Tackling behaviour problems

Transcription

1 Tackling behaviour problems Behavioural and psychological symptoms of dementia (BPSD) lead to considerable distress, risks and reduced quality of life for patients, their carers and families, writes Dr Henry O Connell The ageing of populations in Ireland and worldwide means that the incidence and prevalence of age-related medical disorders is likely to rise exponentially in the coming years. Dementia is among the most devastating of such conditions, affecting approximately one-in-20 of those over age 65 and up to one-in-five of those over age 85. In Ireland, the number of people with dementia is expected to rise from the current number of approximately 40,000 to over 100,000 in the next 25 years. 1,2 Dementia involves wide-ranging and progressive cognitive, behavioural and psychological changes. In the absence of currently available curative or disease-modifying drugs, therapeutic targets involve improved quality of life, delayed institutionalisation and co-ordinated and comprehensive palliative care in the latter stages. Perhaps the most important and potentially modifiable therapeutic target involves the amelioration of the many behavioural and psychological symptoms of dementia (BPSD). Definition of BPSD BPSD is a general term used to describe a range of both behavioural and psychological symptoms, with a wide range of clinical severity. Features of BPSD are experienced by most people with dementia, to some degree, at some stage of their dementia. BPSD lead to considerable distress, risks and reduced quality of life for individual patients, their carers and families. BPSD often precipitate acute admission and long-term care, they are associated with more rapid cognitive decline and greater impairment in activities of daily living, reduced quality of life and greater cost of care. 3 Although BPSD is a broad umbrella term, without a clearly defined neuropathological basis in many cases, the term is useful in helping to focus clinical assessments of people with dementia and in planning therapeutic strategies. BPSD can be divided into the clearly behavioural features (eg. aggression and wandering) and the psychological (eg. depression and psychosis). BPSD can also relate to the type of underlying dementia (eg. visual hallucinations relatively more common in dementia with Lewy bodies). BPSD vary widely in terms of severity, from mild depressive symptoms through to severe psychotic symptoms with associated agitation and aggression. BPSD are seen in the home environment and 11

2 Table 1 General approach to assessment and management of BPSD Thorough history from patient, family and carers Define the nature, onset, duration and precipitants of BPSD Check dementia screen: bloods (full blood count, renal and liver function, fasting glucose, Vitamin B12 and Folate, thyroid function tests, lipids, CRP, ESR, syphilis serology), urinalysis and CT or MRI brain Assess cognition with eg. MMSE or MoCA Physical examination Rule out and manage reversible causes (pain, infection, constipation) Review all prescribed medications (especially those with psychotropic effects) Rule out and manage delirium Consider specialist referral, to old age psychiatry or geriatric medicine Devise individualised care-plan Consider environmental strategies and address sensory impairments (eg. hearing loss) Consider pre-morbid personality Define BPSD treatment targets, eg. relief of psychotic symptoms, safe containment of wandering Educate patients, families and carers Aim for prevention: optimise environment, prevent and treat infection, manage constipation and pain, use of acetylcholinesterase inhibitors and memantine Consider non-medication therapies: eg. bright light therapy, aromatherapy, massage Examine current evidence base for psychotropics (constantly changing) Consider use of rating scale (eg. Behave-AD) for baseline assessment and monitoring of response to treatment Consider acetylcholinesterase inhibitors or memantine as first-line or for prevention For other psychotropics: Define and focus on specific therapeutic targets, eg. sleep, depression, psychosis, aggression Consider risks and benefits of psychotropic use Discuss and document risks and benefits with patients, family and carers Use lowest therapeutic doses, slow titration and regular review with view to discontinuation as soon as possible. 12

