Behaviour Management in Dementia Where Do Antipsychotics Fit? October 2011 Reprinted February 2012 Guidelines/Reviews Background Issues What do we know about the benefits and Dementia Behavioural and psychological symptoms of risks of psychotropic meds in BPSD? 2006 CCCDTD3 : http://www.cccdtd.ca/ dementia (BPSD) create a significant caregiver o Evidence for psychotropic use is limited and Tx Mild‐Mod 2008: challenge. Key symptoms include aggression, all classes have limited efficacy and serious http://www.cmaj.ca/content/17 1 agitation, psychosis and mood disorders. adverse event (SAE) concerns. (See Table 3) 9/10/1019.full.pdf+html 5 Tx Severe Alzheimer’s 2008: For an overview see BPSD chart (Page 4). http://www.cmaj.ca/content/17 Table 1: Common BPSD Neuropsychiatric symptoms 2 9/12/1279.full.pdf+html agitation* resistive emotional Where do Antipsychotics (APs) Fit? NICE (UK) 2006: apathy wandering lability AP effectiveness in BPSD is modest & their role http://www.nice.org.uk/nicemedia aggression*, intrusiveness paranoid 11,12,13,14 6 /live/10998/30318/30318.pdf verbal/physical repetitive behaviours is limited due to SAEs. See CATIE-AD Trial Summary. APs, both typical (e.g. haloperidol) & atypical Other Reviews calling out, behaviours psychosis*, o (risperidone , olanzapine & Cognitive Impairment: screaming vocalizations hallucinations Risperdal Zyprexa http://www.rxfacts.org/professi hostility hoarding /delusions quetiapine Seroquel), have been studied in BPSD. onals/CognitiveImpairment.php sexual dis‐ nocturnal o Placebo response rates often ~40%, reflecting inhibition restlessness high rates of spontaneous resolution & the Pt/Caregiver Resources *symptoms with some evidence for benefit of antipsychotics 15 value of psychosocial input in such trials. First Link Program Alzheimer’s - http://alzheimer.ca/saskatchewan/ Approach to Managing BPSD [The more severe patients may respond better to APs.] - http://www.alzheimer.ca/english/soc 9 o Of these atypical agents risperidone has the iety/FirstLink.htm o Document the target symptom (e.g. DOS form ) o Assess for any triggering factors (See Table 2) most evidence for efficacy (aggression ≤1mg/day RxFiles Related 13,16 & psychosis ≤ ). 3 o Identify if symptom requires treatment (e.g. 2mg/day Anticholinergic Drug List Antipsychotic Chart4 is family/caregiver disturbed or in danger?) Serious Adverse Events (SAEs) for all APs. 5 13,17 BPSD Tx Chart o Use non‐pharmacological measures o SAEs with APs include stroke(OR: 1.3‐3.1) , CATIE‐AD Trial Summary6 whenever possible (See Table 4, next page.) seizures, EPS effects, ↑ falls, drowsiness, 7 Hypersexuality Tx Chart o Is pain a possible contributing factor? cognitive decline, pneumonia & death. Psychotropics Newsletter8 o Try regular acetaminophen; reassess at 1 wk o Death may be ↑ with atypical & conventional Highlights o If drug treatment required: APs in dementia based on RCTs (OR:1.2‐1.6; 13,18,19,20,21 1) Assess for medical o Tailor to the target symptom(s) AR ≥1% /12 wks; NNH=87/12wks). However causes (eg. Infection UTI, o Consider potential harms observational data is equivocal; some suggest 22,23,24 constipation, urinary o Start low, go slow; reassess in 3‐7 days for no increase in death for APs typical or atypical. retention, delirium). both beneficial and any adverse effects Stopping long‐term antipsychotics reduced 2) Look for drug causes o Try tapering the dose or stopping drug every (esp. recent med Δ’s, but mortality by ~25% at 2 years in long‐term follow‐ 3+ months [taper by 25% every 1‐2 weeks]. 25 also anticholinergic load) Some behaviours decline as disease worsens. up to the DART‐AD RCT. {n=165, age ~85; Alzheimer’s 3) Implement non‐drug tx {If treating acute delirium, stop upon resolution!} patients MMSE~11 on APs for ≥ 3months for BPSD; 2 arms: stop AP & switch to placebo vs AP use x12months; no significant difference in before initiating drugs if Table 2: Common Triggering Factors in BPSD survival at 12 months; survival at 2yrs: 71% vs 46%; NNT=4 /2yrs; patient/caregiver in no survival over 2‐4.5yrs: 54% vs 38%, NNT=8, CI: 5‐42} immediate harm. Psychosocial o BPSD outcomes: no statistical difference 4) Unrecognized pain? Try Distress Feeling Loss of except verbal fluency better in patients who oral acetaminophen Fear of danger abandoned autonomy stopped at 6 mos.26 There may have been (650mg q6h while awake, Misinterpretation Paranoia individual differences . or 1300mg LA am & hs). Environmental (e.g. in the more severe) 5) Only certain symptoms “Bad company” Excessive Lighting ‐ o Remember, if antipsychotic use is restricted, are likely to respond to Boredom demands inadequate alternative drugs could be just as harmful! antipsychotics: Confusing Change/lack Loneliness Table 3: Risks of Various