 Dean Jackson, and Mark Dahlia, owner of the world's largest zucchini. And now. Thank you. Thank you. Thank you very much. How nice of you. Thank you. Thank you, everybody. Listen, I appreciate the thanks, but just keep in mind, I'm just a mere microbe compared to Gert Frobe and his merry men of music, the CMS Orchestra, ladies and gentlemen. Excellent, as always. Hey, folks, listen, I just found this out. Did you know that Gert once saved a woman from being killed by a vicious wild animal? No, no, really. It's true. It's true. It's not a safari. It seems like in a place called Lompa Land in a fellow tourist who was about to be charged by a rampaging, uh, vernicious canid, and, uh, what, what, what's so funny? All right. Okay. All right. Mr. Awanka over there, Mr. Barrel of Laughs. All right. Let me finish the story. However, Hemingway here, not withstanding, we have a fabulous show for you tonight. We always have a fabulous show, of course, but tonight is very special. I have, uh, I've got to start, though, with an apology as much as I hate to, but I'm going to have to. As you know, from the opening of the program, Ozzy Osbourne was supposed to be here tonight, uh, live on her show. Uh, however, many of you probably have heard Ozzy had a minor accident, uh, something involving a tricycle and a sheep, uh, yeah, as strange as that sounds, a tricycle and a sheep. Uh, so he's in a hospital right now at home in the U.K. However, since we're willing to go to any length to avoid any disappointment to you, the audience, we've arranged a phone call with Ozzy Osbourne. That's right. A phone call with Ozzy, direct from his hospital bed. Okay. All right. And we're also going to bring back Mark Dalleus and his world record-breaking Zucchini. That's right. As hard as it is to believe, yes, we're going to bring it. You know, we missed Mark the last program, but we, uh, we've got him this time and he's coming to us live all the way from Viewford, Shed, Louisiana. So, uh, the world record-breaking Zucchini is with us tonight, uh, and we appreciate it. And you know, just like one of those old Ronco ads, that's not all. How much would you expect to pay for Dr. Jim Lett and Dr. Jeannie Jackson, both on this program, live with us? That's right. That's right. Got a great program for you. So, let's bring them out right now. Uh, Dr. Lett, Dr. Jackson. Let's go meet them. Doctors. Good to see you. Good to see you. Good to see you. Dr. Jackson. Good to see you again. Nice to meet you, Dr. Lett. Pleasure. My pleasure. Have a seat. Sit down. Thank you. Sit down. It's good to see both of you. Uh, I know you had to travel in, uh, to do the program with us. Uh, not too many hassles going through security these days? No, not too many. Okay. Just takes 20 minutes or so. Half a dozen times to get through. Okay. All right. Always a pleasure to have a special guest with us, and we want to thank you for being with us. All right. I don't know how to say this, uh, but we are, uh, always thrilled to have special guests with us on our program, and, uh, you know, we try to have some special guests, believe it or not. Tanya Harding and, uh, Nancy Kerrigan and the ice skaters. We try to have them here. Same program. Same set. Didn't quite work out. Got kind of ugly. Uh, something about a crowbar and, uh, you know, a bruised leg. Ooh. It was ugly. Two such lovely ladies, too. So we're not expecting any problems out of doctors here today, are we? None at all. No. Psychiatry has become fairly good friends with primary care over the last 10 years, and long-term care. Always good to know. No fights or breakouts on this. Not at all. All right. Now, you as regular viewers of our program are no doubt aware that we often have a live question and answer session with our guests at periodic intervals during the program. This time, a little something different. We are going to open up the phone lines and the fax lines right now at the beginning of this program, and we're going to take some calls as they come in throughout the course of the show. So if you have a question, there's no need to wait for that official Q&A session that we refer to. Just go right ahead, pick up the phone, and call it in. Call in your question. Uh, and let me give you those phone numbers right now. Uh, the phone number for the calls is 1-800-953-2233. And if you want to fax in your question, then you should dial 410-786-0123. Doctors give you a heads up. You may sort of break into some of your presentation if we do get a call. That'll be okay with you. That'd be great. Okay. Thank you very much. Uh, all right. Now, just keep in mind the lines will be open, and you should dial those numbers we just gave you if you want to get through, and we hope that you will call in with either your question or your fax. And we want to move along Dr. Jackson and Dr. Letter here to give us a taste of their expertise regarding the management of distressed behaviors in nursing home residences. Is that correct? Exactly. Stan, this has become such an important topic, um, to certainly the residents who are distressed and their families and staff, as well as to primary care physicians, medical directors such as Dr. Lett. Um, myself as a geriatric psychiatrist providing consults, distressed behaviors is what I do every day all day. Generally people don't come to me because they're feeling great. No, they wait until the distressed ones come. That's right. And so one of, we want to do is just present ideas that we have about management, hopefully helping everybody to get a little bit on the same page. Okay. Sounds like something we can all learn something from. Sounds like you have a game plan. We will not. Okay. Why don't you take it away and, uh, we'll get prepared here. And, uh, let me remind, uh, our viewers right now while you're getting prepared, uh, that if you do have the questions, go ahead and call them in, uh, the phone number for the call-in questions again, 1-800-953-2233. If you'd like to fax your question in, then you should dial 1-410-786-0123. Okay? All right. Dr. Let, take it away. Thank you, Stan. It's a pleasure to be here at CMS today. We're going to talk about distressed behaviors in nursing facility residents. Certainly, the, the most daunting thing I face every day is I practice in long-term care, and I would suspect the surveyors daunting for you as well. Uh, today I'm going to give you the viewpoint of a physician who is in long-term facilities every day, medical director of three of them. I'd like to let you know what goes through my mind when I get a phone call and what goes through the mind of the facility when we see a distressed behavior and try to address it. First, it helps me and I hope helps you define what we're going to talk about today, and we will define behaviors as an individual's observable actions. That is, we're not talking about their cognition, their mental status, their thought process, but the actions that you can physically see that they're having at this point in time. Uh, it's an interesting study that was done that showed the types and percentages of behaviors of residents in long-term care facilities. Most of these, you will have heard, agitation, anxiety, irritability, through delusions and hallucinations occur very frequently. One thing we sometimes forget is that apathy is also a behavior, and in fact, it is the most common behavior that we see in long-term care. Why do we worry about distressed behaviors in long-term care? Well, it certainly increases the tension between patients and caregivers, which is never a positive thing. It can create costly interventions, both in resources and dollars. Those who experience behaviors also have increased illnesses and death as a result of those behaviors, and we certainly can see the overuse of restraints and medications in those who exhibit behaviors in long-term care. Now, we often talk about agitation as if behaviors and agitation are the same thing, and we'll define agitation as well for you. We consider it excessive motor or verbal activity that is either disruptive, unsafe, or distressing to the patient and interferes with their care and is not because of any perceived need that we can see. So while all agitation is a behavior, not all behaviors are agitation. What types of things might you see in agitation? Physical, from hitting to kicking, biting to scratching, verbal threats, accusations, obscenities. And you can imagine the barrier this would put between a caregiver and their resident if you had taken care of someone for long periods of time, or the great deal of compassion and love, and then had these things happen to you. So it's very important to keep that barrier down and away from that relationship. There are some pitfalls, as there always are, in trying to discuss and discover behaviors. Probably the most important one is that almost any etiology of behaviors can result in a similar agitation or other behavior. For example, think of fever. Fever can be caused by a virus, a fungus, a bacteria, by sinus infections, by urinary tract infections. Yet the only manifestation you may see is fever. The same thing with behaviors. You may see a behavior, but it's very difficult sometimes to see the etiology. Plus the people that we deal with have a huge number of risk factors, that is, other diseases. They may be on multiple medications. And they may have just changed environments, which can be very unsettling to this population. So in order to address behaviors, you must then have a process to evaluate the resident for the behavior that you're seeing. The process that I'm going to present to you today is not the only process. It is not the only way. But I think it maintains and has most of the elements that about any facility or any physician will have in mind as they work through dealing with behaviors. The first step is to pick out the target symptoms. That is, the behaviors that bother you the most that you need to deal with. Second, a medical evaluation. Third, you should have a list in your head. That is a differential diagnosis of the potential causes for the behavior. Then if an intervention is required, we've used something we call the ABCs of behavior intervention, the antecedent events, the behavior itself, and the consequences of that behavior. The next to last bullet, I said document three times because it's so important to do. And last but not least, non-pharmacologic intervention always is the first step. When we talk about target symptoms, the ones that we feel are good are anxiety, insomnia, delusions, hallucinations, depression, compulsive behavior, agitation, motor restlessness, and pain. Why do I say that? Well, let's go on to the ones that aren't good and we'll talk about the differentiation. Poor target symptoms that you see here are often secondary symptoms, that is, exit seeking may be as a result of hallucinations, perhaps somebody's after them. It may be the result of anxiety that they're worried and need to pay. So poor target symptoms are ones that tend to be secondary to the prior good target symptoms that we pointed out on the last slide. The next bullet is a medical evaluation. Certainly medical history and psychiatric history is key, but I have to be honest, in long-term care, often a good medical history and particularly psychiatric history is often sadly lacking in that vacuum between the hospital and the long-term care facility that information seems to disappear from time to time. Under the medical evaluation review the medication list, you will hear it from me multiple times today, but medications, medications, medications are often at the root of behaviors and problems in long-term care. Certainly a physical evaluation to look for some obvious causes for the behavior, that is, if someone's short of breath, I