3 all healthcare settings, such as the acute hospital, psychiatric inpatient units and long-term care facilities. BPSD: assessment Reflecting the pervasive nature of BPSD and the wide range of domiciliary and clinical settings in which patients with dementia reside, a wide range of individuals are involved in their assessment and management. These include family members, informal and formal carers, the GP and primary care team, community and inpatient nursing and care staff, geriatricians, old age psychiatrists and neurologists. The assessment, diagnosis and management of BPSD should be thorough and systematic, with an emphasis on a clear description of the background dementia, the particular symptomatology of the BPSD, and the possible causes, especially those that are potentially modifiable. A focused history should be taken from the patient, their carers and family members, in an effort to clearly define the BPSD in terms of onset, duration, character, possible precipitants and relieving factors and associated risks. It is also vital at the initial stages of assessment that the possibility of an acute delirium, either hyperactive or hypoactive, should be ruled out and managed. Obvious and treatable conditions such as infection, pain and constipation may exacerbate BPSD and should be identified and managed initially. Physical examination should be performed and, in combination with the history, should also aim to define potentially reversible causes of distress. Background dementia screening should be checked or performed if not already done, including routine dementia screen blood tests (full blood count, renal and liver function, fasting glucose, vitamin B12 and folate, thyroid function tests, lipids, CRP, ESR, syphilis serology), urinalysis and CT or MRI brain. An assessment of cognition should be performed, such as the Mini-Mental State Examination(MMSE) 4 or MoCA. 5 A formal assessment tool, eg. Behave-AD 6 may also be useful at baseline and to monitor response to treatment. Following this initial assessment, the BPSD should be clearly defined and documented and a care-plan should be devised, involving the patient, their carers and family members. BPSD features and associated care-plans will obviously vary widely, depending on the type and severity of the patient s dementia, the clinical context and the level of supports. For example, a person with dementia who has recently become depressed following admission to long-term care may benefit from simple measures such as reassurance and making their room more homely, while a frail older person with dementia who lives alone and has become paranoid and aggressive towards neighbours may need acute admission to a psychiatric ward for treatment. Treatments for specific aspects of BPSD The general assessment and treatment approach outlined in Table 1 should be used in all cases. Special emphasis should be placed on carer education and prevention strategies. When BPSD arise, then non-medication solutions should be exhausted before psychotropic medication is considered, especially in view of safety concerns with antipsychotics (see below). When BPSD symptoms are severe and disabling and have not responded to initial conservative management approaches, then referral should be made to specialist services such as old age psychiatry and geriatric medicine. Depression As with the assessment of depression in patients without dementia, assessment in dementia should involve a thorough history from the patient, if possible, and from family members and carers. The dementia screen should be checked for completion, with a particular emphasis on untreated medical disorders involved in the aetiology of depression, such as hypothyroidism. Milder episodes of depression may respond to simple reassurance and environmental changes, 13

4 such as increasing social supports and contacts. Where these measures are unsuccessful, antidepressant treatment may be indicated. Options include the selective serotonin reuptake inhibitors (SSRIs), serotonin noradrenaline reuptake inhibitors (SNRIs) or mirtazapine, along with low dose antipsychotics when there are comorbid psychotic symptoms. Tricyclic antidepressants (TCADs) should generally be avoided in view of their side-effect profile and potential to worsen cognitive impairment due to anticholinergic effects. Anxiety As with depression, a thorough history, collateral history and physical examination should be performed, along with a check on the dementia screen. There is no formal evidence base on the treatment of anxiety in dementia and the clinical emphasis should be on avoiding inappropriate or multiple prescribing. In severe cases, the patient may benefit from treatment with SSRIs, SNRIs or mirtazapine and/or a short course of low dose short-acting benzodiazepine treatment such as lorazepam, although this should be reserved for inpatients or patients in a long-term care setting. Longer-acting benzodiazepines used as anxiolytics or hypnotics (eg. flurazepam) are problematic in view of hangover effects, increased risk of falls and worsening of cognitive impairment. Wandering The assessment of wandering should also proceed along the lines of taking a history and collateral history, performing physical examination and checking the dementia screen. Wandering may not in itself be associated with distress or risk and is not treatable with any specific psychotropic medication. Therefore, the emphasis should be on environmental changes and safe containment if possible. For example, in the long-term care setting a wandering loop may be set up whereby the patient may safely wander around the ward without risk to themselves or others. Wandering in the home setting may be more risky and, unless close supervision and safety changes to the home environment can be made, admission to a longterm care facility may be required. Psychosis Following the assessment as described in Table 1, the phenomenology of the psychotic symptoms should be clearly defined, along with their associated levels of distress and risk. Delirium should be ruled out and managed. Where psychotic symptoms are severe, distressing and/or associated with risk, then anti-psychotic treatment should be considered. The patient s dementia type and other clinical characteristics should be taken into account in prescribing anti-psychotics. For example, patients with dementia with Lewy bodies are likely to be far more sensitive to the extra-pyramidal side-effects of antipsychotics. There is now a compelling evidence base linking the use of antipsychotics in dementia with increased risk of stroke and premature mortality (see below). Therefore, antipsychotics should be used in dementia only when environmental measures have failed and when there is significant distress and/or risk. Atypical antipsychotics are preferred over typicals, because of the lower risk of extrapyramidal side-effects. When prescribed, antipsychotics should be used at the lowest possible dose, for a defined period of time (eg. no more than six weeks) and then reviewed and discontinued if possible. Risperidone at low dose (up to 2mg per day) is the current antipsychotic treatment of choice in dementia. See also separate section on use of antipsychotics in dementia. Aggression As with the previous BPSD features, the assessment of aggression should be approached in a thorough and systematic fashion, with an emphasis on environmental and non-medication solutions if possible. An ABC approach to the aggression may be useful, examining the antecedents to the behaviour itself, the actual aggressive behaviour and the consequences. Taking this systematic approach may yield simple and safe 14

