dementia & antipsychotic medications · 2014-07-13 · dementia & antipsychotic...
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Monica JonesBPharm, GradDipClinPharm
Chief PharmacistMoruya and Batemans Bay hospitals
Dementia & Antipsychotic Medications
OVERVIEW
� Behavioural and Psychological Symptoms of Dementia� Management of BPSD� Medications prone to cause BPSD� Management of BPSD
� First line: non-pharmacological� Second line: Antipsychotics
� Evidence for antipsychotics� Side effects� Treatment plan� Doses � Discontinuing therapy� Dementia with Lewy bodies� Identifying problems in your facilities� Drug Usage Evaluations in practice� Key messages
BEHAVIOURAL DISTURBANCES IN DEMENTIA
� Commonly referred to as “BPSD”
� Other common terms� Behavioural disturbances of dementia� Non-cognitive symptoms of dementia� Neuropsychiatric symptoms of dementia
BEHAVIOURAL DISTURBANCES IN DEMENTIA
� Definition :“symptoms of disturbed perception, thought content, mood, or behaviour frequently occurring in patients with dementia”1
1. International Psychogeriatric Association. BPSD: Introduction to behavioural and psychological symptoms of dementia.2002. http://www.ipa-online.orgBehavioural and psychological symptoms of dementia’ (BPSD) refers to the often distressing non-cognitive symptoms of dementia, including agitation and aggressive behaviour.
BEHAVIOURAL DISTURBANCES IN DEMENTIA
� Includes: � Calling out, shouting,� Wandering, pacing� Inappropriate touching, sexual
behaviours� Delusions, hallucinations, anxiety� “Sundowning”� Depression� Restlessness
BEHAVIOURAL DISTURBANCES IN DEMENTIA
� Affect up to 61% of patients with dementia1
� In a recent Australian study2 reviewing more than 10000 residents of hostels and nursing homes staff rated:� 32% of residents as having mild behavioural disturbance,� 22% as moderate, � 14% as severe.
1. Lyketsos CG SM, Tschanz JT, Norton MC, Steffens DC, Breitner JC. 2000, Mental and behavioural disturbances in dementia: findings from the Cache County Study on Memory in Aging. Am J Psychiatry;157:708-18.
2. Opie J, Rosewarne R, O’Connor D.The efficacy of psychosocial approaches to behaviour disorders in dementia: a systematic literature review.ANZ J Psychiatry 1999;33:789–99.
MANAGEMENT OF BPSD
� Review possible causes of the distress:� Pain� Hyponatraemia (side effect of lot’s of common
medicines in the elderly)� Constipation� Infection � Environmental factors (noise, lights, conflicts
with others)� MEDICATIONS
MEDICATIONS PRONE TO CAUSE BPSD
� Anticholinergic medications� Tricyclic antidepressants (amitriptyline,
nortriptyline, doxepin, dothiepin)� Oxybutynin� Tiotropium, ipratropium� Prochlorperazine, promethazine
MEDICATIONS PRONE TO CAUSE BPSD
� Anti-Parkinson's medications� Levodopa/carbidopa� Levodopa/benserazide� benztropine
MEDICATIONS PRONE TO CAUSE BPSD
� Benzodiazepines� Diazepam, Temazepam, Oxazepam� Clonazepam, Nitrazepam, Flunitrazepam
� Others� Tramadol
MANAGEMENT OF BPSD
� First line:� Non-pharmacological management
� Music therapy� Pets therapy� Exercise� Regular social activities
MANAGEMENT OF BPSD
� Second line:� Antipsychotics
� Risperidone, Haloperidol, Olanzapine
� Should be used only if the behaviours pose a serious risk or causes severe distress
ANTIPSYCHOTICS -EVIDENCE
� Limited efficacy to support use of antipsychotics in management of BPSDs
� Symptoms with evidence � Aggression, agitation, hallucinations, delusions
� Placebo response rates in trials were 20% or higher, indicating that BPSD often resolves spontaneously within 12 weeks1
1. National Prescribing Service 2007, PPR 37: Role of antipsychotics in managing behavioural and psychological symptoms of dementia.
ANTIPSYCHOTICS -EVIDENCE
� Placebo response rates in trials were 20% or higher, indicating that BPSD often resolves spontaneously within 12 weeks1
1. National Prescribing Service 2007, PPR 37: Role of antipsychotics in managing behavioural and psychological symptoms of dementia.
ANTIPSYCHOTICS -EVIDENCE
� Troublesome symptoms are less likely to respond� Wandering� Shouting� Incontinence� Touching� Withdrawal
ANTIPSYCHOTICS – SIDE EFFECTS� Side effects are significant
� Increased risk of death1
� Cardiovascular� Cerebrovascular� Infections� Sudden death
1. Rossi S (ed) 2010 Australian Medicine Handbook AMH Ltd Pty SouthAustralia
ANTIPSYCHOTICS – SIDE EFFECTS
� A meta-analysis of 15 placebo-controlled trials found a small but statistically significant increase risk of death compared with placebo. 1
� One death was associated with antipsychotic therapy for every 100 patients treated over 10–12 weeks.1
� Risk greatest with olanzapine, risperidone
1. Schneider LS, et al. Risk of Death With Atypical Antipsychotic Drug Treatment for Dementia Meta-analysis of Randomized Placebo-Controlled Trials, JAMA 2005;294:1934–43.
