PBA symptoms are prevalent in various underlying conditions across clinical settings

Prevalence of PBA symptoms has been collected in multiple clinics throughout the US as well as in long-term care (LTC) facilities1-3

 

PRESENCE OF PBA SYMPTOMS IN COMMON NEUROLOGIC CONDITIONSa,b

Presence of PBA Symptoms

 

Study Description
 

Foley was an observational, retrospective study in which 412 nursing-home residents out of a sample of 804 (51%) were included in the predisposed population. Residents were considered predisposed if they had a documented diagnosis of a neurologic disorder that could be associated with PBA (dementia, cerebral palsy, aphasia, stroke, PD, seizure, hemiplegia, and MS). Primary objective: estimate of PBA prevalence in US nursing-home residents.

Study Description
 

PRISM, a multicenter (173-site) study, enrolled 5290 patients with one of 6 conditions: Alzheimer’s disease (AD), stroke, traumatic brain injury (TBI), Parkinson’s disease (PD), amyotrophic lateral sclerosis (ALS), or multiple sclerosis (MS). Patients (or their caregivers) completed the Center for Neurologic Study-Lability Scale (CNS-LS)—a 7-item questionnaire that provides a quantitative measure of the perceived frequency of PBA episodes—and an 11-point scale measuring impact of the neurologic condition on the patient’s quality of life.

aThe CNS-LS was validated as a PBA screening tool in ALS and MS populations. A CNS-LS ≥13 may suggest PBA but does not confer a PBA diagnosis.

bAs determined by a score ≥13 on the CNS-LS applied to population data for specific neurologic conditions.1,4-6

PBA symptoms may be more common than you think

  • The prevalence of PBA in the US is approximately 2 million, among patients with underlying conditionsa,b,1
  • According to the Centers for Medicare and Medicaid Services (CMS), more than half of US nursing home residents have dementia, and a fifth have had at least 1 strokec,7
How many of your residents with dementia or stroke also have symptoms of PBA?

aThe number of Americans with PBA symptoms was estimated from survey data and applied to the following US prevalence estimates for neurologic conditions: PD, 1,000,000; AD/dementia, 6,800,000; stroke, 5,400,000; ALS, 30,000; MS, 400,000; TBI, 5,300,000.
bA more restrictive definition was also evaluated using a CNS-LS ≥21, consistent with the mean baseline CNS-LS score for patients participating in PBA clinical trials.
cDementia represents all CMS categories of dementia, both Alzheimer’s and dementias other than Alzheimer’s.

Discussing PBA (Stroke LTC)

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SEE A PATIENT WHO HAS EXPERIENCED A STROKE DISCUSS PBA <span class="timecode">(0:23)</span>

Uncovering PBA and associated crying

Pseudobulbar affect (PBA) symptoms are frequent, sudden, uncontrollable outbursts of crying and/or laughing in patients with underlying neurologic conditions or brain injury4

RELATIVE TO MOOD, PBA EPISODES ARE1,10-12:
Exaggerated
Disproportionate to the situation and/or mood
and/or Incongruent
Inconsistent with or opposite to a person’s mood

In a nursing home, many residents may not be able to communicate. Typically, crying is thought of as the physical response of shedding tears or showing sadness or distress. However, in PBA, the episodes of crying may appear differently, as described below.8,9

CRYING IN PBA MAY APPEAR AS1:

Weeping with or without tears

Shedding tears noiselessly, with a sad or distressed expression or sad appearance without actual tears being produced

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and/or

Inarticulate sounds

Can appear as a grunt, cry, scream, snort, wail, howl, moan, sob, snicker, or repetitive vocalizations that are inconsistent with mood

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and/or

Sobbing: Combines noisy crying with loud gasps, sudden convulsions, or in-and-out movements of the chest; talking in between gasps

Wailing: Prolonged, high-pitched howling, or crying out

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and/or

Facial grimacing

Twitching, gagging, and jerking the jaw, and twisting of face muscles

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and/or

In addition, these episodes can be1:

  • Sudden and brief (lasting seconds or minutes)
  • Stronger and more intense than normal reactions
  • Disruptive

PBA episodes follow a stereotyped pattern1:

Over time, patients or caregivers may notice similarities in initiation, length of episode, and expression of crying and/or laughing.

How are you identifying PBA in your residents with dementia or stroke?

PBA symptoms may be mischaracterized as mood swings

Patients with a history of dementia or stroke can experience mood swings or other behavioral changes.9,13,14 Your staff may report that the resident seems sad or depressed, but when asked for details, go on to describe what might be the incongruent or exaggerated crying and/or laughing outbursts of PBA.15

PBA symptoms are often mischaracterized

 


Consider PBA

Probe further: Do your residents’ mood swings match how they say they feel?
If nurses and other staff members report that their residents’ crying and/or laughing are exaggerated or incongruent with their underlying emotional state, it may be PBA.8

LOOK FOR SOME OF THESE TERMS ON PATIENT CHARTS THAT MAY DESCRIBE SYMPTOMS OF PBAa,b,15

Sudden outbursts of crying or laughter
Exaggerated response
Emotional lability
Mood incongruent
Incongruent emotions

aSurvey of 302 long-term care physicians and nurses who were asked, “How would you describe symptoms of pseudobulbar affect (PBA) if notating it in a resident chart? Please use the exact language you would use on the chart.”15
bVarious terms have been used to describe PBA but these are not necessarily synonymous or interchangeable.