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How to help patients experiencing dementia with behavioral disturbance

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Forgetfulness, memory impairment and difficulty with self-care are a major challenge for people living with dementia. But the neuropsychiatric symptoms of dementia can cause the most distress for patients and their caregivers.

Common neuropsychiatric symptoms include behavioral issues such as aggression, agitation and wandering. Mood, psychotic and sleep-related disturbances are also very common. Usually, patients have a combination of symptoms making it very challenging to know how to intervene.

A family who wants to care for a beloved parent at home can become demoralized and burned out when their loved-one is combative, awake all night or prone to wandering. Experienced caregivers in elderly care settings can struggle with keeping patients safe when they are distressed, pacing and paranoid of staff.

In the past, providers routinely prescribed antipsychotic medications to manage even mild symptoms. Today’s providers try to use these medications sparingly, informed by the current FDA warnings about the risks of use of these medications in the elderly. Without medications, providers might feel they have little to offer patients and families in these situations. But in many cases, significant improvements in symptoms and quality of life can be made for these patients without a prescription.

So, how do you best approach your patient with concerning neuropsychotric symptoms?

First, assess the situation: Is there a risk of harm to self or others? If so, ensure safety first by considering increasing the level of care through the addition of caregivers, one-on-one supervision, or hospitalization. In cases with the risk of severe harm, short-term pharmacologic treatment will likely be indicated along with hospitalization.

More commonly, the risk level is lower. In these cases, thinking through a few key areas can have a major positive impact:

1. Identify and treat the underlying cause. Most often, these symptoms do not occur in a vacuum. Pain, distress and underlying illness can be a driver, and one that when properly identified can be alleviated. Below is a list of commonly found underlying causes:

  • Delirium: assess for untreated medical illnesses, new medications, metabolic issues.
  • Medication side effects: have a high suspicion for this with the prescribing of benzodiazepines, anticholinergics and opioids.
  • Pain: a patient with major neurocognitive disorder may not be able to tell you they are in pain, so look at other clues such as body language and facial expression. Scheduled instead of as-needed non-narcotic pain medications can be helpful.
  • Depression and anxiety: assess for this with the help of the caregiver. Consider a trial of an SSRI.
  • Sleep disorders: sleep-wake disturbance is common in dementia. Emphasize good sleep hygiene, exposure to morning light, consistent schedule.
  • Sensory deficits: Poor vision and hearing can worsen confusion and lead to agitation as well as worsened fall risk.

2. At times, simple interventions can go a long way:

  • Implement daily, scheduled activities. Instruct families and caregivers to find activities that are soothing to the patient. Some patients will spend hours sorting through pictures, rearranging a silverware drawer or sweeping. Empower families and caregivers to get creative and try a variety of different strategies.
  • Environmental interventions such as reducing clutter, improving lighting and adding soothing features such as music or pets can help.

As a provider, helping a family discover that their mom loves to arrange silverware, can do so for hours and is able to remain calm and content throughout the day can be satisfying and bring a sense of relief in not having to add a new medication to an elderly person’s already long list. As a prescriber working with geriatric patients, less is always more when it comes to medications.

Author
Amanda Focht, MD
Clinical Assistant Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Medical Director, University of Washington Medical Center, Outpatient Psychiatry Clinic

References
Gitlin LN, Kales HC, Lyketsos CG. Nonpharmacologic management of behavioral symptoms in dementia. JAMA 2012; 308:2020.

Lyketsos CG, Steinberg M, Tschanz JT, et al. Mental and behavioral disturbances in dementia: findings from the Cache County Study on Memory in Aging. Am J Psychiatry 2000; 157:708.

Gitlin LN, Winter L, Dennis MP, et al. Targeting and managing behavioral symptoms in individuals with dementia: a randomized trial of a nonpharmacological intervention. J Am Geriatr Soc 2010; 58:1465.

How to ask about substance use

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If you struggle with asking patients about their alcohol and/or drugs use, you are not alone. Asking sensitive questions in a way that makes it more likely a patient will respond honestly can be challenging, and defensiveness or resistance to answering are not uncommon. Complicating this is the need to build a connection with your patient, and fear that a negative response to being asked will alter your rapport. For some, the challenge lies in asking the question; for others, it is what to do if you suspect a patient has a substance use issue.

Why, then, should providers ask about substance use? The pandemic has fueled escalating rates of both mental health and substance overuse, with one in 10 people reporting they started or increased their substance use during the. Suicide rates are up, as are overdose rates in our state. Before the pandemic, The National Institute on Drug Abuse estimated that there were over 20 million adults in the US with a substance use disorder. Of those, 38% of them also had mental illness.  Substance use disorder has a significant impact to personal health, and early intervention is key to preserving patient health and lowering health care costs. And, primary care is the de facto setting where many patients access mental health and substance use care.

