University Place  Kim Petersen Tools for Assessing Dementia  February 25, 2014 UP987    cc >> We're going to start the session now that addresses tools for assessing dementia behaviors, which Dr. Petersen spoke about in his first session. So I'm going to turn it over to Kim, and we'll work on that level. >> Good. Thank you, Suzanna. I told you that one of the challenges in geriatric medicine has always been having adequate tools. Well, in dementia medicine it's really been a challenge. And so much of our conversation and our dialog and our approach has been what I call anecdotal. There's nothing wrong with that. A story is very important, but it's from a unique person's perspective, yours, as you're reporting what happened last night. And there's all kinds of things that will color how you write in the record or how you tell the story to a family member, to the physician, to whatever. 

There's elements of truth, but nobody else can quite figure out where you're coming from. So I want to share a few tools, and in particular spend most of the time on the neuropsychiatric inventory called the NPI. Does anybody here use this tool? We've got a room full of virgins. All right. [LAUGHTER] Vestal virgins. All right. That's great. I'll also briefly talk a little bit about the behave-AD tool, the Cohen-Mansfield agitation inventory that we talked a little bit about before. Most of you are probably familiar with the geriatric depression scale. It's one of them. 

There's others. Beck, HAM-D and so forth. Anybody here familiar with the pain-AD scale? Oh, boy. Okay. You have these tools all in section number three. All right? You've got the slides in section number two. When we get to the case and we start working through the NPI, I'm going to ask you to forget the slides and move to the tool in section three. It's going to be a complex thing. You take the tab and you flip it over, but we'll get there. Okay, now let's talk about the neuropsychiatric inventory. 

I've been using this for more than 15 years now, so I'm not a virgin as far as the NPI. It really is easy to use, and it works. Jeff Cummings, who designed this, is a neuropsychiatrist in California. So you can already get a little hippie-dippy here. [LAUGHTER] He's actually a nice guy, but he was frustrated too with not understanding how do we assess the different behaviors, and in particular how bad are they. And then when we do something to try to fix them, does it work? I think that's one of the biggest challenges, particularly from the regulatory people called the state when they come in to see whether your plan is working or not. How do you prove that it's working? And of course if you can't prove that it's working, it's sort of the reverse of our judicial system, you're presumed innocent until proven guilty. Well, with the state, you're guilty until you can prove your innocence. All right, you'd think they were Russians. Anyway, this is a tool that is numerical, and it has a scale from one to 144. 

I've got to tell you, doctors love numbers. We're number based. So this will really impress a physician. I'll show you how it works, but there's also a breakdown of whether the behavioral issues are mild, moderate, or severe based on the score, which is really helpful because if you have a mild problem, you're going to do certain things, if it's moderate, certain things, and if it's severe, you've got to pull out all the stops. But even beyond that, the best thing, I think, is helping you categorize what's going on, how bad is it, but then whatever your plan is to deal with it, then you repeat this after X period of time and you compare your scores. Are you getting better? Well, that's what we want to do on blood pressure. That's what we want to do on blood sugars, your lipid levels, whatever. We love numbers going down. It's only a gauge, but it's more objective than what we're doing, in many cases, right now. So what Jeff Cummings did is he broke down behaviors into what we call domains. 

And these are what he came up with. There's 12 of them. That's how we're going to get 144. And I think they cover the waterfront. Delusions. Hallucinations. Agitations/aggression. Dysphoria, which is a low mood, sadness. Anxiety. Apathy. 

Irritability. Euphoria, which very few demented people have but occasionally they do. Disinhibition. Aberrant motor behavior, that can be either pacing or actually not doing anything, just sitting. It's not normal. People move a little bit. Same thing with nighttime behavior. Can either be up all night or sleeping all the time. So we've got some gauges to it. appetite/eating abnormalities. 

