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Neuropsychiatric SymptomsDiagnosing & Clinical Decision Support

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Nicole ConiglioCo-Founder, President, & CMO Psych360

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BioNicole Coniglio is the President, Chief Medical Officer, and Founding Member of Psych360. Since 2015, her strategic and clinical leadership has grown Psych360 from a startup to the largest long-term care mental health platform in Ohio serving over 250 long-term care communities through more than 50,000 annual patient encounters. As a visionary leader in providing psychiatric and psychological solutions in the long-term care industry, Nicole has a passion for evidence-based mental health care, patient experience, and improved quality of life for underserved populations.

Nicole’s leadership and board experience extends to the PALTC Behavioral and Mental Health Advisory Council, the Geriatric Practice Management Corp, and the Ohio Association of Advanced Practice Nurses. She has been asked to speak at engagements for the American Society of Consultant Pharmacists, the Ohio Health Care Association, Leading Age, the Geriatric Association of Advanced Practice Nurses, and the Ohio Society of Healthcare Risk Managers.

Nicole graduated from Kent State University with her Master of Science in Nursing degree and received her Psychiatric Mental Health Nurse Practitioner Post-Master’s Certificate from the University of Cincinnati.

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OBJECTIVES

NEUROPSYCHIATRIC & BEHAVIORAL SYMPTOMS

ASSOCIATED WITH DEMENTIA

TYPES OF DEMENTIA, DIAGNOSIS, &

DIFFERENTIALS

SCREENING TESTS FOR DIAGNOSIS

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NON-PHARMACOLOGIC INTERVENTIONS

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Neuropsychiatric Symptoms in Dementia

98% Incidence

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Behavioral Disturbances Associated with Dementia● Behavioral disturbances can be

difficult to manage, causing stress to the patient and their caregivers.

● Behaviors can fall into 3 different symptom groups::

➔ Activity Disturbances ➔ Mood Disturbances ➔ Thought and Perceptual

Disturbances 14

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4 Categories of Behavioral Disturbances

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Physically AggressiveHitting, kicking, bitng, scratching, spitting, pinching

Verbally AggressiveCursing, screaming, or

threatening

Physically Non-AggressivePacing, wandering, inappropriately handling objects, exit-seeking

Verbally Non-AggressiveConstant repetition of sentences or requests

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UNMET NEEDSAddress Underlying NeedsWhat is causing the inappropriate behavior?

True cause of SymptomsPossible sensory deprivation, boredom, and/or loneliness. Others may need lower lighting, good toileting procedures, better communication, or appropriate pain treatment

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Dice Model

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DESCRIBEWho, what, when, where behaviors occur.

InvestigateHealth, symptoms, medications, sleep habits.

CreateDevelop a plan to prevent and respond to issues.

EvaluateIs the plan working? What needs to be changed?

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Case Study-Dice➢ Tom is an 89 year old male➢ Presenting with Alzheimer’s Dementia, depression &

anxiety➢ Currently taking Lexapro 10mg PO QD for

anxiety/depression and Aricept 10mg PO QHS for dementia

➢ Generally pleasant and calm throughout the day, but becomes anxious & agitated when out in the common area at times

➢ Reported to yell out, become tearful, and repeatedly say “Help me”

➢ Has difficulty communicating his needs and is Cognitively impaired

➢ Does not have these Behaviors while in his room or when out in the Dining area.

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Activity Disturbance▸ Agitation▸ Wandering▸ Verbal or Physical

Aggression▸ Resisting care▸ Apathy▸ Impulsiveness

▸ Eating Disturbances▸ Sleep Problems▸ Diurnal/Sleep-wake

cycle disturbances▸ Socially Inappropriate

Behaviors▸ Repetitive Behaviors

50-80% cognitively impaired LTC residents have Agitation or Aggression

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Mood Disturbances

Elation Anxiety

Mood / LabilityFluctuations

Irritability

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Thought & Perceptual DisturbancePsychosis▸ 40% AD▸ 16-75% PD❖ Delusions

➢Fixed false beliefs

➢Paranoia

❖ Hallucinations

➢ Hearing or seeing non-present entities

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Diagnosis(1) a comprehensive history;

(2) a complete physical and neurologic examination

- cognitive, behavioral, and activities of daily living assessment;

(3) laboratory and neuroimaging studies

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HistoryO- onsetL- LocationD- DurationC- CharacteristicsA- AggravatingR- RelievingT- Treatment

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Emotional Metabolic Traumatic /TumorsEndocrine Infectious StrokeAuto-