imagine they're going to be agitated. If someone has urinary retention, I can assure you it's uncomfortable and they're going to be agitated. The next thing is a mental status examination. Is the resident alert? Are they lethargic? Are they agitated? Are they confused? You need to have a baseline to work with against that behavior. Lab studies including oximetry, they're useful, they're good, and as we'll talk about in a minute, unfortunately, not always available. Many facilities, particularly small ones, rural ones, outlying ones in suburban areas, may not have proximity for getting lab studies done on a prompt basis. Oximetry is usually available in the facility and can tell you if someone is short of breath. Imaging studies, nice if you can get them, but again, the same problem. They aren't often available immediately. What types of medical illnesses might you expect? This is certainly not a comprehensive list, but one that will give you an idea of the types of illnesses that can cause behaviors that we deal with. Anything from reflux esophagitis, angina, side effects of medicines, chronic pain, constipation, hearing or vision impairment, sleep deprivations, even dental problems, all can cause agitation. Now, Dr. Jackson, as a geriatric psychiatrist, the role of the medical evaluation and specifically lab studies and imaging studies. Well, it's always important to think first about safety and what's the acuity. So if a person is dangerous, we will often move to treat and get them in a safe situation. Knowing that our lab studies are imaging wouldn't come due for some days. Also, I think of a medical evaluation as a process. You start out with what's obvious to you or what you think is highest in your differential diagnosis. You're not gonna send someone in for an entire body MRI. You're going to send them in for what you think might be a problem. And as things become negative, then you keep looking. The premise here is that there's almost always things you can find and that it can often be more than one thing. So a person may have lost their hearing aid and have constipation. And with these kinds of residents, that's more the common thing. So even if you solve the problem, we try to do the full evaluation over time. I fully agree. Stan, back to you. Okay, Dr. Jackson, let me very quickly remind our viewers that if you would like to call in with questions for our doctors today, then we would like you to do that. Two different ways you can do it. If you want to phone in your question, then you should dial 1-800-953-2233. If you'd like to fax in your question, then you should dial 1-410-786-0123. Let me give you those numbers again because we want you to get on the phone and either fax them in or call them in right now so we can get right to them. Again, the phone number, 1-800-953-2233. If you'd like to fax it, 410-786-0123. All right, doctors? Oh, we do have a question. Okay, we have a call from Houston, I understand. Terrific. Okay, caller, are you there? Brad from Houston? There we go. We hear you from Houston. Alrighty, recently, this question's for Dr. James Latt. Mm-hmm. I recently moved to Houston. I'm looking for a new family practice doctor to go to. My family's checkups and analysis. How do I choose a doctor and what are some qualifications to look for? I'd have to be selfish as a family physician and say I'd love to direct people towards family physicians. Residency train, board certified is always, are two things that don't guarantee a physician but I think there are big steps towards it. I think the next thing is to try and set up and get acquainted appointment with them or to talk to neighbors or friends who may have already seen that physician and give you some recommendations as whether or not you should go. Okay. Thank you, Houston caller, we appreciate it. And the rest of you can get on the phone and give us some calls. All right, Dr. Latt, if you wanna proceed with the second part of your presentation, sir. Thank you, Stan. We are now into the next bullet of how to approach agitation and behaviors. I mentioned the list in your head. I think it's always worthwhile, at least in my training I was given, to create lists. And this is the list that will encompass most of the etiologies for the types of behaviors, distress behaviors we're gonna talk about today. They are the dementing disorders or dementia, frontal lobe impairment, delirium, medications. Dr. Jackson would, I think, mix those two and I agree with her, but as I've told you before, I admit my bias about medications and elders in long-term care. Something I'll call toxic personality syndrome. We'll talk about it in a moment. Pain and then the primary psychiatric illnesses, depression, anxiety, psychosis, personality disorders and last but certainly not least, environmental stressors. So let's talk about each one of those subjects briefly because I don't think you can treat behaviors until you have some idea of the etiology of the behaviors ultimately. Dementia is not a disease. It's what we refer to as a syndrome. That is a collection of signs and symptoms. And in this case, it's a progressive decline in multiple areas of the ability to think. And ultimately this leads to the inability to take care of themselves and to really function in a social atmosphere. Dementia is very age-related. The older you are, the more likely you are to have it when you're over the age of 85, more than 30% of elders will have a cognitive impairment. And in our population, depending on the study you look at, up to 80% of nursing facility elders will have some type of cognitive impairment or dementia, if you will. And that's really not surprising because they actually, the most common cause of being admitted to a long-term care facility is the inability to take care of themselves on a functional basis. Dementia itself, since it is a syndrome and not a disease, can be broken up into a number of categories. The most common and one we've all heard of the most is Alzheimer's disease. Nearly 2 thirds of people with diagnosed dementia ultimately are felt to have Alzheimer's disease. There is another category called Louis Body Dementia. We'll talk about it in a moment. That is coming up fast in the second place. And then a mixture of Alzheimer's disease with other things. That is, minimal many strokes, Louis Body Disease mixed with Alzheimer's, Vascular Dementia, which means multiple strokes that affect the brain substance over time. And then, of course, the other category, which include infections, alcohol, and other things. Let's talk about Alzheimer's for a second. It is a degenerative brain disease that results in impaired memory, thinking, and behavior. It's a gradual onset. And you'll hear that several times today. That is its hallmark. Progressive symptoms, including memory loss, personality changes, and a decline in the ability to think and function. Again, by far the most common cause of dementia that we see, the important thing to remember is that Alzheimer's is dementia, but not all dementia is Alzheimer's. Some 60, 80% we believe of dementia that occurs in those over the age of 65 is Alzheimer's. Again, the slow, insidious course affecting multiple skills. The work up forth, the evaluation, the imaging, the test, usually they show very minor abnormalities or none at all. And there are no biologic markers. That is, there is not a test that says Alzheimer's, yes, or Alzheimer's, no. Ideology of Alzheimer's, I think the person who answers that will win the next Nobel Prize in Medicine. We know that it's genetic-based, but not all people who have those genetics get the disease. We're learning more. Dementia with Lewy bodies. Seeing it more often, or maybe we're just looking for it more often and thinking about it now. Its hallmark feature, again, is not a test, not an x-ray, but it's a pathologic diagnosis. That is, you only find out unless you get substance from the brain, which no one is going to do prior to death. And at autopsy, you will see some changes and includes some little protonaceous specs we call Lewy bodies and the degeneration of the brain itself, more often in men than women. It seems to happen more the older we are. And again, the insidious onset progressing to profound dementia. To diagnose it, again, is a clinical diagnosis. It's the cognitive decline or dementia, along with two of the following three things, fluctuating ability to think with variation and attention and alertness, recurrent hallucinations, and it looks like Parkinsonism. Treatment issues, why does it matter? It matters because up to 80% of those with dementia with Lewy bodies are very sensitive to some of the drugs we use to treat them. So we need to be careful in using them. Some of them may respond better to acetylcholinesterase therapy, and they're more often depressed. So it is worthwhile knowing. Front lobe impairment is the next category. You may think of it as the Archibunker disease. Mood, liability, inappropriate affect, poor impulse control, rude, caustic bigoted. You can see where I got that if you ever watched all in the family. They can be aggressive, restless, difficult to re-addict, sexually inappropriate or aggressive. And again, it's important, though, this is not psychotic behavior, but simply poor control of their impulses. And again, it is not a disease. It's a syndrome. It can be caused by a variety of things, including Alzheimer's disease, vascular dementia, multiple sclerosis, alcohol disease, among others. Because it's a little different in its treatment, I'll mention that with frontal lobe impairment, you must do an exaggerated politeness, keep your distance from people you communicate concretely. That is, you don't give them open-ended comments. You give them very few suggestions and alternatives and make them very clear. And only medications when you can't control behavior with the aforementioned issues. The next one is delirium. And I really want to focus on, or have you all focus on delirium in your thought process, we define it as a state of acute confusion and attention and an altered level of consciousness, usually very abrupt in onset, several hours to several days. The symptoms can be fluctuations in alertness, mental functioning, and inattention, the inability to really pay attention to what you're trying to say. They can also have anxiety, hallucinations, be disoriented, shaky, delusions, incoherence. Think about alcohol withdrawal, if you all have ever been associated with that, as the hallmark for this disease. What can cause delirium, and this one is important to focus on, because the etiology is so hugely important in its treatment, is almost any acute illness, particularly infections in elders, poor nutrition, endocrine diseases. Again, you notice I like medications per my prejudice, and certainly alcohol, as we talked about before, can trigger it. Again, it's not a disease, it's a syndrome. Fluctuating level of alertness is its hallmark. We often see it in people with dementia, which even makes it that much harder to deal with. And it's important to know the etiology, because if you are going to treat them with drugs, and you know the source, you know the source is time limited, you can time limit the drugs, they aren't indefinitely taking anesthetics. I pulled these from a number of different studies that have been done on hospitalized patients, because I really can't find any on nursing home patients about delirium and its incidence. But I think this tells us a great deal about this disease. That is, it's very common, at least in the hospital practice, it is very common, people over the age of 65, up to 60% of those with hip fractures, which are usually elders, have delirium. And what's important about it is a 35% increase in mortality and death in the hospital with