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Assessment of individual care needs

A — the third step

Every claim the framework makes depends on knowing the individual well enough to make it. A medication that is unnecessary for one person is load-bearing for another, and only an individual assessment tells you which. Assessment is what makes the rest legitimate.

Behavior is communication

A change in behavior in a person with dementia is communication by someone who has lost the other channels. Before it is a psychiatric symptom it is a question, and the usual answers are ordinary: pain, needing the bathroom, hunger, thirst, cold, boredom, over-stimulation, a new infection, constipation, a hearing aid with a dead battery, or a medication started three weeks ago.

One of those deserves particular care, because it is the one most often got wrong in both directions. New confusion is a reason to assess. It is not on its own a reason to culture urine and start an antibiotic — a substantial share of long-term care residents carry bacteria in the urine without infection, and treating that finding adds an antibiotic to the list without addressing whatever actually changed.

The baseline problem

You cannot detect a change without a starting point. A resident described as “confused” is not a finding unless someone recorded what they were like before. This is the least glamorous part of the framework and the one whose absence causes the most downstream error: without a baseline, sedation gets read as decline, decline gets read as progression, and progression gets treated.

Anticholinergic burden belongs in the assessment

Individual drugs can each look harmless while their combined anticholinergic effect produces confusion, constipation, urinary retention, dry mouth and falls. The burden is a property of the list, not of any single line in it, and it is invisible unless someone adds it up deliberately.

Several scoring tools exist — the Anticholinergic Cognitive Burden scale, the Anticholinergic Drug Scale, the Anticholinergic Risk Scale, and the dose-based Drug Burden Index. They are useful and they are not interchangeable: a 2015 systematic review of seven expert-based scales found the ratings inconsistent between them, with quetiapine rated high anticholinergic activity by one scale, moderate by another and low by two others. Any score that gets recorded should name the scale that produced it. More on anticholinergic burden.

The five assessment items

  1. A comprehensive assessment of physical, mental and emotional health.
  2. An identified root cause for the behavior — pain, discomfort, boredom, confusion, an unmet physical need.
  3. Medical history reviewed for contributing conditions: infection, dehydration, constipation, delirium, progression of the dementia itself.
  4. Input from family or long-standing caregivers on past triggers and what has worked before.
  5. Regular reassessment, so that an intervention which has stopped being appropriate is noticed rather than inherited.

Why the family item earns its place

A relative can tell you that this person worked nights for thirty years, or was a teacher and settles when given something to organize, or has never in their life liked being touched from behind. None of that is recoverable from a chart, and all of it changes a care plan. For families: when behavior is communication.

The reassessment trap

An intervention that works gets written into the plan and then stops being questioned. Dementia progresses; the person the plan describes is not the person in the room a year later. That is the failure the last letter of DWARAA exists to catch. Adjusting care plans.

Common questions

What is the difference between delirium and dementia progression?

Speed and course. Delirium comes on over hours to days, fluctuates through the day, and is caused by something — infection, dehydration, a medication, constipation, pain, urinary retention. Dementia progression is slow and does not fluctuate that way. Treating a delirium as progression means missing a reversible cause; medications with anticholinergic activity and benzodiazepines are both associated with delirium in older adults. Anticholinergics and acute confusion.

Should a new anticholinergic burden score change someone’s prescriptions?

It should start a conversation with the prescriber, not replace one. The scales disagree with each other, they measure exposure rather than an individual’s response, and some drugs carrying anticholinergic activity are treating something important. The score is a prompt to look. The medication review.

DWARAA is six steps. Back to the framework overview.

What the evidence does and does not show

Sedating medications impair gait, balance and reaction time, and their labels say so. That part is not in doubt. What has not been shown is that a deprescribing program reduces fall rates — the trials that tested it were small, short, and mostly measured a medication count rather than a fracture. Those are two different questions, and absence of evidence from underpowered trials is not evidence that the drugs do not cause falls. What the evidence actually shows about deprescribing and falls.

References

  1. Salahudeen MS, Duffull SB, Nishtala PS. Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review. BMC Geriatrics. 2015;15:31. PMID 25879993 · DOI 10.1186/s12877-015-0029-9.
  2. Boustani M, Campbell N, Munger S, Maidment I, Fox C. Impact of Anticholinergics on the Aging Brain: A Review and Practical Application. Aging Health. 2008;4(3):311–320. DOI 10.2217/1745509X.4.3.311. Not indexed in PubMed; verified through Crossref. Cite by DOI.
  3. Carnahan RM, Lund BC, Perry PJ, Pollock BG, Culp KR. The Anticholinergic Drug Scale as a measure of drug-related anticholinergic burden: associations with serum anticholinergic activity. Journal of Clinical Pharmacology. 2006;46(12):1481–1486. PMID 17101747 · DOI 10.1177/0091270006292126.
  4. Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Archives of Internal Medicine. 2008;168(5):508–513. PMID 18332297 · DOI 10.1001/archinternmed.2007.106.
  5. Hilmer SN, Mager DE, Simonsick EM, et al. A drug burden index to define the functional burden of medications in older people. Archives of Internal Medicine. 2007;167(8):781–787. PMID 17452540 · DOI 10.1001/archinte.167.8.781.
  6. Clegg A, Young JB. Which medications to avoid in people at risk of delirium: a systematic review. Age and Ageing. 2011;40(1):23–29. PMID 21068014 · DOI 10.1093/ageing/afq140.

Written and medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, founder and medical director of DWARAA. Last reviewed . This page is educational. DWARAA does not prescribe, deprescribe, diagnose or treat.