Behavioral Disturbances of Dementia: Interventions to Reduce the Use of Psychotropic Medications

Live event was held Thursday, March 28, 2013, 1:30 pm Eastern Time
(First in the Mental Health and Aging Training Initiative, Series II*)


As residents in long term care facilities are living longer  the incidence of dementia and other mental health issues has been increasing.  Thus, long term care and skilled nursing centers have been faced with new and more complicated challenges.  There is a need to develop skills beyond those of “basic custodial care” which require problem solving abilities as well as the willingness and ability to implement creative interventions.  

The Geriatric Mental Health Planning Partnership, in collaboration with the VCU Department of Gerontology and the Riverside Center for Excellence in Aging and Lifelong Health is organizing the next in a series of webinars dedicated to “Mental Health and Aging Training.” The first three topics were offered in the spring of 2012 and can now be accessed from this site (see right column). The next three webinars in this series are being offered March, April and May of this year. These webinars are focused on interventions to reduce the use of psychotropic medications, best practices in geriatric psychiatry, and the temporary detention order process. Experts in aging and behavioral health, both within Virginia and outside of Virginia have been selected to lead these webinars.

This presentation was intended for staff from many levels, disciplines and settings (both acute care and long term care).  Attendees included, behavioral health staff, nurse practitioners, nurses, CNAs, Nursing Home Administrators, Social Workers and Case Manages from both Acute and Long term care. 

At the end of this one-hour presentation, participants have learned:

1. To more clearly describe problematic behaviors and possible triggers;
2. Strategies for preventing/reducing problem behaviors; and
3. Appropriate use of anti-psychotic medications.

The live event was open to all and free for all. 

Attendees were required to have a computer with access to high speed internet (to view the slide presentation) and computer speakers OR access to a telephone.  Additional information was provided through the registration form.

The webinar was recorded - access the recording below.

This event is made possible through a grant from the Virginia Center on Aging's Geriatric Training Education Initiative and supported by the Riverside Center for Excellence in Aging and Lifelong Health, the Virginia Geriatric Mental Health Partnership* and the VCU's Department of Gerontology.


Michele L. Thomas, BS, PharmD, BCPP is a Board Certified licensed clinical pharmacist and Pharmacy Services Manager for the Department of Behavioral Health and Developmental Services (DBHDS) located in Richmond, Virginia.  As Pharmacy Services Manager, Dr. Thomas serves as an information resource and provides consultation and guidance to DBHDS / Community Services Board staff and others, on psychopharmacology / pharmacy / clinical related issues as well as pharmacy informatics and technology developments affecting pharmacy practice in the DBHDS health system. Her position also provides advice and counsel on various other issues that contribute to the success of Pharmacy Services in DBHDS including, administrative related issues on policy, compliance, contracting and third party billing. 

Dr. Thomas is a member of several local and national organizations related to pharmacy practice, psychopharmacology, mental health and geriatrics and, is responsible for the development and coordination of pharmacy performance improvement and programs to ensure that optimum pharmaceutical care and services are provided to clients.

Andrew L. Heck, PsyD, ABPP is a licensed clinical psychologist and Clinical Director at Piedmont Geriatric Hospital in Burkeville, Virginia. As Clinical Director, he is responsible for the Social Work, Psychology, and Rehabilitation departments, as well as the overall clinical operations of the hospital. Dr. Heck has dedicated his career to the care and understanding of elderly individuals with moderate to severe mental illness, and is board-certified in Clinical Psychology by the American Board of Professional Psychology, and is a Fellow of the American Academy of Clinical Psychology.

He holds clinical faculty appointments in the Departments of Gerontology, Pharmacy, and Psychiatry departments at Virginia Commonwealth University, and holds leadership positions in several local and national organizations related to mental health and older adults. His particular areas of interest include dementia evaluation, decision-making competency and capacity, behavioral treatment, and ethics in working with the elderly.

E. Ayn Welleford, MSG, PhD, AGHEF, received her BA in Management/Psychology from Averett College, MS in Gerontology and PhD in Developmental Psychology from Virginia Commonwealth University. She has taught extensively in the areas of Lifespan Development, and Adult Development and Aging, Geropsychology, and Aging & Human Values.

As an educator, researcher, and previously as a practitioner she has worked with a broad spectrum of individuals across the caregiving and long term care continuum. As Associate Professor and Chair of VCU’s Department of Gerontology, she currently works to “Improve Elder Care through Education” through her Teaching, scholarship, and Community Engagement. Outside of the classroom, Dr. Welleford provides community education and serves on several boards and committees. She is the Immediate Past Chair of the Governor’s Commonwealth of Virginia Alzheimer’s and Related Disorders Commission. Dr. Welleford is the proud recipient of the 2008 AGHE Distinguished Teacher Award.