delirium. And what's really worrisome is we physicians only correctly diagnose it in less than 20% of cases. Sometimes with all the D diseases, it's helpful to have a column to compare. So let's look at delirium versus dementia. Delirium is acute and onset. Dementia, again, gradual, progressive. Attention and delirium is usually very, very poor. They gaze off, they look off, they hear things, they will not make eye contact with you. That's usually not a problem in dementia. Level of consciousness, people with delirium can be underactive, hyperactive, whereas those in dementia can certainly be normal in their activity level. Delirium is self-limited, almost invariably. And there's a lot of prominent physiologic changes. Depression, depressed mood for at least two weeks. Again, a clinical diagnosis, plus at least four of the following illnesses, four of the following categories, insomnia, sleep disturbances, weight loss, fatigue, inability to concentrate, guilt, even down to loss of pleasure for those plus the depressed mood. It can be diagnosed by something called the geriatric depression scale, which is a questionnaire that you administer to the patient and you get points for each yes within the score. If someone who has demented, they've developed special scales for that called the Cornell. There's even some for ethnic Americans that have been developed. Again, no direct marker. There is not a yes or no test. Depression and elders is different than depression in younger people. Younger people have a more classic cheerfulness, sadness, suicidal ideation. Elders, a lot more quiet, withdrawn, fatigue, multiple somatic complaints, irritability, and just loss of function. Dr. Lett, if I could cut in for just a second. Yes, sir. I think we have a caller on the phone. I believe we have Richard from Albuquerque, New Mexico on the line with us. Richard, are you there? Yes, sir. Yes, sir. Do you have a question for Dr. Lett, Dr. Jackson? I sure do. I recently moved to Albuquerque and I'm looking for a new family practice doctor to go to for my family's checkups or illnesses. How do I choose a doctor and what are some qualifications to look for? I think I know someone in Houston who can help you out. This was for psychiatric illness? Did I hear that correctly? Richard is going now. We don't know if it's psychiatric. I thought I heard psychiatric illness. One of the availabilities from the American Association of Geriatric Psychiatry, AAGP, is that they have a list of physicians in every state. And so, if you would call that number, the American Association for Geriatric Psychiatry, they can tell you exactly who's been board certified and trained in geriatrics that can take care of elders for mental health problems. If it's a younger person, I think you would just have to rely on friends and acquaintances as to who knows of a good person. Dr. Lett, I apologize, but we want to get to those calls when they come in as they come in. Well, I understand. I apologize. All right, sir. It was a very similar question. Thought it might have been the same person. And it may have been. In depression, that's the most common psychiatric, psychological disorder that we see, up to a third, perhaps, of nursing home residents have this. Sadly, this third bullet estimates that primary care physicians, perhaps we fail to diagnose depression half the time. And then when we do diagnose it, do not provide adequate treatment for half of those. So that one is one we need to work on. And what's important about depression is it's closely associated with functional decline and triggering quality indicators, which is very important for the facility. Depression often, often is comorbid with dementia, often post-stroke, maybe 30%. We need to be careful that we don't say, you know what, because someone's elderly, because their friends have passed away, I'd be sad too. You can't allow ageism to make it be a barrier to that diagnosis and always, always look for medical or medication underlying causes. Depression, again, my bias with medications can be caused by a variety of adverse drug reactions. You notice in this list of drugs, some from almost every therapeutic category. So please read the medication list. Again, the D diseases can become confusing. So let's talk about depression versus dementia. And sometimes both may happen in depression. Again, a more clear, recent onset. Dementia has a more gradual onset. Dementia progresses over years while depression seems to be of a shorter onset and duration. There's obviously often a previous psychiatric history while there's not in people with dementia. People with depression tend to complain about their memory. I can't remember things, doctor. People with dementia think everything is just fine. They don't miss the memory at all. And in people with dementia, they tend to remember what happened 50 years ago, what their address was then, but not what they had for breakfast. People with depression tend to have equally bad memories, both remote and recent. Anxiety. Imagine yourself being frightened to death. Somebody jumping out of a closet and scaring you. That's what it feels like without adrenaline rush with people who have anxiety and anxiety symptoms. There are heartbeats. Their breathing is fast. It is a very, very anxious bad feeling with sweaty palms and tremor. And the things that can trigger that sensation may be internal, they may be external. And they may be things that seem to be pretty irrelevant to you and to me, but they are nonetheless very real to the person who suffers from it. For example, I've had a resident who said that she became very anxious, was very distressed because she was elected secretary of the resident council of the facility. While that may not seem like an odious task to you and to me, it was to her and he brought her her symptoms. And again, the anxiety symptoms are far more common than the actual disorder of anxiety. When you have anxiety symptoms, you should think about the differential diagnosis, the list in your head, if you will. Psychosis can cause it, depression can cause it, delirium pain, or they can actually have a generalized anxiety disorder. Always you try to modify the environment to see what may be causing the anxiety, deal with it, and look to medications as always, but not always medications on the MAR. For example, they may be a diet soda drinker, they may be a heavy coffee drinker, they may be taking over-the-counter cold medicines that can cause anxiety-type symptoms, and of course, always medical illness, especially thyroid disease, heart irregularities can cause it. Dr. Lecklin, I interject a question here. Indeed. I'm talking about medications on the subject of lack of memory or loss of memory and the anxiety that it can create, and perhaps Dr. Jackson can come into this question also. I know that there are a lot of families out here who have family members who are starting to show the early signs or middle stages or late stages of Alzheimer's. Some of them are in the nursing home setting, and there are certain new drugs that have come out on the market to treat Alzheimer's, maybe keep them from losing as much memory as possible. One of these drugs is called Aerocept, if I'm not mistaken, is that correct? That is correct. And how is that being used as an application in a nursing home setting, for example? Dr. Jackson, maybe? In the second part of this, I'm gonna go into detail about what kinds of drugs are available to improve cognition. And those are crucial because, as you notice, Dr. Let started talking about dementia as highest on his list, because if we can improve people's ability to think, they're gonna manage their experiences better. If you don't understand something, we tend to get paranoid, uncomfortable, somewhat fearful. Any of us have that kind of experience. So Aerocept is one of those medications that we always wanna see, can we get people who have dementia started on such a drug, not necessarily that one, but one of that class, and give them the best sort of protoplasm, the best ability to manage their world. Is it showing some promising results? Absolutely, absolutely. And some of that I will show you in detail in a bit. Sorry for your break. Great question. Okay, thank you. Thank you, it's a good question, I appreciate it. The next list in the Dementing Disorders or next on the list is psychosis, which is actually impaired connection to reality. And I can give you an example of one resident I have who was developed shingles on the back of his head which is quite painful. And when I asked him about the pain, he said, well, I know you've told me this, but I can confidentially tell you, doctor, that actually the FBI is pouring acid on the back of my head every day. So that is psychosis, that is impaired connection to reality. They may have hallucinations. And again, it's another of these diseases that is not a, it is a symptom, rather than a specific disease entity, may be caused by a variety of things. Dementia, delirium, drugs, both too much and too little, as well as withdrawal from drugs, schizophrenia, mania, and then depression with psychosis as well. And again, as we talked about delirium, the type of diagnosis will dictate the duration of the treatment. You want to know what the etiology is so that you don't treat them longer than the necessary period of time. Personality disorders such as schizophrenia and mania also are under that list of what could be causing behaviors. We often tend to over-diagnose or get excited about the possibility of a schizophrenia or a mania in someone long-term care, but the key to that is to look to the history. That is, people do not develop schizophrenia at age 75. There should be a long-standing history of such problems in order to make a personality disorder diagnosis. Those are usually diagnosed long before they arrive in long-term care. The toxic personality syndrome is kind of a tongue-in-cheek. It's not a disease. It is a personality type, and we've all seen them, both young, old, and middle-age. And the point here is that when people are not very pleasant when they're young, chances are they're not gonna change as they move into long-term care. The personality type is hypercritical, angry, they're accusatory. There doesn't seem to be anything that you can do that really seems to make them happy. So it doesn't require treatment, nor does it respond to treatment. However, we would ask both the facility to recognize that that doesn't require treatment and have the surveyors realize as well when they talk to some residents that some of them just aren't very happy and they're not gonna be. Stan, back to you. All right, Dr. Lett, thank you very much, and certainly can't wait to hear the rest of your presentation because it's very helpful for a lot of folks. However, I'm reminded that we are obligated contractually, by the way, obligated contractually to look at some viewer mail right now, and I just happen to have some of it right here. So let's go right to our very first letter. And this one is from a gentleman by the name of Mr. Al Coleman from Minneapolis, Minnesota. Al, thank you for writing, I think. First, this one says, dear Stan, I'm a little confused about the nature of the universe. Can you explain it for me? Okay, well, Al, I'll try to do my best. Let me say first of all, Al, that perhaps you're a little confused a little more than the nature of the universe. For example, do I look like Stephen Hawking, do you, Al? Hey, the universe, it's big, it's really big. It's really, really big with lots of Bernie stuff in it, you know, some kind of explosive things in it too. You know what I'm talking about? Look at it this way. It's just a really, really, really long apocalypse now. Does that explain it for you, Al? All right, good