Again, eating nothing or Pica, feeding yourself all kinds of things. So in the tool, what you'll see in just a minute when we flip to tab number three, he describes what these mean. But they kind of cover the waterfront, I think, of behaviors. This is one of the neat things that he came up with. A scoring tool, which takes the frequency, how often does the behavior happen, by the severity and multiplies it. That very quickly, rather than adding it, when you multiply from a mathematical point of view it magnifies differences very fast. Well, commonly, two plus three is five, but two times three is six. You'll get a bigger number real quick. So he's got a score of one to four on frequency by defining how often is the behavior happening: occasionally, often, about once a week, frequently, several times a week but not necessarily every day, and then very frequently or more than once a day. Now, severity, how are we going to define that? Well, surprisingly, there are some definitions in the tool that help you decide whether it's mild, moderate, or severe. 

But it's funny, when I work with groups, we call them swat team groups that are analyzing the behavior, we tend to have a gestalt idea about whether it's mild, moderate, or severe, but there actually is verbiage that describes that in the tool. So you get either a one, a two, or a three, and then you multiply those for each domain. Okay, let me cover the tool first, then we're going to go through a case and I'll show you how it works. I think that's the best way to do it. What Cummings also found was a big breakthrough, in my opinion, because I tend to like to reduce things to simple things. I'm a simple person. He came up with what we call clustering. When he analyzed the data from thousands of thousands of nursing home people, he found that the domains tended to cluster by scores in four bigger areas. He called them subsyndromes: hyperactivity, affective, apathy, and psychosis. And within those, these are the descriptors, the agitation domains, the irritability, euphoria, disinhibition, and aberrant motor behavior tend to be clustered under what he called hyperactivity. 

And the affective, as you might imagine, depressed mood but anxiety, nighttime behavior, mostly not sleeping but could also be sleeping all the time, and appetite changes, usually not. Those are pretty classic for affective problems, mostly depression but you've got anxiety mixed in there too. Apathy, which is unique kind of to dementia. There is a domain of apathy itself, but again, not eating may be due to apathy, not moving around, just sitting in one spot. How many of you have gone into some facilities where everybody is in their little wheelchairs in front of the nurses station doing nothing? Hmm? And they don't even look like they're doing anything. The lights are on but nobody's home. That's apathy. Nighttime behavior again. And then the last domain was psychosis, and there were only three things that clustered under that. The delusions, hallucinations that aren't Lewy body based, and anxiety. 

Why is anxiety in there? Well, because if you're paranoid, you're also very anxious because people are out after you. Okay? So that fit. So, he reduced it to four, and those are the four subsyndrome collection of domains that you can use, and I'll show you how it works with our case, to plan treatment. You don't have to deal with each behavior because many people have a variety of domains of behavior. Which one do you go after? That's too confusing. Do you treat the anxiety with anti-anxiety but the depression with this, and then they are hyperactive with that? Uh-uh. You cluster them. That's a good place to start. So what he found in analysis was the subsyndrome was the most common for apathy. Hyperactivity was the second most common. 

Actually, psychosis is not that common but you'd think it were with all the prescriptions for antipsychotic drugs we prescribe. Wrong drug for the wrong problem. I'll get to that when we talk about meds a little later. I'll get on my high horse about it. Anxiety was classified under both psychosis and mood apathy. And then, again, he found that, and it's true in the pharmaceutical world, every pharmaceutical company now uses the NPI to test out whatever drug they want to pervade to doctors. They use the NPI to assess for  the FDA whether it's effective or not. It's that sensitive. It also has great what we call inter-rater reliability. I can take you and you and you and you and have you do it, and you'll be within two or three points of each other. 

