BPSD THE AGITATED ELDERLY

Transcription

1 BPSD THE AGITATED ELDERLY GP Update August 2011 Dr. Carla Freeman Senior registrar Division of Neuropsychiatry Department of Psychiatry and Mental Health, University of Cape Town

2 2002: POPULATION >65YRS

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4 BPSD OVERVIEW Occurs in 70-90% of dementia Symptoms differ depending on stage of dementia Aetiology: biological, psychological, environmental and social Decreased QOL and increased caregiver burden/distress leading to premature residential placement Good evidence supporting a number of non-pharmacological and pharmacological interventions

5 DEFINITION Behavioural Screaming Restlessness Wandering Physical aggression Agitation, apathy Disinhibition (e.g. sexual, culturally inappropriate) Sleep and appetite changes Hoarding, shadowing etc Psychological Mood disturbance: depression, irritability Anxiety esp. anticipatory Hallucinations Delusions

6 MANAGEMENT K E Y P R I N C I P L E S : 1. Differential diagnosis: Is this dementia? The 3D s

7 MANAGEMENT K E Y P R I N C I P L E S : 1. Is this dementia? 2. Consider contributing factors or triggers: Unrecognized or suboptimal management of pain 1 Physical health e.g. dehydration, glycemic control Side effects of medication e.g. constipation (amitriptyline), psychiatric complaints (corticosteroids), confusion(anticonvulsants, lithium, ciprofloxacin, cimetidine) Psychosocial and environmental changes Depression Relationships with carers, care-workers and family members Hearing or vision problems 1 BMJ 2011 ;343:d

8 MANAGEMENT K E Y P R I N C I P L E S 1. Is this dementia? 2. Consider contributing factors or triggers 3. Identify target problems: Allows to plan/formulate the best treatment approach Family: 24hr behaviour chart Monitoring of behaviour following treatment Rating scales to assist with management strategy Clear documentation in notes = essential

9 MANAGEMENT K E Y P R I N C I P L E S 1. Is this dementia? 2. Consider contributing factors or triggers 3. Identify target problems 4. Formulate the problem Develop an understanding of the target symptoms, their duration, possible underlying cause and treatment strategy. Communicate this to both the caregiver and the patient

10 MANAGEMENT OF BPSD

11 NON-PHARMACOLOGICAL INTERVENTIONS Considered first-line Empowers family Needs to be monitored and evaluated Fine balance between activity and over-stimulation

12 NON-PHARMACOLOGICAL MANAGEMENT Rigorous routine Environmental strategies Nursing care interventions Social contact Psychological therapies Avoid punishment!

13 PHARMACOLOGICAL MX Principles of prescribing: Full discussion with patient and care-giver about possible risks and benefits Undertake an individual risk-benefit analysis Start low, go slow Exclude exacerbating medical illness at each stage of treatment Fluctuating nature of BPSD attempt to withdraw meds if possible at appropriate time e.g. sedatives Withdraw drugs with poor response before instating a new drug (one at a time!) Remember drug interactions Record changes in symptoms and cognition regularly

14 AGITATION Definition: mixed-big mental disturbances or perturbation showing itself usually by physical excitement (Oxford University Press 2004) excessive motor activity associated with a feeling of inner tension (DSM IV) Inappropriate verbal, vocal, or motor activity that is not explained by needs or confusion per se. It includes behaviours such as aimless wandering, pacing, cursing, screaming, biting and fighting (Cohen- Mansfield 1986)

15 MANY FORMS OF AGITATION Physically non-aggressive General Restlessness Repetitive Mannerisms Pacing Hiding Objects Inappropriate Handling Shadowing Escaping protected environment Inappropriate Dressing/Undressing Verbally non-aggressive: chanting, constant interruptions and requests for attention Physically aggressive Hitting Pushing Scratching Grabbing Kicking Biting Spitting Verbally aggressive: screaming, swearing etc.