enough. Okay, let's go to our next letter. I hope that, hope you some, Al. This next letter is from a young man by the name of Timmy, and Timmy writes, Dr. Seuss became famous by writing a book using only 40 words. I was thinking that maybe you should try that with one of your broadcasts. It could do wonders for your ratings. Like we worry about ratings here, Timmy. All right, Timmy, let me try to answer this one for you, Timmy. Tim, I could not, I would not with a fox, and I could not, would not in a box. I will not do it here, I will not do it there, Tim. I will not do it anywhere. I don't like green eggs and ham, Tim. And you know what? I don't care much for your idea or your question either, Tim. You should be in bed. You're a young man. Go to bed. Stop writing questions. All right, I hope that answered Tim's question. Enough of that for you, right? All right, Dr. Lett, sorry for the interruption. Let's go back to you. Thank you, Stan. I appreciate it. Well, we've talked about possibly the etiologies of behaviors. Now we've decided we need to make some type of intervention, and we have borrowed from Dr. Slatter in his group, an ABC method of behavior intervention, A, being the antecedent event for the behavior, B, the behavior itself, C, the consequences of that behavior with which we need to deal. First of all, the antecedent event, you know, it is rare that a behavior occurs without some trigger. It may not be obvious to you. It may not be obvious to me, but I can guarantee you, it's very obvious to the resident involved. And it's especially important to look for antecedent events in a demented population because they don't tend to learn from consequences, so therefore you need to be especially keen looking for the triggers that initiate them. What kind of triggers would you look for? They could be physical triggers, such as pain and ability to hear or see, impaction, needs repositioning. They could be emotional triggers. They're afraid, they're distressed, they're frightened about something. Environmental triggers, it could be the lighting, it could be the heat, it could be the number of people around them or the activity. Task triggers, that is a task such as even brushing their teeth or putting on their shirt may be an insurmountable obstacle to them. They get frustrated, they get angry, they develop a behavior. We need to find those and take those frustrations away. And then communication triggers. It can be very vexing, not to be able to say what you think or hear what people are saying to you. Those can often trigger behaviors. Certainly, we mentioned environment and stressors. Very, very applicable here to the A part of the ABCs. Decrease control, crowding, stimulation. Burnout of caregivers can also do it as well as not feeling the residents feeling their approach with respect and not redirected in a proper fashion. B, the behavioral event. And that is any behavioral episode that is disrupt or adverse and I italicize this on purpose, jeopardizes. Jeopardizes the safety of the resident, other persons or objects in the environment. Because the goals of treating behaviors are to reduce the risk of injury to the resident and those around him or her. Reduce the patient distress itself. Minimize adverse drug effects by minimizing drug use. Maintain the resident in the best environment and an important piece is recognize for whom this behavior is a problem and the example I'll give you is a very lovely lady. I was called by the family in the facility, said, go treat her, she's having hallucinations. This isn't right. When I went to see this lovely lady, she's sitting on the edge of her bed, staring off into the corner, smiling. Very benignly, lovely smile. I knocked on the door, walked in, introduced myself, spoke with her. She was very pleasant but kept looking off into the corner and I said, do you see something there? She said, oh yes, I'm dancing with my husband. We were married for 50 years. He died last year and we used to love to dance. It's what we did every weekend. We danced and I love to watch us dance and I left the room and told the family this is not a treatable behavior. This does not jeopardize. It actually augments her life. So define for whom it's a problem before you feel you need to treat a behavior. Well, what are the impacts of behaviors? Here's a nice study by Souter and his group that determined that 25% of behaviors required no intervention at all and less than 1% resulted in injury to others, less than 1% injury or physical damage to the environment. Any percent is high but these are relatively no numbers when you think about the number of behaviors we see but the last bullet is very telling. The intensity of resources necessary to control behaviors in average of 24 minutes of staff time required for intervention. When you think about an average facility being between 100 and 150 beds, it's a lot of 24 minute increments of time. See the consequences. It is if possible if you have a cognitively intact resident if you can give them positive reinforcement and as a physician I hate to admit it but we have some patients who respond very well to being given a cigarette and allowed to smoke outside with good behavior. Now in people who are cognitively not intact they don't understand consequences and that's why we go back to the antecedent, the A part of the ABCs to talk about trying to reduce or eliminate the triggers that bring them about. The next bullet on how we approach behaviors is documentation and it is just so important. It is important to diagnose it or to document it in the orders on a monthly basis which I now see done almost all facilities where I attend. It's good to get in the progress notes, the IDT notes and the interdisciplinary team notes certainly need to keep in mind those target symptoms that we talked about earlier. What's been done non-pharmacologically? What's been done pharmacologically and what are the results of those interventions? Especially results aimed at the target symptoms. How did they respond? And if you possibly can something that is concrete that is if you have something like depression you've used geriatric depression scale prior to treatment use it periodically afterwards to see if your intervention is making a difference. Where do we tend to fall down in long-term care and documentation? This article in 1999 in 108 bed community nursing home says that we do a pretty good job in indications. 95% of the residents on antidepressant therapy and antipsychotic therapy in this study got documented why it was necessary and basically what was the target behavior. But the outcome of that intervention was only documented in a little over half some 57%. And adverse drug monitoring, probably one of the most important things that we deal with was only documented in about 20%. So what's the take home message? The take home message is we need to do as good a job in monitoring outcomes and adverse drug reactions as we do in documenting why we use drugs to begin with. The last bullet is non-pharmacologic interventions. What behavioral strategies can you try before you talk about medications? Which is what Dr. Jackson we bring into you shortly. Certainly in cognitively intact residents, behavioral contracting, positive reinforcers as we talked about, even written contracts, communications with people will be somewhat useful. Those who are not cognitively intact one-on-one intervention, but that is intensely resource-expensive and difficult to sustain, redirection, distraction of the cognitively non-intact residents, even things like traffic controllers, physical people standing in the hall at breakfast or lunch directing wheelchairs. Go this way, go that way. And I've even seen facilities who have painted or put tape lines on the hallway itself. Wheelchairs going this way to the right. Even those things seem to help. Signs and symbols amazingly, putting up stop signs on rooms you don't want them to enter or if you want them not to leave for any period of time. And even the wander prevention nets or ribbons that are velcroed across doorways are very useful remarkably. Sometimes after having heard all the bullets and our good ideas about interventions, things happen that are so dramatic, so dangerous, so jeopardized, though the environment and the resident that you simply have to take action. But you should at some later date, whether it's the next day or whenever it's appropriate, go through the paradigm that we talked about looking for why did it happen in the first place. One last thing I've told you my bias about medications and elders, here it is again, I try to always talk about the prescribing cascade. That is using a medicine, then using another medicine to take up for a side effect from the first medicine, then you give another medicine because there are side effects from the second. And before you know it, you have people on multiple drugs that may not need to be on them. And let me give an example of someone with depression. You put them on antidepressant that is an exciter type antidepressant. They become insomniac. You then put them on a sleeping pill at night because they can't sleep. They then because they can't sleep and are on this medicine become more agitated and even psychotic perhaps in their behavior. And they're on an antipsychotic. So you now have somebody who was depressed who was on three different drugs at this point in time. Not because they have three different syndromes, but because they have adverse drug effects that really weren't recognized from the first one. Stan, back to you. Dr. Led, I've got a very quick question for you. If I could, talking about medications and I know that you are not a big advocate of medications. Let me ask you, when it comes to, let's say, taking multiple prescriptions for dealing with psychological issues, can you explain the impact on the medical point of view of mixing so many different psychological type drugs? I'm not sure if Dr. Jackson's gonna address that in her segment, but I'd like to get your comment on it as well. She will, and I'll go ahead and put my piece into it now. First, it's not that I dislike medications. They're wonderful. They are wonderful creations. However, they should be used for very specific purpose and that purpose only. When you start mixing drugs, you are taking someone, someone being an elder who may have or probably does have impaired liver function, impaired kidney function, perhaps heart disease, lung disease. They don't act like you and I do in a normal body with normal physiologic processes in terms of metabolizing that is getting rid of a drug and how that drug reacts in the elder. So you already have an unknown factor to begin with when you start adding other drugs with equal unknown factors, you have a potentially explosive situation. This doesn't mean that I don't prescribe multiple drugs. It means I do it with a great deal of caution and forethought. Yeah, but the potential exists for exacerbating existing medical conditions. You keep adding more and more medications for... That is correct. You certainly can induce medical conditions from the adverse drug reactions to medications you're given. Okay, Dr. Lett, thank you very much for a very informative presentation and we're gonna hear from you a little bit later. I just wanna remind our viewers that our phone lines are still open, our fax lines are still open. If you'd like to call in your question, the number to call again is 1-800-953-2233 and the fax number to call is 1-410-786-0120. Okay, Dr. Jackson, I believe your time to take it away here. That's great. I'm going to talk more specifically about the psychotropic drugs that you can use to treat the various illnesses that you have defined through the process of assessment. First of