So it's very reliable. Same thing with different shifts of the facility. The nighttime staff can do it, and the daytime staff may be seeing different things because people are different depending on whether it's night or day. But within the group, they have a lot of commonality of their score. All right, in your slides is the case. So turn to whatever page that is. Bill Jones is a 76-year-old man with mid-stage Reisberg stage 5, just take my word for it, Alzheimer's disease. He's living in a facility for six months. The only behavior meds he's taking is Aricept for his Alzheimer's. In the past month, he's developed more behavioral problems that include striking out during showering and dressing, these should be familiar to a lot of you, often hitting the staff with his hands, starting arguments with his table mates about which is his food, then gets disgusted, throws the food on the floor and won't eat anymore. 

Pacing around the facility, wandering into other's rooms claiming it's his room, and ordering them to get out. Ever heard of that? Getting up in the middle of the night wanting to get dressed and go to work. Sitting in his room crying saying no one loves me. When the staff tries to comfort him, he gets angry, yells at them and says you really hate me, leave me alone. He's not eating as much and has lot five pounds of weight. Bingo. That should trigger a weight thing. You've got a problem from the state's point of view. Okay, we're going to do this but what we're going to do is what you do, and now turn to section three. Flip ahead to the test. 

The first page you should see is the scoring sheet right in front of you, with the 12 domains along the side. And then a no and a yes column, a frequency column, a severity column, and an item score. We won't talk about the caregiver's stress because it's a little more than I want to deal with today, but there is a part of that that also asks the care provider, whether we're talking about home or in a facility, to answer the question how disruptive, how much is this behavior bothering you. That's kind of interesting. And actually, DONs might want to do that to see how stressed their staff is about taking care of the resident. So anyway, what you're going to do is go through each domain and first ask the very simple question: does the resident have this behavior, yes or no. If it's no, you can either mark an X, put a 0 or just ignore it because you're not going to score that domain. We don't care. If it's yes, then the first thing you do is what's the frequency? Is it a one, two, three, or four, based again on occasional, often, frequent, or every day. Then the next thing you go is how severe is it: mild, moderate, or severe. 

And then hopefully in your head you can do the multiplication, but if not, use a calculator, and you multiply the two scores, and you put that score in the item score box. I think we can do that. All right. Then, after all of the domains have been scored, then you add it up, and what's the score out of a potential 144. The 144 becomes 12 domains times a maximum score of 12 for each domain. That's where it comes from. So, where are they? If their total score is less than 20, it's defined as mild behavioral problem, 20-50 is moderate, and 50-plus is severe. Pretty obvious. It's not hard. And that doesn't take you long. 

I've timed this. It can take less than five minutes. Yes, ma'am. >> How many people do this? >> Well, you could do one, but the more people you have, the more objective it is. I like to get a team together. You always need the front care provider. Your CNAs, nursing, social work, anybody that's involved. As I said, we develop swat teams that want to analyze the behavior. But it's got to be somebody that sees it, and, as I said, you might want to do all three shifts as you're analyzing it because things change during the daytime, and if it's always a problem for the afternoon/PM, you might think about maybe it's when everybody's coming and going that's causing this. So do it to all three shifts. 

It doesn't take long. Then the next page, there's one more in here. Okay, the last one before you get to the behave-AD. It's page number six called the grouping. What we're going to do then is take each item score and we're going to put it in the corresponding domain box. They're numbered and they're also described. For example, under hyperactivity, domain number three is agitation/aggression. Move the item score there and put it down, and you do for each one of them. So NPI domains of three, seven, eight, nine, 10 will all cluster and so forth. We'll get to that. 

I'll show you how it works. It's easier to show you than to describe it. So there's two parts. You score the tool to begin with, and then you take the next tool, which is the grouping, and you fill that out. And then we're going to go from there. Okay? All right. Flip back because we're going to go through Bill. Flip back to the first one so you can kind of see how this works. All right, this is what it should look like in front of you, blank. Bill Jones. 

Now, I'm going to make decisions about the behavior. We could argue about it and it might be kind of fun to do, but forgive me, I just need to do it and you'll just take my word for it on this case. All right? All right. So, does he have delusions? No. I'm going to say he does not. Did he have hallucinations? No. So we don't have deal with those. Is he agitated? Oh, yeah. How often? Every day. How severe? I'm going to rate it, I live with him, I'm his care provider, he's a two. 