There are over a dozen evidence-based screening tools for substance use, including the DAST, AUDIT-C, and CAGE. While the screening tools set a clear framework for what to ask, it’s important to know how to ask — how to set the stage — so the patient’s answers are more likely to be reliable and valid. Setting the stage includes managing our own anxiety, mitigating the patient’s anxiety, and being mindful of the wording, order and form of the questions you are asking.

To begin, be aware of your own anxiety and fears about asking sensitive questions. What’s driving them? What feels uncomfortable about asking these questions? To quell their own anxieties, some people find it helpful to practice and to ground themselves in the reasons why the answers are so important. Asking sensitive questions eventually becomes more natural, but until then, take a minute to check in with yourself and what you need to feel confident.

The words you use to ask sensitive questions, and how you set up the structure of asking, is key. Where does asking about drug and alcohol use fall in your assessment? Your psychosocial assessment should have flow, and it can be helpful to ask less loaded habit questions before asking about drug/ETOH use. For example, consider asking about diet and exercise before asking about other habits around smoking, alcohol and drugs. Starting off with questions about more socially acceptable substances like caffeine, tobacco, and then alcohol can be helpful in normalizing this line of questions.

As you head into the more sensitive questions, it can be helpful to start off with close-ended or fixed choice questions. “Have you ever drank alcohol?” or “Have you ever used any drugs or Cannabis?” This can then be followed up by asking “How often do you use?”, “How much do you use?”, and “How do you use?” if appropriate.  Asking additional questions to identify potential harms associated with their use can identify potential areas of intervention and education. “How often do you use a fresh needle when you inject…never, sometimes, almost always, always?” Asking about access to Narcan is important if the patient is using opioids or methamphetamine which may have opioids like fentanyl mixed in.

Be careful to use words that are less loaded—don’t use the term “illegal” when referring to drugs, for example, and try to ask about each drug specifically. “Have you ever used cocaine” is better than “have you ever used street drugs.” When talking with patients, be careful too about terms that are defined by each of us individually, like “drunk,” “high,” “frequently,” etc. Ask specific, quantifiable questions.

After you have a thorough substance use history from your patient and it turns out they have some concerning use patterns, what do you do now? Behavioral interventions have shown effectiveness in reducing substance use in those who are at risk for developing dependence. Commonly used elements for engaging in behavioral interventions are described in the FRAMES acronym—Feedback of risk, encouraging Responsibility for change, Advice, a Menu of options, therapeutic Empathy and enhancing Self Efficacy. Motivational interviewing can help you engage with patients who have more problematic use, but who are not yet expressing interest in change, or are contemplating change but not stating a readiness to change.

Remember, you can always call the PCL for advice on what to do once you have determined a patient does have some concerning substance use habits. Many providers feel ill-equipped to treat substance use and mental health conditions and the PCL adult psychiatrists and addiction psychiatrists are there to support you in the care of your patient. Call us anytime – we are a part of your team!

Author
Jennifer Magnani, MSW, LICSW, is the Assistant Program Director of the Psychiatry Consultation Line.

Learn more
Screening, Diagnosis, and Medication Assisted Treatment for Alcohol Use Disorders (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Mark Duncan, MD
The objectives of this presentation are to 1) identify the current screening tools and recommendations for alcohol use disorders, 2) discuss what to consider in diagnosing alcohol use disorders, and 3) review the current medications used for alcohol use disorders.

What Are Some Behavioral Strategies to Help My Patient Stay Sober? (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Mark Duncan, MD
The objectives of this presentation are to 1) review the importance of behavioral strategies for relapse prevention, 2) describe which behavioral strategies can be incorporated, and 3) learn when to use these strategies in a clinical situation.

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.

Resources provide guidance on psychotropic medications

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Many providers who lack formal training in mental health or addictions find themselves caring for patients with behavioral health conditions, but prescribing medications for mental health and/or substance use disorders can be daunting. To help bridge this gap, the UW AIMS Center developed a summary of Commonly Prescribed Psychotropic Medications that providers can use to familiarize themselves with effective medication treatments used in primary care.

The AIMS Center also created a collection of Brief Medication Prescribing Directions for common psychotropic medications used to treat adult patients. The succinct protocols are organized into three sections — dosing information, monitoring and general information — and are tailored to the outpatient setting.

Both resources are intended to facilitate the best possible prescribing practices in the outpatient setting. They should always be used with discrimination and, where questions arise (e.g., as new prescribing information comes out about a medication), in consultation with a pharmacist, current FDA drug label guidelines and/or an on-call UW psychiatrist staffing the Psychiatry Consultation Line.