Behavioral and Psychotic Symptoms of Dementia vs. Delirium in Hospice: Challenges in Diagnosis and Management in the Long-Term Care Setting: Part 1 (FR439)

Abstract

•Describe characteristics distinguishing behavioral and psychological symptoms (BPSD) of dementia from terminal delirium in nursing home residents with advanced dementia at the end of life.•Review the evidence for the pharmacologic and non-pharmacologic management of BPSD and delirium.•Building on the Centers for Medicare and Medicaid (CMS) regulatory requirements for management of psychotropic medications in nursing home residents, develop a framework for successful hospice-nursing home team collaboration for management of BPSD and terminal delirium through engagement of palliative, medical, nursing facility and family caregiver engagement. A majority of patients with dementia suffer from at least one behavioral and psychological symptom (BPSD) of the disease. BPSD describes a wide spectrum of non-cognitive manifestations of dementia, including apathy, dysphoria, verbal and physical aggression, agitation, psychotic symptoms, sleep disturbances, oppositional behavior, and wandering. Symptoms are highly prevalent in the moderate to severe stages of dementia, when the patient is typically admitted to hospice. It has become apparent that antipsychotic treatment for BPSD shortens life expectancy and exposes these patients to morbidities including sedation, falls, fractures, aspiration, and movement disorders, with only slight efficacy for achieving improvement in target behaviors. Long-term care (LTC) regulations require gradual dose reductions in psychotropic medication, and precise behavioral documentation to support starting or continuing psychotropic medications. Hospice providers who understand the regulations can support the facility in both caring for the patient as well as adding to the documentation that the facility needs. However, terminal agitation is also a common finding at the end of life and it is important for hospice providers to differentiate between BPSD and terminal delirium. In this two-part session, we propose a case-based approach with audience participation to: 1) Differentiate BPSD from delirium for hospice dementia patients in order to appropriately treat BPSD and 2) Diagnose, manage and treat delirium in hospice dementia patients in the LTC setting. In part 1, we introduce a hospice case study of moderate to severe dementia in a nursing home. Hospice providers may initially mistake the agitation in BPSD for terminal delirium. We will discuss how to differentiate between BPSD and terminal delirium, and suggest non-pharmacological and pharmacological interventions for BPSD in this patient. We will review the literature to highlight our evidence-based approach, and allow the audience to participate in deciding management based on the literature.