5 treatment solutions. For example, a patient with dementia and hearing impairment in a long-term care setting may become frightened and hit out when approached from behind and surprised by care staff. When environmental measures fail and there are significant associated risks and distress, then low dose atypical antipsychotic treatment in the form of risperidone may be used in the shortterm and discontinued as soon as possible. See also section on antipsychotics in dementia. Sleep disturbance As with other BPSD, follow the systematic assessment outlined in Table 1. Good sleep hygiene measures should be instituted, such as a regular bed-time and rising time, some exercise during the day and the avoidance of stimulants such as caffeine in the evening. The sleeping environment should be optimised in terms of lighting, temperature and the potential for noise and interruptions. Should all of these measures prove unsuccessful, then a non-benzodiazepine hypnotic may be used, with regular review and a view to discontinuation in a matter of weeks. Disinhibited behaviour Disinhibited behaviour, either social or sexual, may occur in all forms of dementia. Certain variants of frontotemporal dementia are especially associated with disinhibition. Unfortunately, there are no psychotropic drug options available and the emphasis is on outruling reversible causes and safe containment of the behaviour. Antipsychotics in dementia Evidence has emerged over the past decade linking the use of antipsychotics in dementia with an increased risk of cerebrovascular adverse events and mortality. 7 Other major adverse outcomes associated with antipsychotic use in dementia include Parkinsonism, sedation, gait disturbance, increased respiratory infections, oedema, accelerated cognitive decline and other thromboembolic events. Because of these findings and subsequent recommendations from different groups 8,9 extreme caution is advised in the use of antipsychotics in dementia. In severe cases of BPSD where an antipsychotic is the only treatment option remaining, and following a thorough review of the clinical situation as outlined in Table 1, the current guidance is to use low dose risperidone (up to 1-2mg per day) and review and aim to discontinue treatment after six weeks. 9 n Henry O Connell is a consultant psychiatrist, Psychiatry of Later Life, Laois- Offaly Mental Health Services, An Triú Aois Day Hospital, Portlaoise and adjunct senior clinical lecturer at the Graduate Entry Medical School, University of Limerick References 1. O Connell H. Dementia care in Ireland: What s the plan? Irish Journal of Psychological Medicine O Shea E (2007). Implementing Policy for Dementia Care in Ireland. The Time for Action is Now. The Alzheimer Society of Ireland 3. Hersch EC and Falzgraf S. Management of the behavioural and psychological symptoms of dementia. Clinical Interventions in Aging 2007:2(4) Folstein MF, Folstein SE, McHugh PR. Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3): Nasreddine ZS, Phillips NA, Bedirian V, et al. The Mntreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4): Reisberg B, Borenstein J, Salob SP, et al. (1987) Behavioural symptoms in Alzheimer s disease: phenomenology and treatment. Journal of Clinical Psychiatry, 48 (suppl.), Ballard C, Waite J, Birks J. Atypical antipsychotics for aggression and psychosis in Alzheimer s disease. Cochrane Dementia and Cognitive Improvement Group Salzman C, Jeste DV, Meyer RE et al. Elderly patients with dementia-related symptoms of severe agitation and aggression: consensus statement on treatment options, clinical trials methodology, and policy. J Clin Psychiatry 2008;69(6): Ballard C, Burns A, Corbett A. Best Practice Guide: Optimising treatment and care for people with behavioural and psychological symptoms of dementia: A best practice guide for health and social care professionals. Alzheimer s Society (UK)