So he gets an eight. All right? Dysphoria? Yep, but it's not all the time, just some of the time. So frequency is a two, but when it happens he's pretty depressed and he's pretty anxious. He has a low mood. So he gets a, two times three is a six. I had to check my arithmetic. I'm not the best in arithmetic on this. Okay, anxious? Yes. Almost very many times of the week but not always every day but it's pretty bad. So he gets a three times three is nine. 

All right, we doing okay? Is he apathetic? No. That was one problem he doesn't have. I wish he were a little more. Is he irritable? Oh, yeah. Even on a good day he's always cranky. So he gets a four times three. He gets a max of 12. Can't get any better than that. Euphoric? Nope. Disinhibited? Yes. 

He acts out. He throws his food on the floor. He urinates in the tub. He does whatever he wants when he wants. So he gets 12 there. Aberrant motor behavior? Yeah. Many times of the week but it's not too bad. I'm sorry there's two sixes there. My finger got overactive. It's really just a six, not 66. 

Nighttime? Yeah. Again, many times of the week but it's pretty bad when he gets up. Can't get him back to bed. He gets a nine. And eating. Oh, yeah. We've got a weight loss. He isn't eating. Something's happened. So he gets a 12 on that. 

See how that works? Really, it almost took just as long as I really would take. And a group does it pretty fast. It's really interesting. Okay, we've done that. Now flip to that next one, the page six of the grouping. Let's group this guy. Here's what the tool looks like with no scores, and presto chango, I'm going to put the scores in just like that. I almost wish I had Vanna White here to do this. This would be interesting. So I just transposed his scores, and that's what it would look like. 

Oh, I'm sorry, let me back up one more. I forgot to add up his score. He got a 74. Hmm, okay. And his grouping was this. Now, what you do in each group is you add up how many points does he get under hyperactivity, affective, apathy, and psychosis. I think you can see very quickly he only had nine points under psychosis. That was real fast. You'll have to take my word on the arithmetic for the other guys. He clustered in hyperactivity with a total score of 38. 

Hmm. And affective depression he was right behind at a 36. If you try to go through each of those domains separately, you would have missed, I think, that he had two big subsyndromes that are involved here. They actually kind of go hand in hand but not always. Apathy was a little lower at 27. And we also see some of the behaviors of apathy mixed in with both hyperactivity and affective, but not the domain of apathy. So his major behavioral challenges are in two subsyndromes: affective, mostly anxiety and depression, and hyperactivity. He is not psychotic. He does not need Risperdal, Haldol, Quetiapine, any of those guys. All right? All right. 

You can't just defy it pharmacologically. All right, so that's how that works. We'll come back to med treatment in the next talk. Questions? Let me stop here because I want to be sure you see how this works. Did I do a good sales job? You've got the tool right here. It's in public domain. Jeff doesn't care that you use it, just so you don't make money off of it, which you're not going to. You don't make money in long-term care. That's easy. [INAUDIBLE] Say that again so we get it on tape. 

>> Where do we get the multiplier two for each of them? >> Okay, let me back up. >> I missed that part. I'm sorry. >> Okay. The multiplier, frequency times severity. >> Okay. >> Whatever score you get in those two areas, you multiply them together. >> Okay. >> So like number three, agitation, he had a four under frequency but it wasn't that severe so he got the eight. See how that works? The maximum you can get is four under frequency and three under severity. 