Psychotropic Meds ‐ severe agitation surroundings of routine Noise ‐ aggression Medical Benzodiazepines: falls, fractures, confusion ‐ psychosis B12 /folic acid Hypo‐ Metabolic Carbamazepine: falls, many DIs & side effects 6) Reassess need for deficiency thyroidism Nocturia Antidepressants: ↓sodium, falls, osteoporosis 27 antipsychotics after ~ 3 Hunger/thirst Infection (UTI, Pain Opioids: delirium; constipation, fractures, ?CV months as behaviours Hypercalcemia pneumonia) Constipation Avoid the use of psychotropic meds for BPSD if stabilize (stopping ↓s Medications (e.g. rule out drug induced delirium) risk of adverse events) Anticholinergics 10 Cholinesterase Opioids at all possible. When needed, assess for 7) Caution with combo & Benzodiazepines inhibitors Substance abuse tolerability in ≤3‐7 days & reassess for possible PRN overuse of APs Digoxin …& many others taper and/or discontinuation every 3 months. Table 4: Select Non‐drug Treatment Tips Sleep Insomnia & Dementia Allow behaviours that are not problematic Sleep patterns naturally change as you get older. Older adults: ‐ Ok to wander within limits; delusions can be ok o Sleep fewer hours & take longer to fall asleep Institute a patient centered or relaxed schedule that allows o Sleep less deeply & wake up more often during the night flexibility for the preferential routines of each patient: o Have more trouble adjusting to changes in sleeping conditions, such as a new bed Öe.g. medication times, meals, bathing, sleep times, activities o Have changes in their sleep cycle Æ Older adults spend ÖAssess daytime naps: limit/avoid in most, but may be ok to less time in the most restful stage of sleep allow aggressive patient to sleep while others are awake Sleep disturbance in Alzheimer’s Disease (AD) is very common; ÖMake time for regular exercise to ↓ restlessness; refer to nocturnal sleep disturbance in AD patients is often accompanied by increased daytime napping, frequently in direct association daytime programs if available 7 ÖEncourage daily activities to minimize sun‐downing (eg. with the extent of dementia An after dinner walk may help in promoting nighttime sleep playing cards, gardening) In the later stages of AD, patients may spend ~40% of their time Make a positive environment that avoids triggering factors: in bed awake and a significant proportion of day‐time hours Öaromatherapy ♬ asleep. This ↑ day‐time sleep consists almost exclusively of Öplay music suitable to the individual stage 1 & 2 sleep; it does not replace or compensate for the night‐time loss of slow‐wave sleep (SWS) or REM sleep 6 Öreduce noise or number of persons in room 3 Öremove keys from view if no longer driving Cholinesterase inhibitors can cause insomnia (& nightmares) The presentations of abnormal nocturnal behavior in AD often Ö distract person with snack or activity exceed the limits of what might otherwise be termed insomnia Öif wandering, ensure house/room etc. is safe, put buzzers on in a nondemented geriatric population 7 doors, provide light, ↓ fall risk Behavioural intervention should be tried before pharmacological Öprovide clock & calendar if confused regarding time & date interventions whenever possible Öif inappropriate sexual behaviour, consider room placement Limit drug tx to short term/intermittent use whenever possible changes to minimize interactions of concern Agents sometimes used for insomnia, and their limitations34 Minimize unnecessary & problem drugs. Tools to review include the Beer’s list28, or the START / STOPP Criteria.29,30,31,32 Melatonin (1 – 3 – 5mg po HS) ⊗ [Look for product with NPN or DIN.] 35,36 ÖDifficulty swallowing can cause severe agitation. If drug Limited short‐term evidence (over 3‐8wks) for benefit. Trazodone DESYREL (12.5 – 25 – 50 – 100mg po HS) necessary, look for better formulations (e.g. dissolvable tablets) Limited evidence. Historically used for “sundowning”. Sedating without ÖAs disease advances toward the end of life, transition over anticholinergic effects. Minimal effect on sleep architecture. AEs include to comfort care, rather than curative/preventative hypotension, especially in those with interacting drugs or comorbidities. ÖReview meds with consideration for stopping statins, Mirtazapine REMERON (7.5 – 15 – 30mg po HS) vitamins, herbals, bisphosphonates Useful when antidepressant effect desired. AEs: weight gain, anticholinergic ÖReview BP & blood sugar goals; too low can lead to falls Zopiclone IMOVANE / RHOVANE (3.75 – 7.5mg po HS) ⊗ Similar in effect to benzodiazepines. Some consider safer, but evidence Only do lab work when necessary lacking. AEs include tolerance, dependence, bitter taste. Providing access to false teeth, hearing aids & glasses may Benzodiazepines (e.g. temazepam, lorazepam; clonazepam