Overview of Challenging Behaviors in VISN 6 Jorge Cortina, MD DFAPA

“…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

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

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

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

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

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?

Requires intensive assessment, ABC’s Except for SMI and perhaps delirium,

antipsychotics are not indicated Non pharmacological interventions have been shown to be effective

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.

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.

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

Percent of patients Disease with diseaseHeart 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. InnoVAVAtions in Non-Institutional Care. GEC Leads Conference. New Orleans, LA. June 81, 2010

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