>> All right. Thank you. >> That's a 12. Okay? And again, different people, different times will evaluate it, but what you'll find, even though you might have different staff doing it, their total score and the total picture of his subsyndromes is probably going to be the same. He's going to probably have, rather than a 38 he may have a 39 or whatever in hyperactivity. That's not the important thing. What you want to know is which subsyndromes are driving his behavior by using his individual domains of psychological and behavioral difficulty and scoring it. Okay? All right, so let's cover the other guys. Now, the behave-AD, which is also in your packet under tab number three, I've given you a copy of it, this is used, it's very good. It's predominately supposed to be used for just people with a diagnosis of Alzheimer's or more likely it's Alzheimer's. 

And it is nice in that it quantifies, again, very common behaviors with AD. The paranoia, the hallucinations, activity disturbances, aggressiveness and so forth.  So it does that, and it has a scale, again, a scoring from 0 to two or three. It varies a little bit by which of the questions you're asking. But it's a little bit long, but it's another one that you can do and you're welcome to have it. It covers a lot of the same behavioral domains that the NPI does. And I've used it on a few patients, but I've just found the NPI is quicker. The next one is the Cohen-Mansfield agitation inventory in your packet. And it, again, is kind of a Likert scale thing. Again, it measures from never to several times an hour, and it goes through a variety of different behaviors that are linked to agitation and aggression. 

It's a good one, again, if you're having a resident that has got a lot of problems in that domain. Plus, it will also crystallize whether we're talking about the physical or verbal, aggressive or non-aggressive differentiation of agitation. So, Cohen-Mansfield has done a great job with that. It's long. It does take a little bit of time, but it can be very revealing. Or if you've got a resistant family member that just doesn't believe that dad does this, you can use this and demonstrate very clearly yes he does and here's what's going on. I know you folks are very familiar with the GDS or geriatric depression scale. The reason we tend to used it in geriatrics is it has eliminated vegetative symptoms and other symptoms that may be from other physical illnesses that are often reflected in HAM-D or Beck that work better a little bit for younger people. So it minimizes somatic symptoms. And it can be used through all the stages of dementia, but it becomes less reliable because they have loss of insight. 

But you can have a care provider do the GDS for themselves and the person. You take what they say on the person, you throw it out, and you look at their GDS because there's almost 100% correlation between a depressed caregiver and a depressed person with dementia. I'm always screening for it because they are reacting, and we'll get to it when we talk about mirroring, they are reacting to what the person with dementia is expressing even though they may not be able to do it in the classic symptoms of depression. So be very aware. And I wish more facilities would screen direct care providers, like front line CNAs who are dealing with them, particularly if they're having performance problems. They're missing work, they're late, don't think that there's, there may be other things going on in that person's life, and most of them are women but not all. I'm wondering if they're depressed and they just don't want to come to work. And you want to know that because it's manageable. It's treated. So, there's the GDS. 

The short form is just as reliable as the long form. And I often use the 15 with dementia people because the only difference is that they ask the question twice in the 30 question form in different ways. 15 is good enough. The other thing I hope you're doing is if they're on an antidepressant med or you've got a program of exercise and music therapy and other things to treat their depression, you should be repeating that test in X period of time. How much time? It varies. Two weeks, four weeks, I don't care. Repeat it. And the score better be coming down. Two things: if the scores isn't coming down, it may be the apathy of dementia is the real issue. It's not depression. 

Then you've got to ask: do they need to be on the antidepressant? Or number two, it's the wrong antidepressant, the wrong dose, whatever. We'll talk about that a little bit later when I talk about the meds. Use your tools repeatedly, please, because what you do is you put them in the chart, you talk to the physician, you talk to the family members about it, what you're analyzing, just like you would be for their blood sugars or blood pressure or whatever, their weight. You've got numbers all over the place. You should be doing the NPI and the GDS if they have those problems. And then you put it in the chart, and when state comes you whip that chart out and say here. Here's our care plan. Here's our results. They'll be impressed. Maybe. 