ImmuneDegenerative

Alzheimer’s DiseaseParkinson’s DiseasePick’s Disease

DepressionPsychosis

Liver failurekidney failureToxins

Hypothyroidism Brain injuryCancer

BacterialFungalViralPrion

Multiple sclerosislupus

Brain InfarctionHemorrhage

DifferentialsMedical conditions that can cause Dementia

Encephalopathy or Delirium Mental Retardation Language Disorders Psychiatric Disorders

Drugs Cerebral Palsy Strokes Depression

Differential Diagnosis for Dementia

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Disease 1st Symptom Mental Status Neuropsychiatry Neurology Imaging

Alzheimer's Disease

Memory Loss Episodic Memory Loss

Initially Normal Initially Normal Entorhinal Cortex and Hippocampal Atrophy

Fronto-temporal Dementia

Apathy; poor judgment/insight, speech/language;

hyperorality

Frontal/executive, language; spares

drawing

Apathy, disinhibition, hyperorality,

euphoria, depression

May have vertical gaze palsy, axial

rigidity, dystonia, alien hand, or

MND

Frontal, insular, and/or temporal atrophy; spares posterior

parietal lobe

Dementia with Lewy

Bodies

Visual hallucinations, REM

sleep disorder, delirium, Capgras'

syndrome, parkinsonism

Drawing and frontal/executive; spares memory; delirium prone

Visual hallucinations, depression, sleep

disorder, delusions

Parkinsonism Posterior parietal atrophy; hippocampi

larger than in AD

Vascular Dementia

Often but not always sudden;

variable; apathy, falls, focal weakness

Frontal/executive, cognitive slowing; can spare memory

Apathy, delusions, anxiety

Usually motor slowing, spasticity;

can be normal

Cortical and/or subcortical infarctions, confluent white matter

disease

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NPI-Q► Self-administered questionnaire

► Review of the previous month

► 12 NPI-Q Domains► Rate the Severity of

Symptoms (3 pt scale)

► Rate the caregiver distress (5 pt scale)

Initial response “Yes” or “No”Yes responses

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Dementia Severity Rating Scale

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SLUMS

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BIMS

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Cornell Scale for Depression in Dementia▸ Screening tool; not diagnostic▸ Clinician interviews caregiver▸ 19 items▸ Review of week prior then expand

on onset and changes▸ Brief interview of the patient

▸ Scoring▹ 0= absent, 1= mild or

intermittent, 2= severe, n/a= unable to evaluate

▹ Suidice; 1= passive suicidal ideation, 2= active suicidal wishes or recent attempt

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CNS-LS (PBA)

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Helpful Non-Pharmacological Interventions► Sensory interventions ► Social contact► Staff training► Structured activities ► Environmental interventions ► Medical/nursing interventions► Self care

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IMPORTANCE OF NON-PHARMACOLOGICAL INTERVENTIONS

ADVERSE REACTIONSAND RISKS Control Behaviors REDUCE PATIENT AND

CAREGIVER DISTRESS

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Sensory Interventions

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Sounds❑Music❑White noise❑Decreasing noise

Touch❑Hand Massages

Smell❑ Essential Oils

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Social Contact

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● Pet Therapy● One to One Interaction● Patient Activities and Socialization Groups● Personal Relationships with Family and Friends

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Staff Training

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● Training on adapting ADL’s to patient levels

● Communication skills● Empathy training● Crisis Prevention Intervention

training/Trauma Informed Care

● Teepa Snow training

In-Service Training on Various Topics

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Structured Activities

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● Games● Social Activities● Singing ● Physical Activities● Reminiscence Therapy

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Environmental Interventions

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● Wandering Areas● Nature Enhanced Environments● Reduced Stimulation ● Reassuring Safety

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MEDICAL/NURSING CARE▸ Sleep▸ Hygiene Interventions▸ Pain Management▸ Meeting Patient Needs▸ Communication▸ Empathy▸ Redirection/Reorientation▸ Continuity of Care▸ Maintaining Schedule and Familiarity▸ Having Patience

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Conclusion▸ 98% incidence Neuropsychiatric Symptoms of Dementia▸ Non-Pharmacologic measures most effective▸ Pharmacologic measures

▹ 84% of nursing home and 29% of community-dwelling elders residing in the USA

▸ Presence of neuropsychiatric symptoms leads to greater functional impairment in patients with dementia & cognitive impairment

▸ Behaviors accelerate or lead to Nursing home placement

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