all, psychotropic drugs is a very broad term and a lot of people have different opinions about what it actually means. At least in my training, it was defined as a medication that affects cognition, mental status, mood, behavior, any of the things that affect the brain's ability to function and perceive. Now CMS and our regulations has divided that into four different categories. Things such as antipsychotics, antidepressants, anti-anxiety medications and hypnotics. But there are two other categories that are very important and those include our cognitive enhancers, becoming more and more important as we learn about the benefits of improving cognition and behavioral control, as well as the mood stabilizers. So although they are not discussed at length in the regulations, we as good clinical care need to be including these. And so the first idea is that psychotropics can have either a good effect or do harm depending on how appropriate they are for what they're treating. For example, a very nervous person may appear so anxious that an anti-anxiety medication is given. If that would happen, for example, if you didn't do a proper assessment and realize it was actually a depression. And if it was caught as a depression and treated with an antidepressant, you might see some of the quality indicator domains actually improve. If we had given an anti-anxiety drug, for example, they may be doing more falling or they may stop eating as much. They may sit around more and get skin wounds. If we treated appropriately with an antidepressant, perhaps they would walk more, have a better appetite. Their skin would heal better. All of the domains can be affected in a positive way if we're treating an exact illness or in a negative way if we're just kind of quieting the situation and leaving it at that. Now, this paradigm that Dr. Let talked about, I always think of dementia as the top of the paradigm. And then I go through, again, what is the brain capable of doing? And I want to maximize that. So the first thing that I think about are the cognitive enhancers. And in this case, we have both the cholinerasterase inhibitors and now memantine. We are going to be going through the paradigm as we discuss the different classes of drugs. So we have dementia, then the frontal lobe symptoms, then delirium, then medical illnesses, then psychotic illnesses, affective disorders, anxiety, and then personality. And it's important to see that anxiety is at the bottom because we don't want to call anybody just an anxiety disorder when anything higher than that could make a person look anxious. So to maximize brain function, we want to look at improving cognition with things such as the cholinerasterase inhibitor. There are three of them out on the market now. And probably the most common mistake that's happening is people are started on the initial dose. And only aerosept actually has a therapeutic benefit at the initial dose. All of the others, and aerosept as well, the goal is to get the treatment to the highest tolerated dose. When you make those adjustments up in dosing, you want to wait enough time so that, particularly, the GI tract is adjusted and you want to just push every few weeks for exhalon and reminil, and about every four to six weeks for that second increase in aerosept. But again, your goal is, in three months, everybody should be at maximum dose tolerated. What we've seen is that, even initially, you can see improvements in their ability to function. Sometimes, they're actual mini-mental status score. But what's far more important is people's ability to dress or interact with their peers to know what's going on rather than say, know what day of the week it is. We also know that if you look at a full six months, about 20% will show a true kind of hallelujah effect, a clear positive benefit. And that only occurs when the maximum dose has been reached. We know that if we wait that six months or a year, about 80% will remain above baseline. And that's really what we're giving them is an entire year extra of relating to their world in the same way instead of losing it inch by inch. There are lots of people out there trying to figure out whether it is financially viable to give people their cognition. And I guess whether that works out to be true or not, as in minutes of staff time, I still would argue that for most of us, our brain is our most precious organ. And if we're gonna go to the lengths we do to protect people's kidneys and get pap smears and mammograms, we should at least be doing the basics for our brains. When people historically went to nursing homes, the colonester's inhibitor was taken away. For a long time, we blamed that on transition trauma. In fact, that was probably the result of withdrawing the colonester's inhibitor. You will often see a very sudden decline. Initially, the data from the Erecept studies, going back four to six years, show that people who stayed on the medicine more than four years, compared to people that dropped out initially, actually had a delay in nursing home placement for 21 months. I think when I ask people, how long do you wanna spend in a nursing home? Most people say zero days. So if I can offer them months and maybe more than a year, I think that's an incredibly powerful and really our responsibility to make sure it happens. Additionally, just recently, memantine came into the market. It was given to patients in Europe for the last 20 years or so. They have a different nomenclature than we do. They call things organic brain syndrome. I never knew what that meant. I don't know of an inorganic brain syndrome. So when I think about Nemenda, it's given a whole bunch of hope now. So it's very well tolerated, equal to placebo in many ways. And it's actually given in addition to colonester's inhibitor. So to stay on your question about, what about multiple drugs? This is a case where two drugs is more than one and one in another person. You want both. You want to maximize brain function. So the number of drugs is not inherently bad. It's when drugs are used and they're not clean and they're not doing specific actions and they're not well tolerated. And with memantine, those studies showed an improvement globally, function, cognition. They also stayed more stable compared to where we would have expected them to decline. And importantly, caregiver time decreased. Institutionalization rate decreased. And in this study, the cost decreased. The side effects were less or equal to placebo. Now, again, going back, that's my baseline. In every human being, I want to make sure their brain is maximized. Secondly, I look at, are they having a brain illness causing disinhibition or impulsivity? Then I will think about the mood stabilizers. Historically, if a person had impulsivity, they would get an anti-psychotic or maybe a benzodiazepine. Over the last decade or so, we've learned that it's cleaner to give them a mood stabilizer. Now, sometimes that can be some of the atypical anti-psychotics could serve as a mood stabilizer, but we're giving it whichever drug we use, specifically for its mood stabilizing ability. We have to be a little careful about these mood stabilizers because there aren't great studies that have been done. We have a little information, some of which I'll show you. For example, the original study with carbamazepine or tegratol showed that of these 56 demented elders, they had a significant improvement in agitation and a decrease in staff time. Tegratol, however, because rarely can cause bone marrow disasters, actually, aplastic anemia, we've been hesitant to use such a drug and newer anti-convulsants have come out that although they're being just studied now, we don't have a lot of data. That would include things like topomax or topiramate and Neurontin or gabapentum. So the old standard was tegratol, then depicote came into being. We tend not to use lithium because of its poor tolerance in the elders. So we're still even learning the mechanism for how mood stabilizers work. The advantages are they don't have the movement disorder risk. Even very low serum levels, much less than it takes to treat convulsions or seizures can be very effective in giving people a little bit more impulse control. So we're looking at how should we document? So I think it's always true if you have a drug you're gonna use, you have to tie it to an illness and in what exact symptoms you're going after to treat. What are the risks of that medication? How are you gonna monitor it? And when are you gonna reconsider it? Because remember, demented people's brains are shrinking. They may not need the same drugs in a year. Depicote or Divalprox had a nice study of nearly 200 residents that showed really nice decrease in the level of distress of those folks. There's a nice graph here showing almost within two weeks people were remarkably better. This study had a particularly high dropout rate because they pushed the dose so quickly. We would wanna start all these medications out fairly low dose and go up incrementally always with the caveat that we change the rule somewhat when things are more dangerous. We do push harder, faster to try to avoid hospitalizations and protect the community. Valproate much safer than Integratol because of its improved side effect profile. We know that we take serum levels just to make sure we're not too high but we don't treat according to the level. That number's not relevant as long as it's low. We stop raising the dose as soon as the behavior is more stable. So again, when I'm thinking about treating someone who's distressed and they're yelling and they're saying, help, help. I start with saying, okay, are they demented? Well, if that answers yes, I say, can I improve cognition? Then I say, could it be a frontal disturbance? And if that answer is yes, I think about a mood stabilizer. Then I think, could there be a delirium component? And if so, I'm going to wanna treat the actual cause of the delirium because if I take an infection, a bunch of bacteria on a petri dish, anti-psychotics don't treat it. They don't kill that bacteria, only antibiotics do. We've gotta get to the cause of the delirium. And if I need a short-term anti-psychotic, I'll use it. Then medical illness. And again, this is where I would say, remember that things that affect mood aren't just what we call psychotropics. Iron can affect mood if it makes you constipated. I don't know anybody who's more cheerful, constipated. And so when I'm thinking this entire paradigm through, I stop at that point and think through medical problems. Are you? No, no. Well, we have outpatient appointments available, Stan. Listen, I just wanted to interrupt you. It seemed like an appropriate time to do it. We got a couple of facts here. Folks are loving the PowerPoint presentation. We got facts from the staff at Grandview Good Samaritan in St. Peter, Minnesota. It would be possible to get copies of the great PowerPoint presentation that you're using today. Let me just simply tell the folks at the staff at Grandview that if you go to the CMS website, and that website is cms.internetstreaming.com, then you can pick up the PowerPoint presentation that is being presented right now. And also, if I could get into question for Dr. Lett while we're on the subject of medications, the question is, how would you recommend the family approach a nursing home staff about excessive, what they perceive to be excessive drug use when the physician seems to approve of it? That's a very good question and sometimes hard to broach. But I do believe that the best thing to do is first sit down with the staff, see if the staff has similar concerns or they feel that the medications as they've been added and as they're being used in conjunction are helpful. If they are, then you should have some