Who can tell with the state. All right, I like to pick on them because I also teach at the state. [INAUDIBLE] How often do you recommend repeating the tests. That varies. It's so hard to give you an actual time frame. What I would, ideally, ladies and gentlemen, when a person comes into your facility that you know from a history point of view that they have had some behavioral problems, rather than worry about, if you're in a nursing home setting, their MDS, you've got to do that too, but right away do their NPI. You want a baseline. I think everybody should have a baseline. Every dementia person in a facility, assisted living or nursing home, should have an NPI baseline because something's going to change. Remember that chart I showed you over three years study? They're going to have something happen. 

You want to pick up that right now, and you can't do it if you don't know where they started from. So that would be ideal. And then when a behavioral thing happens, you repeat it, you get the scores, you change the care plan, meds, non-meds, and then depending on how acute it is, if it's severe I think I'd repeat it in a week. You want to know if you're on the right track. Even if they're budging down a point or two, you may be making some progress. But it varies. A week, two weeks. For mild problems or depression, it's going to take a month for the drugs to work. Blah, blah, blah. You customize it. 

I don't care about how often. I just want you to repeat it. All right? Not, obviously, in six months, but use it as a tool. Just like you're going to monitor if their sugars are out of whack, you're going to be monitoring them more frequently. Something's out of whack with their behavior, you need a tool to monitor it. You can't overdo it. You really can't. It's not that it will become less effective the more you do it. >> Kim. >> Yeah. 

>> I have a question. What do you have to say about the PHQ-9 using that in place of the GDS? >> You could. >> Or do you have one preference? >> I'm not familiar with that, but the people in the psychology world may be more familiar with that. And, again, if you like the HAM-D or the Beck, that's okay. Just use something. Not just anecdotal and they look depressed. That doesn't cut it. That's not objective, and I know you don't do that. So just use some tool. The last tool I want to talk about is the pain-AD scale, and this is particularly helpful with people who are non-communicative. 

But it also works for any stage of dementia because it's merely observational. And you don't have to ask them a question, you don't ask them to give you a smiley face, a frowny face, a Likert scale one to 10. I always chuckle, my father-in-law, who's deceased, had spinal stenosis and a bunch of arthritis things and whenever they would ask Jess on a scale of one to 10, what was his pain? He'd say 15. Okay, so the pain-AD scale is observational. It was designed by nurses. It can be incorporated in cares that are going on in the room because you don't have to talk, and when the dementia people can't talk back at you effectively to tell you from a judgment point of view how much they're having for pain, you need some other kind of tool. And I've listed the website, and the data, again, is public domain. You can pull it up on the web. It was published in JAMDA in 2003. It has five domains. 

They're breathing, negative vocalization, like crying, whining, whatever, what their face looks like, primate time, face, we'll get back to that, body language, and how easily they can be consoled. Now, take yourself sometime, I'm sure all of you have had something happen to you that hurt. From bad to relief, not so bad. But anyway, your breathing changes. When we have pain that's an autonomic problem, you can't not have a change in your respiratory. And so if they're breathing normally but if it's labored or short periods of hyperventilation, that gets a point. If it's really noisy or chain stokes, that gets two points. So that you observe. You listen to their vocalization. You watch their face. 

Is it smiling or no expression but if it looks sad or frightened or frowny or downturn of the lips. Walk into a nursing home sometime and although older people faces do change, and if you've noticed any of you over age 50 everything's sagging, it's gravity, the mouth actually doesn't go that much. And it always has the capacity, if they're happy, to smile. But look around at the number of people who have kind of that-- [grimaces] You get that squinty, these are called think lines. I don't know if you've ever heard that. The little lines between our brow up here, when we hurt or are anxious we tend to furrow, all primates do that, we tend to furrow our brows, these lower, and we get the thinker lines in the middle. That's what they're called. You want to watch for those because they're a clue that something is distressing this person, either a physical symptom of pain or a psychological symptom. Body language, just holding, sometimes we diagnose a hip fracture only because they got their hand down here on their hip or their knee, those are referred areas, and they didn't used to do that. So you watch for that. 

