Dementia Management: Regulations, Rules, and Research Moderator and Speaker: Larry E. Tune, MD. Speakers: Anton Porsteinsson, MD, and Andrew Weinberg, MD, CMD, FACP When a patient with dementia displays behavior problems or psychological symptoms, care providers should attempt to identify any manageable cause and take appropriate remedial action. Sometimes, a nonpharmacologic approach will suffice. Medications often are both the cause and the solution for behavior problems. Regulatory issues complicate optimal medication management. FINDING THE CAUSE Behavior difficulties often are caused by environmental problems or medication side effects, according to Dr. Tune. The patient’s prior personality also can explain some behavior problems. “Premorbid aggressive traits predict difficulty in the long-term care community, especially if the resident has de- mentia and is disinhibited,” said Dr. Tune. Environmental issues that may account for management problems include activity and recreational programming, lay- out of the facility, and inadequate staff education. Dr. Tune told of a resident who, a few years ago, complained that Monica Lewinsky and Linda Tripp were tormenting her. It turned out that the facility had a big-screen television that was kept tuned to the news coverage of the presidential scandal. “We had the same problem after 9/11. We’re having the same problem now,” Dr. Tune said in early March, as President Bush prepared to go to war with Iraq. “If you keep the television on, you constantly see the military build-up. It agitates people.” Dr. Tune told of another resident who became uncooperative at bath time. The nursing assistant told him she was going to get him ready for his shower. She wheeled him down the hall to the shower and started to undress him. He lashed out and hit her. “About five minutes had elapsed since she had told him that she was going to bathe him. By the time she started to undress him, he had forgotten why,” Dr. Tune explained. In an instance such as this, staff education often can alleviate further behavior problems. The nursing assistant who was at- tacked when she tried to prepare the resident for a bath should learn to remind a patient why she is undressing him. Staff also need to be flexible about scheduling. “If the patient is uncoop- erative and does not want to take a bath, try again later, or skip the bath that day. Manipulating the bath schedule may elimi- nate the need for pharmacologic intervention. Many times nonpharmacologic intervention is adequate,” said Dr. Tune. Besides environmental causes, medications can also be re- sponsible for behavior problems in long-term care settings. “Medications, especially anticholinergic drugs, may worsen behavior symptoms,” said Dr. Tune. “There are hundreds of anticholinergic drugs, and they are given disproportionately to the elderly. Many medications have a little anticholinergic mix in them,” he noted, adding that taking several medica- tions with anticholinergic activity could result in anticholin- ergic toxicity. Table 1 lists common anticholinergic drugs that are often prescribed for the elderly. Some years ago, Dr. Tune did a small study in 28 nursing home residents. Each had been taking at least one anticho- linergic medication for 2 weeks or longer. When the anticho- linergic dosage was reduced, the patients’ delirium and mem- ory improved significantly. Because use of anticholinergic medications is so common, all the drugs that a patient is taking should be scrutinized. A medication prescribed a long time ago may no longer be medically necessary, but the patient continues to receive it. “When a new resident comes into a nursing home, review all the medications. Verify that there are appropriate clinical indications for the continued use of each medication,” said Dr. Weinberg. Delirium is common in patients with dementia, he ob- served. “Acute delirium could be due to a medical illness that is partly masked or is undiagnosed. In a patient with acute delirium, do a medical workup before ordering any medica- tion,” Dr. Weinberg said. Appropriate treatment of the underlying medical condition may be all that is needed. For example, when called for a consultation for acute change in mental status, he sometimes has found that a urinary tract infection is affecting the patient’s underlying dementia. After the patient begins taking an antibi- otic such as trimethoprim-sulfamethoxazole, previous mental status returns, without the need for antipsychotic medication. MAKING OPTIMAL MEDICATION CHOICES “When treating behavior problems, it’s important to identify the target symptoms,” said Dr. Weinberg. “A common mistake is to automatically prescribe antipsychotics, which will not do anything for some annoying behaviors, such as repetitive vocal- ization. No medication will effectively treat that.” Dr. Tune introduced the concept of “behavioral and psychological symptoms of dementia (BPSD), a term he said is used to describe a heterogeneous range of psycho- logical reactions, psychiatric symptoms, and behaviors oc- curring in people with dementia of any etiology.” Five BPSD “clusters” of behavioral and psychological symptoms, he explained, are seen in patients with dementia-aggres- sion, psychomotor agitation, apathy, depression, and psy- Sponsored by ABcomm, Inc., and supported by an unrestricted educational grant from Abbott Laboratories. Copyright ©2003 American Medical Directors Association DOI: 10.1097/01.JAM.0000078011.62552.B3 SUPPLEMENT Tune et al. H13