ANTIPSYCHOTICS – SIDE EFFECTS
� Increased risk of stroke (fatal and non-fatal) and TIAs
� Risk greatest with risperidone and olanzapine but haloperidol may carry similar risks
� Increased falls risk
1. Rossi S ed 2010 Australian Medicines Handbook, AMH Ltd Pty Adelaide
ANTIPSYCHOTICS – SIDE EFFECTS
� Parkinsonian symptoms (abnormal gait, shuffling)
� Type 2 diabetes� Sedation � Confusion � Urinary incontinence� Hostility � Weight gain 1. Rossi S ed 2010 Australian Medicines Handbook, AMH Ltd Pty Adelaide
ANTIPSYCHOTICS –TREATMENT PLAN
� Before commencing antipsychotics� Determine specific behaviours to be
targeted� Review past medical history to assess
risk versus benefit� Measure baseline weight, BGLs,
cholesterol levels� Document BP
ANTIPSYCHOTICS –TREATMENT PLAN
� After commencing therapy:� Frequently review targeted behaviour
� Response expected within 1-2 weeks� Clinical improvement within 12 weeks1,2
� Monitor to ensure side effects are tolerated
1. Schneider LS, et al. Am J Geriatr Psychiatry 2006;14:191–210.2. National Prescribing Service 2007, PPR 37: Role of antipsychotics in
managing behavioural and psychological symptoms of dementia.
ANTIPSYCHOTICS -DOSES
� Australian Therapeutic Guidelines1
recommend this following:
1. Therapeutic Guidelines Limited. Therapeutic guidelines : psychotropic. 6, 2008. ed. West Melbourne, Vic.: Therapeutic Guidelines Limited; 2008.
Antipsychotic Dose
Risperidone 0.5-2mg/day (in one or two divided doses)
Olanzapine 2.5-10mg /day in one or two divided doses
Haloperidol 0.5mg at night up to 2mg twice daily
ANTIPSYCHOTICS - COST
� Risperidone requires authority prescription
� Olanzapine not TGA listed for use for BPSD� Approved for bipolar and schizophrenia
only� In the top 20 drugs for PBS expenditure
for last 2 years!11. Dept Health and Ageing: PBS statistics http://www.health.gov.au
ANTIPSYCHOTICS –TREATMENT PLAN
� Start with lowest dose� Preferable at night to reduce sedation
during the day1
� Slowly titrate dose every 2-3 days until symptoms controlled or maximum dose of range reached2
1. Rossi S ed 2010 Australian Medicines Handbook, AMH Ltd Pty Adelaide2. Therapeutic Guidelines Limited. Therapeutic guidelines : psychotropic. 6,
2008. ed. West Melbourne, Vic.: Therapeutic Guidelines Limited; 2008.
ANTIPSYCHOTICS –TREATMENT PLAN
� Use minimum effective dose� Although common, minimal evidence
to support PRN dosing1
1. Therapeutic Guidelines Limited. Therapeutic guidelines : psychotropic. 6, 2008. ed. West Melbourne, Vic.: Therapeutic Guidelines Limited; 2008.
ANTIPSYCHOTICS –TREATMENT PLAN
� Review use of antipsychotics every three months:� Discontinue antipsychotic if:
� If no change to targeted behaviour � BPSD stable (often temporary symptoms)
� Many studies show that patients discontinued on therapy show no worsening in BPSD1
1. Ballard CG, et al. J Clin Psychiatry 2004;65:114–9.
DISCONTINUING THERAPY
� Discontinuing therapy� Do not cease abruptly� Reduce dose by 50% ever two weeks� Stop after two weeks on minimum dose1
1. National Prescribing Service 2007, PPR 37: Role of antipsychotics in managing behavioural and psychological symptoms of dementia.
DEMENTIA WITH LEWY BODIES
� Accounts for approximately 10% of all dementias
� Increased risk of extrapyramidal side effects and neuroleptic malignant syndrome with typical antipsychotics haloperidol 1
1. Rossi S ed 2010 Australian Medicines Handbook, AMH Ltd Pty Adelaide
IDENTIFYING PROBLEMS IN YOUR FACILTIES
� Regular Psychotropic use audits � Commonly completed by RMMR service
provider
� Drug Usage Evaluation� National Prescribing Service published a
DUE for antipsychotic use for the management of behavioural and psychological symptoms of dementia
DRUG USAGE EVALUATION IN PRACTICE
� Putting DUE into practice� We recently completed the DUE at one of the
local 70 bed RACF� 40 patients were included� 30% patients were prescribed an antipsychotic for
BPSD, other indications were excluded� High levels of prescribing of medications known to
cause/exacerbate BPSD were found� Nil documentation of targeted behaviours� Minimal documentation of alternative non-drug
therapies
DRUG USAGE EVALUATION IN PRACTICE
� After identifying the problem,� The findings were presented to the
Medication Action Committee� Individual education sessions were
completed with nursing and medical staff utilising the NPS facilitator
DRUG USAGE EVALUATION IN PRACTICE
� Results� 50% reduction in the prescribing of
antipsychotics� Documentation of targeted behaviour
increased to 75%� Increased uptake of non-pharmacological
options and documentation
KEY MESSAGES
� BPSD is common in dementia� Review any causes
� Ask for a medication review
� First line treatment is non-drug options� Second line treatment: antipsychotics� Low doses are used� Significant side effect profiles for all
antipsychotics
KEY MESSAGES
� Benefit: Risk ratio must be assess for each patient
� Limited evidence to support efficacy� Regular review of BPSD and therapy
is required� BPSD often temporary� Discontinue therapy if no response after
12 weeks� Taper by 50% every two weeks
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