1. Managing Challenging Behaviors in Older AdultsAugust 23 – August 24, 2010 Overview of Challenging Behaviors in VISN 6 Jorge Cortina, MD DFAPA

2. Definition of Behavior Problem • “…associated with subjective distress, functional impairment, or compromised interactions with others or the environment “ • Tariot PN, Mack JL, Patterson MB et al. The behavior rating scale for dementia of the consortium to establish a registry for Alzheimer's Disease. Am J Psychiatry 1995;152:1349-57. • Behavioral Excess vs. Deficit • Allen-Burge R, Stevens AB, Burgio LD. Effective behavioral intervention for decreasing dementia related challenging behavior in nursing homes. International J of Geri Psychiatry 1999;14:213-232

3. Conditions w/Challenging Behaviors • Dementia: wandering, aggression, etc. • SMI:psychotic and/or inappropriate • Delirium: wandering, psychosis, varying state • PTSD: flashbacks, anger, irritability • Brain injury: dis inhibition, explosive anger • Substance Abuse: testing limits, organized • Personality D/O: splitting, entitled, manipulative

4. Dementia related: Common Challenging Behaviors • Aggression (provoked or unprovoked) • Physical-hitting, grabbing, pushing, biting, scratching • Verbal-cursing and abusive language • Hyperactivity • Physical-pacing, shadowing, wandering, repetitive body motions, rummaging or hoarding • Verbal-incoherent verbalizations, screaming or repetitive questions • Hypoactivity- social withdrawal, declining ADL’s

5. Presentations differ by DX • Psychosis • Delusions Bizarre vs. Non Bizarre vs. in context of relationship • Hallucinations vs. Illusions • Hallucinations (auditory vs. visual) • Wandering • Mania • Exit seeking • Modeling • Self Stimulation • Antipsychotics side effect, Akathesia

6. Prevalence • 50-90% of individuals with mod-severe Dementia • Allen-Burge R, Stevens AB, Burgio LD. Effective behavioral intervention for decreasing dementia related challenging behavior in nursing homes. International J of Geri Psychiatry 1999;14:213-232 • 64-83% in US Nursing Homes • Swearer JM, Drachman DA, O'Donnell BF, Mitchell AL. Troublesome and disruptive behaviors in dementia. Relationships to diagnosis and disease severity.J Am Geriatr Soc. 1988 Sep;36(9):784-90

7. What About Our Special Population? • More Men= More Testosterone= More Aggression? • Veterans • Action Oriented • Fighters:“Trained to kill” • More PTSD • More SMI due to demographics of SMI • More Dementia due to PTSD, head trauma?

8. Treatment • Requires intensive assessment, ABC’s • Except for SMI and perhaps delirium, antipsychotics are not indicated • Non pharmacological interventions have been shown to be effective

9. VA NHCU Similar to Non VA NH • 59% in VA NHCU Overall • 66% among those who aged with Mental Illness • 69% among the Dementia pts • 68% among those with both Dx • McCarthy JF, Blow FC, Kales HC. Disruptive behaviors in Veterans Affairs nursing home residents: how different are residents with serious mental illness? J Am Geriatr Soc. 2004 Dec;52(12):2031-8.

10. SMI vs. Dementia in NHCU • 16% verbal disruption overall • 29% SMI vs. 22% Dem vs. 23% Both • 11% physical aggression overall • 16% SMI vs. 19% vs. Dem vs.19% Both Dx • 54% inappropriate behavior overall • 58% SMI vs. 61% Dem vs. 62% Both Dx • McCarthy JF, Blow FC, Kales HC.Disruptive behaviors in Veterans Affairs nursing home residents: how different are residents with serious mental illness? J Am Geriatr Soc. 2004 Dec;52(12):2031-8.

11. Numbers of Veterans in CLC in FY09 • 2777 veterans treated in CLC (59%=1638) • 104 veterans with Dementia Tx Specialty • 36 with Psychiatric Tx Specialty • DSS Tx specialty report pulled 8/16/10

12. HBPC Population Percent of patients Diseasewith disease Heart disease 72% Diabetes 48% Depression 44% Heart failure 35% Dementia 33% Substance abuse 29% Cancer 29% Anxiety/Personality Disorder 24% PTSD 21% Schizophrenia 20% Tom Edes. InnoVAtions in Non-Institutional Care. GEC Leads Conference. New Orleans, LA. June 81, 2010

13. Daily Census of HBPC Veterans (801)

14. Summary • Our veterans are like everyone else • Prevalence is about 60% of CLC residents • Prevalence of behaviors is nearly equal in SMI vs. Dementia (except for verbally disruptive) • High prevalence of SMI and Dementia in HBPC • Need for increased capacity to manage across settings