dementia – managing behavioural and psychological symptoms dr. jonathan hare consultant old age...
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Dementia – managing behavioural and psychological symptoms
Dr. Jonathan Hare
Consultant Old Age Psychiatrist
Barnet, Enfield & Haringey Mental Health Trust
Dr Robert Tobiansky
Dementia
A syndrome due to disease of the brain usually of a chronic or progressive nature
Multiple disturbances of higher cortical function Global impairment: intellect, memory,
personality Changes in emotional control, social behaviour,
motivation In clear consciousness Decline in usual functional abilities
Dementia
Many causes but commonest are: Alzheimer’s Disease Vascular Dementia Lewy Body Dementia Alcohol related dementia Frontotemporal dementia
Dementia: general signs & symptoms
Early stages: memory impairment, loss of planning, judgement, difficulty with administrative tasks etc
intermediate impaired basic ADL can’t learn new information, increasing disorientation time & place
increased risk of falls and accidents due to confusion and poor judgment
Dementia: signs & symptoms
severe dementia: no ADL skills, totally dependent for feeding, toileting, & mobilising. Severe global cognitive impairment
risk of malnutrition and aspiration poor mobility & malnutrition increases risk of
pressure sores Seizures, dehydration, malnutrition,
aspiration, pressure sores death from infection (resp., skin, UTI etc)
Dementia: signs & symptoms
Behavioural problems (BPSD): Persecutory delusions, suspiciousness in c.
25% wandering, aggression, agitation Depressive symptoms in c. 60% Depression in c. 25%
Delirium: DSM 4 criteria Disturbance of consciousness with reduced
ability to focus, sustain or shift attention Change in cognitive function not due to pre-
existing or evolving dementia Development over short period of time –
usually hours or days & tendency to fluctuate during course of day
Delirium: causes Infection Drugs (prescribed & illicit, intoxication or
withdrawal) Organ failure (cardiac, resp., hepatic, renal) Electrolyte disturbance (dehyd. Na/Ca/K) Endocrine & metabolic – thyroid, glucose CNS- CVA, subdural, SOL Nutritional – thiamine deficiency Malignancy Hypothermia
Delirium: management Clarify history Assessment of physical & mental state Identify & treat underlying cause May need to treat neuropsychiatric
symptoms with modest doses of sedatives or antipsychotics
Well-lit, quiet room, address sensory impairment
Levels of evidence
1.Metanalysis2.Randomised placebo controlled trials3.Other studies4.Expert opinion,
National guidance, local protocols, expert opinion etc
BPSD
Behavioural and Psychological Symptoms in Dementia
BPSD symptoms include: Agitation Aggression Repetitive vocalisations Sexual disinhibition Wandering Shadowing Depression Anxiety Apathy Delusions Hallucinations Irritability Restlessness & overactivity
BPSD
Very common in people with dementia Almost all will have at least one symptom at
some point in illness Distress to patient & carers Associated with increased institutionalisation Faster rate of decline Increased mortality Increased stress for care staff
NICE guidance CG42
1.7.1.1 assess PWD who develop behaviour that challenges the person's physical health
‐ depression‐ possible undetected pain or discomfort‐ side effects of medication‐ individual biography, including religious, spiritual & cultural ‐ psychosocial factors‐ physical environmental factors‐ Individually tailored care plans, recorded & reviewed
regularly
1.7.1.2 Approaches that may be considered include:‐ aromatherapy‐ multisensory stimulation‐ therapeutic use of music and/or dancing‐ animal-assisted therapy.
Aetiology of BPSD (after Brodarty)
Biological
Psychosocial
Environmental
Biological potential causes
Frontal pathology – disinhibition, depression Basal ganglia lesions-delusions Temporal lobe pathology – delusions,
hallucinations Locus coeruleus – psychosis, depression Previous / current psychiatric disorder:
depression / anxiety / psychosis
Biological causes Acute medical illness eg UTI, RTI causing delirium Medication Pain syndromes Constipation Urinary retention Sensory impairment Basic needs – tiredness, hunger, thirst
Psychological causes
Previous psychiatric illness Premorbid personality- no meaningful
correlations Frustration fear Interpersonal / reaction of others
Environmental factors
Overstimulation Understimulation (boredom) Overcrowding Inconsistent care givers, high staff changes Provocation by others
“Something must be done”
Who’s problem is it? What is the behaviour? When does it occur? Where does it occur? Try to understand the behaviour, why is this
person presenting like this at this time? Intervene if behaviour results in distress or
risk to patient or others
Before intervening
Clarify the nature of the problem Document /keep ABC chart of behaviour Confirm most difficult challenging behaviour Are there triggers? Exclude non-dementia causes treat medical disorders & any causes of
disability (mobility, vision, hearing etc ) NB PAIN!