reassurance that there's a good reason for the medicines. If the staff seems to have doubts or is unsure whether those medicines are making any difference, I think it's worthwhile contacting the physician, talking with him or her, sometimes even in conjunction with the staff and the physician, because physicians will be in making rounds on a regular basis. You can sometimes set up an appointment at the interdisciplinary team meeting where all of you all can sit down and discuss those. But anytime you have a concern about your loved one for any reason, but particularly with the medications, absolutely. It's time to start talking, not in a, I don't want to use the word accusatory, but in an inquiring fashion about, please tell me more about this medicine, what it's doing and how it's helping my mother or my father or my loved one and is it causing any potential problems that we need to be looking for? Okay, Dr. Jackson, I think I'm feeling better now. Okay, you can proceed now. Terrific. I do think that in my paradigm approach, again, medical problems can affect people's level of distress. And so looking at every single medicine is a critical factor in getting somebody's distress under control. It may be that they have had a history of reflux and they're not on prilosec. And again, I'm doing kind of the devil's advocate argument here, that I don't want people to throw the baby out with the bathwater. Unnecessary, disregarded medicines. People twitched once so they got an anti-seizure medicine for 17 years. That kind of thing is absurd and shouldn't be tolerated. We need to assess and make sure every medicine has a function. But it's better to give people treatment. For example, if they're in pain, my sad fact is that most people in pain and long-term care do not get treated because they don't have the language to say the words I'm in pain. And so even though 80% have arthritis, we don't give routine Tylenol. Because of our complete obsession with more meds is bad. It isn't that more meds is bad. Inappropriate medications are bad. If you had 16 meds and you had those kind of problems and everyone was perfect and had a benefit, then that's fine. And I really feel strongly that I don't want to be too black and white about the medication issue. So as I'm going down my paradigm, I'm not gonna allow myself to think about anti-psychotics per se other than an emergency. Until I have gone through the dementia, the frontal lobe assessment, the delirium, the medical illness factors, then I could think about, is there a psychotic process going on? If so, based on my assessment, I then start to think about the anti-psychotics, which as you know, have a large amount of regulations relating to them. We can only use these medicines if they interfere with function or cause danger to themselves. Just calling a person agitated is an insufficient reason. And I actually would argue that the word agitation should be banned from the entire language because it doesn't tell you anything. One nurse's agitation is another nurse's, they're just fine, they're always like that. And the charting is terrible and so if it's hitting that you mean, please write hitting. If you're talking about someone spitting or calling you a cow, then that's what we write. And that's what we target for our monitoring. And so I would agree with this rule that agitated behavior should never be used. I like that Cohen Mansfield, the slide we had, and I'll post that at nursing home stations and they use those words to describe. It's certainly clear that you could never use an antipsychotic without appropriate documentation. None of these regs would be new to, I think, anyone out there. There are many psychotic disorders that often need long-term, if not lifelong, treatment. Most of our work goes into this 11th category, organic Mendel's syndromes, which again is an older term. But presuming that it's a new onset illness like a demanding disorder, that's okay to use an antipsychotic for those situations if certain criteria are met. And things such as the behavior has to require intervention. You have to assess, do you think it's a moment or a more permanent behavior? Could it be caused by social or situational issues? Has the daughter been gone, that kind of thing? Environmental causes have been ruled out. Medical causes have been ruled out. That's a little more problematic for things like urinary tract infections and delirium and psychosis, because they often do go together. You want the symptoms to be persistent. If they're only there for five minutes and gone, it would be a sad thing to give that person a drug that lasts all day. And it can't be caused by a preventable reason, which is a difficult concept to know what that means, at least for myself. I think about organic Mendel's syndromes and using antipsychotics. We want them to have specific behaviors. They have to be dangerous or they have to be of such a level that you can't provide care for them. Or they have to be truly psychotic, such as hearing voices, seeing things that are not there or being paranoid. And I agree with Dr. Lett completely that if someone's only visitors are the little children and they enjoy it, please leave them alone. Because that is a good thing in their life. Our job is not to make them like us. Our job is to help these people become on the right side of content. So a person who's just wandering around or sad or fidgeting or just saying, leave me alone should never get an antipsychotic because number one, that's not emergent. And number two, I can't believe you're already there on the paradigm. I will guarantee there's something higher like the dementia or feeling depressed or that they have some medical problem or medication we haven't addressed. Maybe it's depression, but antipsychotics wouldn't be called for. We know that we have to treat specific conditions for these drugs. We know that we have to try to decrease the doses. We used to say there was no drug approved for agitation. That's gonna be changing because IM-ziprexa is going to get an indication for acute emergent type agitation and aggression. It's not on the market yet, but it has been approved. But typically these drugs are reserved just for aggression and true psychosis. But I would disagree heartily with all of our regs that say that it's okay to wait six months. I know that the regs actually say that you have to consider a decrease within six months, but what ends up happening is we've lost sight of why are, what exactly are we treating? If a person has dementia, they will need an antipsychotic for at least a few months. If that psychosis is drew directly to just their dementing process, it can happen to quite a few of them. If they get a delirium from a urinary tract infection and you treat their urinary tract infection and they're better the following week, I can't imagine why they're still on their antipsychotic. And I think that the diagnosis that we are working with should determine when we're gonna try a titration down. Obviously we're gonna combine that with how's the person doing and all of the other information gathering. But we wanna make sure that we understand psychosis is different depending on what drove it. And if it's a psychotic depression, we treat it with both an antipsychotic and an antidepressant. It's another example of where multiple medications improves your rate of response. And a couple months later, you take away the antipsychotic. For things like long-term illnesses, schizophrenia, bipolar, they may be on it for life. In the old days, we only had conventional antipsychotics, things like Haldol and Thorazine. Luckily in long-term care, we're seeing those go away because we have better drugs. And I'm really not convinced why anyone would have to take a drug with a much higher side effect profile. The newer drugs include the original clausaryl, which is extremely rarely to see used because of its potential bone marrow problems. But the newer ones, Resperidols, Iprexa, which is also a Lanzapine. We look at things like Quintiapine or Zeprazidone and Aripiprazole. These are the new ones that have come out that we don't have to consider the movement disorders to near the same degree. And that's really why they're called atypicals. They are able to treat the psychosis without causing the kind of movement disorders we had grown accustomed to seeing. We had seen things like Parkinsonism. And just about the time we thought all these new drugs were really our saving grace, we've come to learn that all drugs do have risks. And one of the new ones we've come to be aware of is stroke risk. Just last year, we found out that Resperidone had an associated stroke risk. We didn't know that until they looked at every international study across the globe. More recently, they went back and looked at the Zeprexa or a Lanzapine data. And a similar kind of label change is now in the works for that. It does look like probably this whole stroke risk increase while rare is going to be a class effect of the atypicals. So whenever you're thinking about atypicals, you wanna include the stroke risk factor in your assessment. It's like a Motrin could cause a GI bleed. We don't not use Motrin. We use it knowing that that's a part of the risk benefit. And we have to factor it in. And that's true for stroke risk factors as well as even now diabetes. So in summary, atypicals are effective for psychosis. They're effective for emergent aggression. But we really wanna make sure we're using the best atypicals because of the improved tolerability because even within the atypicals, one may have more sedation or more weight gain or more risk of Parkinsonism. So as you pick an atypical, you wanna pick that in concert with what can that human being tolerate the best? That's what makes a good drug choice. Particularly regarding Parkinsonism, I know that historically we were very concerned about tardive dyskinesia. Tardive, by the way, means late. And I don't think most of my 88 year olds have to worry about late symptoms. Now I'm being a little tongue-in-cheek because they can develop mild T.D. earlier, some jerking movements. But the disaster symptom would be Parkinsonism because of its association with falls. And so I'm very careful even with atypicals. Again, after we've gone through the paradigm, I'm now gonna think, could it be a depression? And so we'll talk a little about such things as this gentleman who looks somewhat like some of my nursing home residents. So the slide reads, would the gentleman prefer an antidepressant? And that indeed is, sometimes you just take one look at them and you know they could be treated yesterday and that would be good. Dr. Jackson, I got a quick question for you. Sure. It sounds to me that since accurate diagnosis of a condition is so key to prescribing the right medications, it certainly wouldn't be out of line of a family, for example, the facts that we got, the family members who were concerned about over-medication to possibly get second, even third opinions before you engage in a regimen of medications? Well, I think that's very true, but I think that they should first go to their primary care physician or psychiatrist whoever they're considering the med class to be from and go through all the medicines. Why are they there? What are the risks and benefits? Some people, again, it could be that they've been on prolaseca, a GI bleed and reflux kind of medication. They could have been on that for the last seven years because they once had a surgery and they had to take some steroids and they only needed it for a few weeks, but no one took it away. So all the meds need to be reviewed and I really strongly believe that. They also need to go through and say, how long have they been on them and do they continue to still need them? I think