And then, again, how easily can they be consoled because if you have pain that's not relieved, until that's relieved you can't do anything to make them feel better. So, this works, and a score of over four out of 10 indicates you need to have a pain program going, whether it's new assessment, which you probably should do. Do they have a knew fracture? Is it a worsening of known arthritis? Whatever, you've got to answer what's going on. Is it something acute and new, or is it a worsening of chronic conditions in which case we need to readjust our pain protocol for medications and/or physical medicine, whatever, heat packs, whatever. You've got to do something. And I have been out of medical directorship for a few years, but it's always been my understanding that surveyors are really looking for non-treated pain. It's a big, big problem, and nobody should have that. You don't want it, and a dementia person who can't tell you about it, they don't want it either. So behavior is often driven, a lot of it, by untreated or inadequately treated pain. I tended to have a protocol, not on absolutely everybody, but when behaviors were going on and we had a hint that they have arthritis or spinal stenosis or just immobility, I often put them on some acetaminophen, regularly. 

Two or three times a day. And I had a care plan reason for it, but it was amazing how many people got better just with the good ol' Tylenol. Now you've got to watch the dose and there's some other things to do, but simple treatment like that almost ought to be, not quite be de rigueur for dementia treatment. But many people, and just remember that immobility, the muscles get spastic and they hurt. So if they're not moving, not walking around, sitting on the behinder a lot, they're probably hurting. So that's something to think about. Okay, questions on that? Yes, ma'am. Here, we've got to get this microphone. We want you on the record here. >> It seems as though a lot of these, although they are pretty obviously indicators of physical pain, also almost make a panic attack. 

So it seems like there could be a pretty obvious psychological pain. >> There could. >> Is there something to sort of differentiate or is that sort of left up to who's ever... >> It's sort of left up to the observer whether there's something else going on. But oftentimes you can't separate the physical from the psychological, and if there's a joint that's hurting, it's going to drive their psychological expression of that too. So you can deal with both of them, but until you deal with the physical nerves projecting hurting, you're not going to get anywhere with anything else. >> Right, thank you. >> Yeah. But treating the pain successfully and then also giving comfort and reassurance and whatever else you're going to do psychologically, they do go hand in hand. But I'm just saying until you recognize that pain is an underlying current that's there and needs appropriate treatment, there's so many things we can do. 

You do not need opioid narcotics for everybody. You really don't. I'm very impressed with physical medicine. Even the old fashioned ones like ice and heat, they really work. And acupuncture works for some things. E stimulation works. There's a whole variety of modalities. Actually, music therapy works. We don't have time to talk about that today, but it does. I can block your pain, oftentimes, with the right music. 

Anyway, there's a whole bunch of modalities. You don't have to go to the powerful drugs right away. There's a step rise thing that you do, but don't forget the other non-pharmacological because there's a price to pay for opioids. Sometimes you have to pay it, but there's a price to pay. If there's anything else you can use rather than go up to the real powerful drugs, and you're going to want to stay away from the non-steroidal anti-inflammatories that really do terrible things to stomachs and kidneys. Yes, ma'am, in the back. >> What is the price that's paid for the opioids? >> Well, all opioids cause constipation. So you put them on I don't care what, codeine to, what's the popular one? Oxycodone. I don't care what it is. The minute they go on a pain med that's an opioid family, you need to have a bowel program going because they're all going to bind up. 

And old people are bound up anyway on a good day. They don't drink enough water, they don't eat enough fiber. And then they cause confusion. They can increase the risk for falls. There is a price. Sometimes it's worth paying. But I'm just saying, look at other things that are safer, and you're going to kind of get the feeling that I'm kind of a therapeutic nihilist for drugs. I've just learned the hard way in geriatrics that they can be your friend, but they can also turn around and bite you, and you don't want that. My principle of treatment is first do no harm. If I can't you better, I must not make you worse.