16 RULE NUMBER 3 S Y N D R O M E S F I R S T, S Y M P T O M S S E C O N D (courtesy of Dr John Joska) For Alzheimer s disease, use anti-dementia drugs before anti-psychotics For depression, use anti-depressants before antipsychotics For everything else, use other drugs before benzodiazepines

17 C O G N I T I V E E N H A N C E R S Cholinesterase inhibitors: Donepezil (Aricept/Ariknow ) 5-10mg nocte Rivastigmine (Exelon ) 3-6mg twice daily Galantamine (Reminyl ) 8-12mg twice daily Equal efficacy, tolerability may differ Mild to moderate DAT some use in severe and vascular dementia Shown to improve cognition, behaviour, functioning and delay placement 1/3 improve, 1/3 remain stable and 1/3 deteriorate

18 COGNITIVE ENHANCERS (2) NMDA receptor antagonists Memantine (Ebixa ) 5-20mg daily in divided doses Severe DAT, consider for vascular dementia Safe to use with Donepezil Monitor adverse effects Long term effect is unknown

19 AGITATION TREATMENT CONT. Antidepressants Antipsychotics Later Anticonvulsants Prominent mood features (previous BPMD/affective instability) ictal like outbursts Agitation unresponsive to other treatment Valproate 20mg/kg range mg/day divided doses High side effect profile (hair loss, weight gain, GIT, plts, osteoporosis?) Carbamazepine fallen out of favour, may be useful if other drugs are contraindicated) Lamotrigine increasing evidenc

20 DEPRESSION Common DAT: 0-20% have full syndrome, up to 50% have depressive symptoms Significantly impairs QOL, increases care-giver burden Increases mortality Features include: anhedonia, rejection sensitivity, self-pity and psychomotor disturbances Symptoms often fluctuate Commonly recurs

21 DEPRESSION: TREATMENT Avoid TCAs SSRIs are useful beware agitation Treatment response = longer Suggested regimens: Citalopram 10-20mg Mirtazapine 15-30mg Mianserin 30mg Venlafaxine 37.5mg (hypertension) Agomelatine??

22 ANXIETY Common: GAD, Godot syndrome, fear of being left alone, pacing, wringing hands. Avoid use of long term benzodiazepines dependence, cognitive deficits, falls Look for co-morbid depression treat with antidepressants Rational use of benzodiazepines if absolutely necessary

23 PSYCHOSIS Definition: Criteria for dementia are met + hallucinations or delusions or both Present intermittently for longer than one month and interfere with function. NB chronology Not due to another psychiatric illness or part of a delirium syndrome Bizarre or complex delusions are rare, misidentification syndromes are common Exclude epilepsy, intra cerebral pathology.

24 PSYCHOSIS: TREATMENT Antipsychotics are indicated for psychosis and severe agitation High side effect profile: First generation: EPSEs Second generation: Metabolic side effects Both: Risk of CVA Risk-benefit assessment and informed consent Risperidone 0.5mg bd, Quetiapine 25mg at night Not recommended for longer than 3 months, reassess regularly!

25 SLEEP DISTURBANCE Common: day-night reversal Non-pharmacological = NB: Keep awake during day Limit naps Sleep requirement decreases with age Stimulus control at night White noise Assist carer relief nights Pharmacological: Sedating antidepressants, anti-histamines, non-benzodiazepine hypnotics, melatonin.

26 ADDITIONAL PROBLEMATIC BEHAVIOURS Sexual disinhibition Cyproterone acetate (Androcur ) Substance dependence: Alcohol OTC analgesia Benzodiazepines Consider detox/withdrawal inpatient/outpatient rehab

27 WHEN TO REFER: Valkenberg Geriatric clinic: Memory Clinic: >60 years Graduates from adult psychiatry Unmanageable BPSD Fax: VBH OPD Att. Dr. Joska (021) Diagnostic dilemmas Unusual presentation/symptoms Full MDT evaluation Fax referral to Sonja Hendrix at IAA forms on internet

28 REFERENCES 1. Husebo BH, Ballard Clive et al. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomized control trial. BMJ 2011; 343:d Chen Y, Briesacher BA, Field TS et al. Unexplained variation across US nursing homes in antipsychotic prescribing rates. Arch Intern Med 2010; 170: Devanand DP, Schulz SK. Consequences of antipsychotic medications for the dementia patient. Am J Psychiatry 2011; 168: Howland RH. A benefit risk assessment of agomelatine in the treatment of major depression. Drug Saf 2011; 34(9): Australian Guidelines for BPSD Alzheimer Europe: Treatment for behavioural and psychological symptoms of dementia 2011

29 T HANK YOU! QUESTIONS?