that generally a primary care physician should be able to sit down and explain every drug. It should have an associated illness, target symptom, monitoring plan, and when we're gonna reconsider it. And if they can't, maybe that sends up a red flag and that's when you would get a second or third opinion. At least an orange level flag. Yeah, Stan, if I could also add, one of the problems we have in long-term care is we don't always have someone of the ability and quality of Dr. Jackson out there. In many rural nursing facilities, there may be one doctor for the entire building. So while second and third opinions certainly would be ideal in an urban setting or where you have the expertise, many times you don't have that ability. I would go back to the absolute necessity of communication, of talking to the nursing staff, talking to the physician, almost all issues I've ever found in long-term care are a matter of communication. If you have communication, those things really get better. Okay, Dr. Jackson? Sure. So looking at our next part of the algorithm, depression, it's really important just to emphasize that just because a person has a good reason for depression doesn't mean we wouldn't treat it. If you have a good reason for pain, we don't withhold treatment. We treat your pain, correct? And the same thing would be for depression. Doesn't matter if they've lost their home, their job, their wife, their pet. It may be true that they've had a lot of stress to develop this illness, but their chance of recovery and having any pleasure in life requires treatment. And as much as I do believe in our adage of start low and go slow, the greatest mistake I see regarding depression is that people are started on microscopic doses that really, in good studies, show them to be the same as placebo. And that's the kind of medication use that I find very tragic. We want to start low, go slow, but we want to get somewhere. We have to go. Our job is not to take them from miserable to mediocre. Our job is to help get them to be the best they could be. And one way to do that is to monitor. First of all, our MDS system doesn't assess depression very well at all. I think all would agree with that. But simple things like a geriatric depression scale that the patient fills out and you can grade, a happy answer is great, a sad answer, like do you enjoy getting up in the morning? If the answers no, that counts against you. So if you have more than five out of 15 questions sad, that weighs heavily, you need treatment. And if their score, let's say is 10 and you treat them, you come back in six weeks and their score is six. Then you say, okay, we're on our way. And you come back in another six weeks to see if you've really done it. So the Cornell, we would use a CNA of the secretary, a family member, anybody who knows the patient well could fill out the Cornell. It's so easy and it's so much better of a way to monitor what is going on with your treatment intervention. Now, often with depression, you have a sleep disturbance. Most of the time it's insomnia. Occasionally for younger people, it's that they sleep too much. At least that's what the teenagers of my life say. But with depression and elders, they have insomnia. I do believe that it's important to treat that sleep disorder upfront so that the person starts to have a little hope. Nobody is better sleep deprived. So even though I'm gonna be starting an antidepressant, I'll consider a trasadone or an Ambien or a Sonata, that kind of thing for the first couple of weeks and then change that to a PRN by then hoping that the antidepressant, by treating the actual driving force, will have resolved the sleep disorder. Once you get them up to a real dose and they're doing great, you have to really be careful about when you might wanna take it away because if you're 88 years old and I take your medicine away and you relapse, I'm gonna, it's really gonna destroy a good three or four or five months while you relapse and we restart the medicine. So there are times when I will kind of not follow conformity which was all done by the way for younger people where we're supposed to try taking the medicine away after a year. If they're quite elder, if it was a serious depression, if there was a hospitalization, suicidality, failure to thrive, I simply don't take them off their antidepressant if they're tolerating it well. Common antidepressants, we now have lots of choices in the SSRI category the non-serotonin reuptake inhibitors like wellbutrin or bupropion, myrtazepine or remeron, benylophaxine or afexer. Those are also very good medicines and we will often use those targeting particular side effects or that we want or they may have illnesses where a side effect will be to their benefit. We tend not to use trasadone as an antidepressant. One of the confusing things in long-term care is when we look at what is our treatment rate for depression, trasadone is being included. It's not being used as an antidepressant. Trasadone's a great sleeper. If we gave people enough trasadone to treat their depression, they would not be awake enough to enjoy their remission. So we look at, let's say someone's very frail, not eating, not sleeping. In that case, I would choose perhaps remeron or myrtazepine because that'll get them sleeping and eating quickly. I might choose sertraline or zoloft if they're very constipated. If they have irritable bowel syndrome, I might choose wellbutrin because it's one of the ones that actually slows your gut down. So you think about the combination of that drug and that person. Dr. Jackson, can I ask you a question right quick? Sure. Since we're going through the ABCs of the drug world, most of which I can't even pronounce, by the way, but we do have a fax here that came in and it's about the very thing that you're talking about. The question is, with the rising cost of medications, the newer atypical antipsychotic agents generally cost more and oftentimes insurance won't cover it. So if a family has to manage the cost of medications, sometimes they're left with having to make a choice. Which one they should go with when it's cost effective and not cost effective? Well, I think that it's an important issue about the direct cost and I think that's an issue we need to contend with. The fact is these drugs cost several dollars a day on average and if you were to give someone a very cheap medication like a Hallow Paratol, I don't know, cost about nine cents a month and that drug, you could give a lot of people treatment for their psychosis but one simple hip fracture is 20 to $30,000. When you include all the surgeries, the hospitalization, the rehab, mortality, it's just, how many zyprexes and saraquals can we give for one hip fracture? And the problem in my opinion is that everybody has their own tunnel vision of where the money comes from. Typically in long-term care, we have Medicaid patients and to my knowledge, most all states are allowing for pass-through costs for anti-psychotics and we have private pay and private pay are gonna spend down until they become Medicaid. And so again, if it were my own loved one, why would I let them be exposed to something that will make them drool, flat, shuffle, fall when I wouldn't have to for the price of a few hundred dollars? The safety clause, yeah. That's my own bias. Obviously it's a biased belief. Dr. Lett, in the managed care world and many of these patients we're now seeing in long-term care are in managed care, they often will have a preferred formulary that does include the typicals, if you will, and not the atypicals unless. And the unless is that often the physician can complete a form, there's always a form, in which you can say the resident has either failed treatment with the typicals or there are overriding reasons why they should get the more expensive atypical drug. So that's always an avenue to take, I'm not aware as to whether the Medicaid formularies allow that escape at this point in time. I don't believe so, but you'll have to check each individual state. To my knowledge, every Medicaid formulary allows at least one atypical. And again, this is because we're talking about a frail population, 70 to 80% have dementia. And so walking is already difficult when they've only opened their eyes and woke up in bed. We already know they're gonna have trouble. So these kinds of medicines make a much bigger difference than say a 25 year old schizophrenic with lots of padding, really good reflexes, great vision, all of those things that don't exist anymore for our elders. When you think about these medicines, you know, a lot of times there is pressure for more medicines, both from the doctor's point of view, they wanna do something for the distress that they see. But also from the patient or the family's point of view, they say, I can't stand what I'm seeing, it hurts so much, do something. And in this particular cartoon, the woman sits down and says, I think the dosage needs adjusting. I'm not nearly as happy as all those people in the ads. And that's like the Zoloft or the sertraline little happy face bouncing around. We imagine sometimes that these drugs will make us happy. That's not their intent or their use. They are to help you have the capacity to do the best you can. They don't actually make you skip or sing or any of those things. So now that I've gotten past depression and the affective disorders, and by the way, I often stop there and think a little about, could I be missing a bipolar? If a depression is there, maybe I missed the earlier manic episode. And that's an important distinction so you end up treating it appropriately. But after and only then do I allow myself to think about an anti-anxiety drug other than an emergency, okay? So I think about an anti-anxiety drug. Our regulations say things like, you have to use a short acting one, you have to keep the doses within a certain limit. We need to do behavioral monitoring knowing that nobody's telling us how to behavior monitor. And I guess this is the point where I will say to everyone, however we developed these Q shift charting to write down a zero or a one didn't work. I think every one of us have gone into facilities and looked at people who were clearly distressed and looked at behavioral charting that was filled with zeros, which I was trained to understand means they're perfect. But they're not perfect. The way to monitor people is not with these Q shift forms. There's no research on this. All research tools would use some other kind of validated instrument. And so it's time that we kind of did a better job with our monitoring. Again, using the GDS or the Cornell for depression. If you're looking at behaviors that are erratic and multiple, you can use things like the Cornell, I'm sorry, the behave AD or the co-enmanse field. Again, very easy, very easy. Even the CNA, a family member, the neighbor who knows them well could fill these out. And we could actually monitor well. Other things that we're asked to do is to consider a dose reduction twice within a year before we say that it's clinically contraindicated. And that can be difficult because I guess I have a problem with that because we should be thinking more frequently than once a year. We wanna make sure that other reasons have been considered eliminated, that we are monitoring functional status, that about four months we need to try one reduction. And you need a specific diagnosis. And I just wanna make sure that we've done the paradigm approach so that we're not missing the fact that we lost their hearing aids and that's why they're anxious. Those kinds of things truly happen. Here are some of the doses that I started to put in here. It looks like I didn't quite finish. That they're all within our survey or guidelines. And the goal here, we