TO DOWNLOAD THE SLIDES (sorted 3 on a page), PLEASE CLICK ON THE "DOWNLOAD" ICON BELOW (this will save the file on your computer).

TO DOWNLOAD THE SLIDES (sorted 1 on a page), PLEASE CLICK ON THE "DOWNLOAD" ICON BELOW (this will save the file on your computer).





Q: What can you tell us about gradual dose reductions on antidepressants?

A: [Thomas, Michele]: This really depends…The AGS recommends for Acute depression in the geriatric individual, goals are to reverse the current episode and continue to prevent a relapse, for at least 6 months.
To prevent recurrence – if in a maintenance period, goals are to continue for 12–18 months or indefinitely if hospitalization was required in the past or suicidality or psychosis was present. When one does wish to taper however, I try to stick to the 10% rule, e.g., 10% dose reduction every 4-6 weeks – and may adjust that based on individual factors, comorbidities, etc.

Q: What was the answer to the first poll question?  Is it appropriate to medicate for physically aggressive behaviors, ever?

A: [Heck, Andrew (DBHDS)] Once everyone’s safety has been accounted for, it is only justifiable to medicate for aggressive behavior if (a) the aggression is directly related to a mental disorder that the FDA has approved as a target for the drug (e.g., antipsychotics are approved to use for individuals with a formal diagnosis of psychosis), or (b) a facility can document that virtually all other contributing factors (e.g., using the HEAR method) have been explored and ruled out.  Medicating with an antipsychotic medication for individuals with dementia is an absolute last resort intervention, and must be documented as such.

A: [Thomas, Michele]: For the poll, A, B, C = are appropriate antipsychotic treatment targets and, I agree with Dr. Heck’s statements above.

Q: Why do you caution against bright light exposure for clients with bipolar disorder?

A: [Heck, Andrew (DBHDS)] Research indicates that bright light therapy can induce a manic episode for individuals with a history of Bipolar Disorder.  Regular exposure to sunlight does not do this, only concentrated amounts of bright light from light therapy equipment.  The exact frequency at which this happens and the mechanism that causes it is not precisely known.

Q: Why is bright light adversive for Those with Bipolar Disorder?  is this for all those with Bipolar do or just cognitively impaired people?

A:[Heck, Andrew (DBHDS)] This pertains to any individuals with a history of Bipolar Disorder, not just older adults and not just for individuals with cognitive impairment.



The Geriatric Mental Health Partnership (GMHP) is an informal, voluntary group which focuses on geriatric mental/ behavioral health care. The group began in 2007 in response to the challenges of difficult behaviors of elderly residents in long-term care (LTC) facilities. Participants of the GMHP include representatives from mental/ behavioral health, aging services, and long-term care professionals representing the private, public and academic sectors. Organizations represented include the Virginia Health Care Association; the Virginia Hospital and Healthcare Association; the Virginia Association of Nonprofit Homes for the Aging; various Community Services Boards (CSB); State agencies including the Department of Medical Assistance Services; Department of Social Services Department of Health; Department for the Aging Long-Term Care Ombudsman; Department of Corrections; Department of Behavioral Health and Developmental Services; Piedmont Geriatric Hospital; Eastern State Hospital; the Center for Excellence in Aging and Geriatric Health (CEAGH), the College of William & Mary; Eastern Virginia Medical School; Virginia Commonwealth University (VCU) Department of Gerontology; Long-Term Care Facility Providers (e.g., nursing homes); and Behavioral Health Consultants.

The GMHP has worked tirelessly to improve communication and service coordination between the mental/ behavioral health and long-term care systems, so that older adults are able to receive needed care in a timely manner in the most appropriate setting. One of the key obstacles the group has identified is a lack of relevant training for facility and community staff. In order for seniors in long-term care facilities to receive timely and appropriate mental health treatment, staff members need to understand the issues involved and the procedures necessary to address and implement appropriate treatment. Traditionally, staff persons in long-term care facilities have received training which was more focused on the daily care and clinical needs of residents. Meanwhile, the staff at the local CSBs (individuals usually involved in psychiatric hospitalization of these older adults) have traditionally focused on behavioral health issues common to adults and children, without specialized training regarding the geriatric mental health issues more common to seniors residing in long term care facilities.

The GMHP has identified six key training issues important for developing a workforce prepared to effectively address the behavioral health needs of the growing aging population.  Three of them are part of the current series titled "Mental Health and Aging Training Initiative":
  1. Behavioral Disturbances of Dementia: Interventions to Reduce the Use of Psychotropic Medications
  2. Best Practices in Geriatric Psychiatry and Long Term Care
  3. The Temporary Detention Order (TDO) Process: What Staff Need to Know.
The current webinar is the first in the series described above.


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