PAID to DECODE. The ABCDecode of BPSD. By Dr A.J.Niesser

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1 PAID to DECODE The ABCDecode of BPSD By Dr A.J.Niesser

2

3 Dementia WHO 1992 A syndrome due to disease of brain, usually chronic or progressive. Disturbance of multiple higher cortical functions, incl: memory, thinking, orientation, comprehension, learning capacity, language & judgement. Consciousness is not clouded. Impairment of cognitive function are commonly accompanied or preceded by deterioration in emotional control, social behaviour or motivation

4 Learning Outcomes Brief over view of dementia. Simple analogy of short term memory & why they remember the past. Limited ability to express concerns. What behaviour is trying to communicate. Anti psychotics do harm. Poor Pain control & difficulties with EOL prognostication.

5 Age Related Memory changes Normal and normal ageing Subjective Memory Loss Mild Cognitive Impairment Dementia

6 Rationale for Early Interventions It is easier to treat a dying neurone, than to resuscitate a dead one. Patients have choices Carers have choices Exclude treatable conditions Mitigate rate of decline EOL planning

7 Prevalence 1 in 100 aged 60 years in UK 1 in 5 80 years 1 in 4 85 years However : 1 in 2 aged 85 years in USA (the difference may be due to the obesity epidemic which is 20-30years ahead of us!) MCI is twice as common as dementia and 50% will develop dementia. Prevalence 5-8% gen. pop.

8 Prevention/Postponement If it is good for the It s good for the

9 Short term memory

10 4A s Amnesia -Inability to remember Agnosia -Inability to recognise Aphasia -Inability to communicate Apraxia -Inability to do

11 Patient 1 Nurse rings GP to ask for sleeping tablet for Mr X as he wakes up at 5am.

12 ABCD Antecedents Behaviour Consequences Decode What is the behaviour trying to communicate?

13 Patient 2 Elderly 95 yrs old lady with end stage vascular dementia and difficulty swallowing, screams when she is turned in her bed.

14 Meeting the pain needs of patients with dementia Suboptimal Prevalence of pain in elderly in nursing homes- not recognised In acute setting- 67% of older pts with normal cognition received analgesia, only 17% of those with dementia

15 PAID to DECODE Physical Infection -uti/ lrti, constipation, dehydration, pain, visual or hearing loss, sleep disturbance, hypoxia, Activities when, where, who, what was the time Intrinsic to Dementia hallucinations, sun downing Depression/ Delusions

16 Physical constipation, dehydration, pain, visual or hearing loss, sleep disturbance, Infection -uti/ lrti, hypoxia, Medication side effects etc

17 Patient 3 Elderly frail 82yr old lady with end stage dementia, unable to communicate verbally, has suddenly become violent and aggressive. Something has to be done!

18 It is a truth universally acknowledged: Patients DO NOT usually CHOOSE a NURSING HOME for the SCINTILLATING company of the inhabitants.

19 Activities when, where, who, what was the time. If you do not ask the questions, you may never find out!

20 Patient 4 72yr old man partially sighted with Charles Bonnet syndrome and vascular dementia starts seeing pixies around his ankles. He talks quite freely about them. He is not distressed.

21 Intrinsic to Dementia hallucinations, Sun downing: Factors that may aggravate late-day confusion include: Fatigue, Low lighting, Increased shadows, Disruption of the body's "internal clock, Staff arriving and leaving

22 Depression/ Delusions Mood-anxiety, passivity, irritability, sadness, Behaviour-agitation, loss of interest, retardation,, multiple physical complaints, Physical Signs-appt, wt, energy Cyclical variations-diurnal mood changes, difficulty falling asleep, multiple wakening during the day, early morning wakening, acute loss of interest, Idealisation disturbance-suicidal, selfdepreciation, pessimism, mood congruent delusion- delusions of poverty, illness or loss,

23 Chemical COSH Burstow: Doctors face jail over dementia 'chemical cosh Doctors will face up to five years in jail under a plan to stop anti-psychotic drugs being used as a potentially fatal chemical cosh to sedate dementia patients, The Daily Telegraph has learnt.

24 Core Medical Ethics Autonomy: Respecting individuals, promoting choices, truth telling, keeping confidences, informed consent etc Beneficence: Doing Good Non-malevolence: Not doing Harm Justice: Treating people fairly

25 Anti-psychotics Cause harm (Banergee report 1) 180,000pt received antipsychotics- only 36,000 benefited 1622 additional CVA per year 1800 additional deaths per year Constipation, sedation, extra-pyramidal side effects. Falls, ankle oedema, dehydration, chest infection, accelerated decline etc (Ballard& Howard 2006 Risperidone for neurophychiatric symptoms: adverse outcomes in Nature Neuroscienc Review.)

26 Antipsychotics how to use Of those prescribed anti-psychotic drugs only 1 in 5 patients needed them- (according to Banergee) Trial of alternatives Alzheimer BPSD Document reasons Start low, go slow, review & stop with in 6-12/52 Only Risperidone is licensed for BPSD in Dementia

27 . There are not many areas of medicine where we give powerful potentially dangerous medication to vulnerable individuals for the benefit of a third party. (Stirling University 10 tips for GPs.)

28 Reframe Dementia as a Disability

29 Dementia Disease vs Disability Takes over person Looks for causes & cures Everything is defined negatively Disengages person There is not much we can do positively until a cure Personhood intact- depends crucially on the Quality of Care Manages condition Positive reinforcement Engages & respects person s abilities Great deal we can do with insight & skill Care for basics needs & safe environment Care to maintain & enhance personhood. Meeting basic needs & physical care only part of care of the whole person

30 CARERS Best allies & resource They have choices LPOA & MPOA, They know most about your patient They do NOT stop being a carer Patients change care homes.

31 Enhanced Dementia Care Life into years, not merely years of life

32 Engagement Studies in nursing homes show that some residents spent 80% of their day without human contact. Others only 2mins human contact in a 2hr shift

33 Malignant Social Psychology (T.Kitwood 1990a) Treachery Disempowerment Infantilization Intimidation Labelling Additional Ignoring Imposition Withholding Accusation Stigmatization Outpacing Invalidation Banishment Objectification Disruption Mockery Disparagement

34 Patient 5 Retired postman with moderate dementia is found in female clothing at 5am. He is knocking on the door of the newsagent s. Something has to be done.

35 Wanderers They may not recognise where they are & want to go home. They may have experienced something unpleasant and want to get away. They may have somewhere or something specific they want to go or do. They might just want exercise & a breath of fresh air

36 Patient 6 Mr Y is screaming & hitting out? What do you do? What do you prescribe? Can you give it against his will? Can you hide it in his food

37 End of Life When do you stop living with Dementia and start dying with dementia?

38 End of Life Prognostication & importance placed on predicting the approach of death with dementia Meeting the pain needs of patients with dementia

39 Summary Good for heart good for head Reframe dementia as disability Emphasis on what people can do Respect personhood Listen & support carers ABCDecode behaviour/ PAID to decode Think analgesia Be specific- explain use of anti-psychotics

40 Rapunzal