Environment Modify environment (nidotherapy) Adequate space Privacy available Personalised space Avoid over / under stimulation Lighting, colours, furnishing, architecture Size of unit Mix of residents staff
Possible Interventions Bright light therapy- weak evidence Aromatherapy (lemon balm, lavender)
moderate evidence, cochrane review Snoezelen:multisensory stimulation (modest
evidence) Music therapy Person centred / dementia care mapping My life package Cognitive stimulation therapy
Interpersonal Staff education, support & training Dementia care mapping Person centred care (Kitwood) individualised care
planning, fairly good evidence can reduce BPSD Psychoeducation for carers Behaviour management techniques
Therapeutic approaches Reminiscence groups Relaxation training Behavioural management techniques
Medication
Medication for Behavioural & Psychological Symptoms in Dementia (BPSD)
Medication: Antidementia drugs
-cholinesterase inhibitors: donepezil (Aricept) rivastigmine (exelon) galantamine (reminyl)
-Memantine (Ebixa)
Licenced drugs
Risperidone is the only licensed drug for the treatment of BPSD (aggression)
Antidementia drugs are licensed for treatment of cognition not behaviour in restricted severity groups• Cholinesterase inhibitors for mild to moderate AD • Rivastigmine for mild to moderate Parkinson’s
Disease Dementia• Memantine for moderate to severe AD
Other medication for BPSD
AntidepressantsAnxiolyticsHypnoticsAntipsychoticsAnticonvulsants
Cholinesterase inhibitors for BPSD
Systematic review & meta-analysis Statistically significant vs placebo Modest clinical benefit Biggest response on individual symptoms,
apathy, hallucinations,
Memantine for BPSD
Several RCTs vs placebo (eg Reisberg,et al; Tariot et al; Van Dyck et al; Gauthier et al)
Small effect aggression, agitation
Depression in dementia: Cochrane review
AntidepressantDose Study N Duration
Outcomes
Sertraline
25-150mg Lyketos et al 2003 44 12 wksPositive
Clomipramine
25-100mg Petracca et al 1996 21 6 wksPositive
Imipramine
50 -150mg Reifler et al 1989 61 8 wks n.s.
Antidepressants in dementia
Study of Antidepressants for Depression in Dementia (SADD) study: Banerjee et al Lancet 2011
Mirtazapine & sertraline vs placebo No significant benefits
CATIE-AD study Citalopram effects on BPSD Siddique et al 2009 Trend reduced irritability & apathy
Reduced hallucinations
Antidepressants in dementia: conclusion
Modest evidence efficacy May benefit agitation
Antipsychotics in dementia
RCT evidence: Haloperidol Risperidone Quetiapine Olanzapine Aripiprazole
CATIE-AD: 42 sites, 421 pts randomised to olanzapine, quetiapine, risperidone, placebo
Antipsychotics in dementia
Meta-analysis evidence: medium effect size Benefit for severe aggression, delusions
Antipsychotics in dementia
2-3 x increased risk cerebrovascular adverse events
1-2% increased risk death
Defensible prescribing of antipsychotics in Dementia
Consider non-pharmacological alternatives Address vascular risk factors Consent / capacity / best interests Discuss risks & benefits with patients or carers Identify target symptoms (psychosis, hostility,
aggression) Choose effective drug & dose Choose time-frame during which to assess benefits
(discontinue if no evidence benefit or if harm) review need & aim to withdraw in c 3/12 if possible
Doses of antipsychotics start range
Risperidone 0.25mg 0.5 to 2mg/day Olanzapine 2.5mg 2.5-10mg /day Quetiapine 25mg 25-100mg Aripiprazole 2mg 5-10mg
Anticonvulsants in dementia
Review of RCTs Weak to modest evidence carbamazepine
further trials needed Poor evidence / negative for valproate
mostly no significant difference Adverse events more frequent in treatment
groups
Benzodiazepines
RCTs: Benzos reduce agitation Adverse effects: falls, sedation, worsen cognition
Using medication in BPSD
Pharmacotherapy can be effective for BPSD First step: identify target symptoms Correct reversible factors Try environmental & psychological
approaches first unless high risk of harm to self / others
Use medication carefully, “start low go slow” Review treatment
Thank you