know that benzodiazepines are addictive, that your body learns to tolerate them. That means you need a greater dose. And what's sad is, at least in my experience, most of the time that's not the mainstay of their treatment. That should be for breakthrough or more catastrophic events. Benzodiazepines really have very poor efficacy data. We know there's a sedating. We know they cause memory impairment. And if 80% of our population has a memory impairment, I don't know why we'd wanna be okay about making it worse. It's associated with falls. Some people, you know, benzodiazepines hit the same exact receptor as alcohol. And just like alcohol, some people get paradoxically disinhibited. So, they also can build up some, especially the long-acting ones, so we avoid those. If you have to use them, think short-acting. You may even consider low-dose trasadone. Buce bar may work for some people. Look hard, very hard, higher on the paradigm that dementia have we maximized, the medical stuff. If it's psychotic, think about very low-dose atypicals. Sometimes I will even say, let me just try an antidepressant because a depressed person without good communication may just look like a nervous wreck. We know that insomnia is a pretty big issue. And I guess my huge request here would be that we think of insomnia not as a illness, but rather as a consequence. And we should be looking much harder for things like pain. Tylenol, if out in the community, that's what most people say they take for their sleeping pill, is Tylenol. And we need to make sure we've at least tried that in long-term care. The rules are that if you're gonna use it for more than 10 days, you have to document the necessity. And you have to try to reduce at least three times within six months. These are the kinds of medications that I would think about it if I had to use it for just pure insomnia for some short time. Trasinone, mortazepine, short-acting benzos. And then you have both the ambience or sonata. It's important if you're gonna use melatonin that you would use it around six o'clock in the evening rather than before bed so that it can actually stabilize your circadian rhythm in the right increment. We've talked a lot about medications. And I really do believe in the power and the very need for them. If you had shortness of breath and it was caused by something like a pneumonia, nobody would ever give you oxygen and just say, do you feel better and walk out. We would always find out what's driving it. And so the story goes. But sometimes remember also that the change in what they've lost is so overwhelming. On the very best of days, these people wake up and they've lost their home and their spouse and their job and a lot of their choices and maybe their mobility. And this is a good day. All they've done is open their eyes. And then sometimes somebody disregards them or their dining partner is a little obnoxious. And it's overwhelming. And there is a real anxiety drug. Our regulations say things like you have to use a short-acting one. You have to keep the doses within a certain limit. We need to do behavioral monitoring knowing that nobody's telling us how to behavior monitor. And I guess this is the point where I will say to everyone, however we developed these Q shift charting to write down a zero or a one didn't work. I think every one of us have gone into facilities and looked at people who were clearly distressed and looked at behavioral charting that was filled with zeros. Which I was trained to understand means they're perfect but they're not perfect. The way to monitor people is not with these Q shift forms. There's no research on this. All research tools would use some other kind of validated instrument. And so it's time that we kind of did a better job with our monitoring. Again, using the GDS or the Cornell for depression. If you're looking at behaviors that are erratic and multiple, you can use things like the Cornell, I'm sorry, the behave AD or the Cohen Mansfield. Again, very easy, very easy. Even a CNA, a family member, the neighbor who knows them well could fill these out. And we could actually monitor well. Other things that we're asked to do is to consider a dose reduction twice within a year before we say that it's clinically contraindicated. And that can be difficult because, I guess I have a problem with that because we should be thinking more frequently than once a year. We wanna make sure that other reasons have been considered eliminated, that we are monitoring functional status, that about four months we need to try one reduction. And you need a specific diagnosis. And I just wanna make sure that we've done the paradigm approach so that we're not missing the fact that we lost their hearing aids and that's why they're anxious. Those kinds of things truly happen. Here are some of the doses that I started to put in here, it looks like I didn't quite finish, that they're all within our survey or guidelines. And the goal here, we know that benzodiazepines are addictive, that your body learns to tolerate them, that means you need a greater dose. And what's sad is, at least in my experience, most of the time that's not the mainstay of their treatment. That should be for breakthrough or more catastrophic events. Benzodiazepines really have very poor efficacy data. We know there's this sedating, we know they cause memory impairment. And if 80% of our population has a memory impairment, I don't know why we'd wanna be okay about making it worse. It's associated with falls. Some people, you know, benzodiazepines have the same exact receptor as alcohol. And just like alcohol, some people get paradoxically, disinhibited. So, they also can build up, especially the long-acting ones, so we avoid those. If you have to use them, think short-acting. You may even consider low-dose trasadone. Busebar may work for some people. Look hard, very hard, higher on the paradigm that dementia have we maximized, the medical stuff. If it's psychotic, think about very low-dose atypicals. Sometimes I will even say, let me just try an antidepressant, because a depressed person without good communication may just look like a nervous wreck. We know that insomnia is a pretty big issue. And I guess my huge request here would be that we think of insomnia not as a illness, but rather as a consequence. And we should be looking much harder for things like pain. Tylenol, if out in the community, that's what most people say they take for their sleeping pill, is Tylenol. And we need to make sure we've at least tried that in long-term care. The rules are that if you're gonna use it for more than 10 days, you have to document the necessity. And you have to try to reduce at least three times within six months. These are the kinds of medications that I would think about it if I had to use it for just pure insomnia for some short time. Trasinone, mortazepine, short-acting benzos. And then you have both the ambience or sonata. It's important if you're gonna use melatonin, that you would use it around six o'clock in the evening rather than before bed, so that it can actually stabilize your circadian rhythm in the right increment. We've talked a lot about medications. And I really do believe in the power and the very need for them. If you had shortness of breath and it was caused by something like a pneumonia, nobody would ever give you oxygen and just say, do you feel better and walk out. We would always find out what's driving it. And so the story goes. But sometimes remember also that the change in what they've lost is so overwhelming. On the very best of days, these people wake up and they've lost their home and their spouse and their job. And a lot of their choices and maybe their mobility. And this is a good day. All they've done is open their eyes. And then sometimes somebody disregards them or their dining partner is a little obnoxious. And it's overwhelming. And there is a real place for therapy. Not just psychotherapy for people very intact but behavioral therapy, looking at behavior plans, trying different interventions and tracking them. In this case here, we have Lassie watching the situation and somebody's drowning and he's yelling, Lassie get help. So Lassie promptly does. He goes and lays on the psychiatrist's couch. And that is a help. And I think we have given that a little, it kind of minimized that. Partly because our resources are so sparse but also because we often think dementia doesn't respond. If a psychiatrist is good, they will find things that can be a benefit to that human being. In very last summary, I wanna remind everybody distressed behaviors are only symptoms. That unless it's urgent, we need to be doing a complete assessment to develop all of the working diagnoses that compounding on top of each other are overwhelming that person. And it's those diagnoses that tell us what we should be doing for our treatment care plans. Even if the person does have, for example, Parkinson's disease and they get a good drug for their Parkinson's like cinnamon and now they get the cascade where they're hallucinating. And we come in and we say, okay, we have to adjust these medicines. No matter when there's a clear cut medical thing to do, we should also in every single case be using non-farm. We should always look at a person knowing that we can make their life better if we just focus on it. And it may be talking to their daughter. It may be talking to their themselves. It may be making them get some golf magazines if that's what they liked. But everybody's life can be made better. And we should never say farm or non-farm. Everybody should get non-farm. Some people with diagnosed illnesses should get pharmacologic measures as well. When we've got it, we should monitor what we're doing much more carefully. Use all of the tools that are out there that have been validated and are very helpful. We've come a long way in the last 15 years of how do we wanna provide care? The regulations that are out there aren't supposed to be telling us what good care is. They're supposed to be telling us what we're not allowed to do. I think we're all ready to kind of raise the standard of care. None of us are happy with the state of nursing homes in America yet. To do that, to raise it so that it's safe for all of us and our loved ones, it's gonna require this kind of teamwork. To CMS's credit that they would share this information with the community and with AMD and AEGP and providers and surveyors so that we could all be educated showing the mutual respect. Actually modeling for our patients out there what it can look like when we are really doing our best. With that. You know what? You have given us such a dearth of information. Dr. Jackson and Dr. Lett, first I wanna thank both of you very much for being here today and offering up expertise presentation on your particular fields of expertise. Thank you very much for joining us. And I also wanna thank our viewers out there for those of you who tuned in today, for those of you who phoned in, for those of you who faxed in with your questions. Thank you very much. It's what helps to make these presentations very positive and upbeat and informative. We're sorry we couldn't get to Mark Dalius and Ozzy Osbourne on this particular show, but oh well that's show business, isn't it? And remember, you can see this entire broadcast for up to one year from this date. All you have to do is go to cms.internetstreaming.com. Again, that's cms.internetstreaming.com. You can see this program for up to a full year. And be sure to join us for our next broadcast. It's scheduled for January 16th, our broadcast on preventing falls with Dr. Courtney Lider. Until then, just keep in mind, remember it's what's on the inside that really counts. For now, I'm Stan Stovall. Good night, everybody.