles University of Southern California(323) 442-7600Website: http://www.usc.edu/schools/medicine/departments/psychiatry_behavioralsciences/research/gsc/

Los Angeles/DowneyUniversity of Southern CaliforniaRancho Los Amigos National Rehabilitation Center(562) 401-8130

Los Angeles/San Fernando Valley University of California, Los AngelesGeneral Information: (310) 206-5238UCLA Appointments: (310) 794-1195Centinela Freeman-Marina Center: (323) 563-5915Olive View/UCLA Center: (818) 895-9541Website: http://www.npistat.org/adrc/

Martinez University of California, Davis(925) 372-2485Website: http://alzheimer.ucdavis.edu/

Palo AltoStanford University/VA Palo Alto Health Care System(650) 858-3915Website: http://arcc.stanford.edu/

Sacramento University of California, Davis(916) 734-5496Website: http://alzheimer.ucdavis.edu/

San DiegoUniversity of California, San Diego/SOCARE(858) 622-5800

San Francisco University of California, San Francisco(415) 476-6880Website: http://memory.ucsf.edu/index.html Alzheimer’s Disease ProgramMail Station 7210Post Offi ce Box 997413Sacramento, CA 95899-7413Phone: (916) 552-8995

© 2006 Family Caregiver Alliance

Caregiver Resource Centers and the Regions They ServeBay Area Caregiver Resource Center/Family Caregiver AllianceStatewide Resources Consultant180 Montgomery Street, Suite 1100 San Francisco, California 94104Phone: (415) 434-3388 or (800) 445-8106Website: www.caregiver.orgE-mail: [email protected] • Contra Costa • Marin • San FranciscoSan Mateo • Santa Clara Counties

Coast Caregiver Resource Center1528 Chapala Street, Suite 302Santa Barbara, California 93101Phone: (805) 962-3600 or (800) 443-1236 (regional)Website: www.coastcrc.orgE-mail: [email protected] San Luis Obispo • Santa Barbara • Ventura Counties

Del Mar Caregiver Resource Center736 Chestnut Street, Suite FSanta Cruz, California 95060Phone: (831) 459-6639 Website: www.delmarcaregiver.orgE-mail: [email protected] Monterey • San Benito • Santa Cruz Counties

Del Oro Caregiver Resource Center5723A Marconi Avenue Carmichael, California 95608Phone: (916) 971-0893 or (800) 635-0220 (regional)Website: www.deloro.org E-mail: [email protected] Alpine • Amador • Calaveras • Colusa • El Dorado Nevada • Placer • Sacramento • San JoaquinSierra • Sutter • Yolo • Yuba Counties

Inland Caregiver Resource Center1420 East Cooley Drive, Suite 100Colton, California 92324Phone: (909) 514-1404 or (800) 675-6694 (California)Website: www.inlandcaregivers.comE-mail: [email protected] • Mono • Riverside • San Bernardino Counties

Los Angeles Caregiver Resource Center3715 McClintock Avenue Los Angeles, California 90089-0191Phone: (213) 821-7777 or (800) 540-4442 (California)Website: www.losangelescrc.orgE-mail: [email protected] Los Angeles County

Mountain Caregiver Resource Center2491 Carmichael Drive, Suite 400 Chico, California 95928Phone: (530) 898-5925 or (800) 822-0109 (regional)Website: www.caregiverresources.org/MCRC_home E-mail: [email protected] • Glenn • Lassen • Modoc • Plumas • ShastaSiskiyou • Tehama • Trinity Counties

Orange Caregiver Resource Center251 East Imperial Highway, Suite 460 Fullerton, California 92835Phone: (714) 578-8670 or (800) 543-8312 (regional)Website: www.caregiveroc.orgE-mail: [email protected] County

Redwood Caregiver Resource Center141 Stony Circle, Suite 200Santa Rosa, California 95401Phone: (707) 542-0282 or (800) 834-1636 (regional)Website: www.redwoodcrc.orgE-mail: [email protected] Del Norte • Humboldt • Lake • Mendocino • Napa Solano • Sonoma Counties

Southern Caregiver Resource Center3675 Ruffi n Road, Suite 230 San Diego, California 92123Phone: (858) 268-4432 or (800) 827-1008 (California)Website: www.scrc.signonsandiego.comE-mail: [email protected] Diego • Imperial Counties

Valley Caregiver Resource Center3845 North Clark Street, Suite 201 Fresno, California 93726Phone: (559) 224-9154 or (800) 541-8614 (regional) Website: www.valleycrc.orgE-mail: [email protected] • Kern • Kings • Madera • Mariposa • Merced Stanislaus • Tulare • Tuolumne Counties

www.californiacrc.org

understanding and treating difﬁ cult dementia behaviors…understanding and treating difﬁ cult...

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