Presentation on theme: "Behavioral and Psychological Symptoms of Dementia (BPSD)"— Presentation transcript:
1Behavioral and Psychological Symptoms of Dementia (BPSD) Leon Kraybill MD CMDLancaster General Hospital Geriatric FellowshipFebruary 4, 2009
2“Agitated” behavior What is the challenging behavior? Whose problem is it?Is it just not doing what “we” want “them” to do?
3Behavioral and Psychological Symptoms of Dementia (BPSD) A heterogeneous range of psychological reactions, psychiatric symptoms, and behaviors occurring in people with dementia of any etiology.Any verbal, vocal, or motor activities not judged to be clearly related to the needs of the individual or the requirements of the situationAn observable phenomena (not just internal)
4Objectives Identify the range of behaviors in dementia Discuss possible causes of these behaviorsReview types of nonpharmacological responsesReview medications used for emotional relief
5Prevalence of BPSD Present in all types of dementia 80-90% of patients develop at least 1 distressing symptom during the course of their dementia60% of community dwelling patients with dementia80% of dementia patients in nursing homes
6BPSD – distressing for all Individual – distress is key to tx decisionsFamily - noncognitive symptoms are most distressing, could cope with a 'memory' disorder. Unpredictable violence or aggression = desperationLTC staff need to understand and have tools for response
7Consequences of BPSD Caregiver stress Increased ER visits Prolonged hospital staysIncreased use of medicationsPlacement in LTCIncreased financial costs**Decreased quality of life for patient and caregiver**
8The “unmet needs” model (Cohen-Mansfield) There is an underlying unmet need that is causing the inappropriate behavior.This need is frequently not apparent to the observer or the caregiver,or else caregivers do not feel able to fulfill this need (example -sensory deprivation, boredom, and loneliness)Ideally can identify and prevent the resident from reaching the point of unmet needPossible responses:Providing sensory stimulation, activities, and social contacts -The provision of hearing aids may decrease isolation due to sensory deprivationEasily accessible outdoor areaReduced levels of restraintsSufficient levels of lightGood toileting procedures, betterProper treatment of pain
9Learning/behavioral models (Cohen-Mansfield) Behavior is a learned connection between antecedents, behavior, reinforcementMany problem behaviors are learned through reinforcement by staff members, who provide attention when problem behavior is displayed.ABC approachA = antecedent or triggering event that precedes the problem behaviorB= the behavior of concernC= the consequence of that behaviorChanging either the antecedent or the consequence may change the behavior
10Learning/behavioral models (Cohen-Mansfield) Identify precisely the problem. The more clearly it is defined, the easier it is implement an effective responseGather information about the circumstances surrounding the problem immediately before and after. There may be several triggersSet realistic goals, and make plans to achieve them. Seek to be creative, realistic and tailored to the individual and caregivers. "Increasing pleasant activity" is more realistic than "be happy all the time.“Encourage rewards (to all) for small successes. Changing behavior is hard work for everyone.Continually evaluate and modify plans. Consistency but flexibility. Strategies may need to change.
11Environmental vulnerability/reduced stress-threshold model (Cohen-Mansfield) The dementia process results in greater vulnerability to surroundings and a greater chance that an event will affect behavior.Persons with dementia progressively lose their coping abilities and therefore perceive their environment as more and more stressful.Concurrently, their likelihood of being bothered by the environment increases, resulting in anxiety and inappropriate behavior when the environmental stimuli exceed the threshold for tolerating the stressAn environment of reduced stimulation is supposed to limit the stress experienced and thereby reduce the level of inappropriate behaviorRelaxation will reduce the stress and thereby decrease the undesirable behavior.
12TerminologyAgitation – abnormal behavior (ie aggression, restlessness, etc.)Psychosis – abnormal perceptions/beliefs that may lead to agitated behavior (ie paranoid delusions)Dementia treatment principle: agitation generally responds better than psychosis
13Range of behavior Psychosis (delusions or hallucinations) Agitation/aggressionApathy/indifferenceDepression/dysphoriaAnxietyElation/euphoriaDisinhibitionIrritability/labilityAberrant motor behaviorInsomniaAppetite disruptionFrom Neuropsychiatric Inventory (NPI) rating scale (Cummings et al. 1994)
14Subtypes of BPSD (Cohen-Mansfield) see handout Physically aggressive behaviors (hitting, kicking, biting)Physically nonaggressive behavior (pacing, inappropriate touching)Verbally nonaggressive agitation (repetitive phrases or requests, calling out)Verbally aggressive behaviors (cursing, screaming)
15BPSD vs other causesAcute/evolving/sudden is often med related or other medical diseaseProgression of underlying dementia – generally more insidious and persistant
16EvaluationObtain a clear description of problem behavior, temporal onset, course, circumstancesAssess ability to express basic needs (hunger, thirst, fatigue)Look for delirium – acute/rapid change (dehydration, UTI, pneumonia, angina, constipation, pain, uncontrolled DM)Look for mood disturbance (sadness, irritability, withdraw)Check med changes – always suspect the medsAsk about environmental precipitants: change in routine, roommate, caregiver, overstimulation/understimulation, other disruptive patients, family illness
17Framework for treating agitation: Important to adopt a pragmatic approach to treatmentMost situations allow for an initial non-pharmacological approach to management“Four D” MethodDefine and DescribeDecodeDesign and ImplementDetermine
18Principles of restorative care Focus on bigger picture of health and emotional wellbeing, rather than just “problem behavior”Capitalize on the individual’s remaining abilities and strengthsCreate an enabling and motivating environmentProvide appropriate tasks and assistance (ie activities that will be successful)Practice and repetition are needed (repetition is the mother of learning)
19Staff Techniques Communicate face to face, speak slowly & clearly Use verbal cluesApproach slowly and deliberately (don’t surprise)Serve as a “calming force”Humor and laughterKnow what makes the resident tickAct as if they function at a higher level of cognitionSensory experience: music, dance, visual contrast, fragrances, foods, tactile stimulationDistraction, redirectionFlexibility, “go with the resident’s pace”Anticipate challenges and difficulties – they are the norm
20Behavioral interventions Tx underlying medical illnessCorrect sensory deficitsRemove offending medicationsKeep environment comfortable, calm, homelikeRegular daily activities and structureAssess sleep and eating patternsEducate and support caregiver
21Nonpharmacologic interventions See handout - Specific situations of agitation
22Medication for BPSDCurrently there are no FDA approved treatments for agitation and psychosis in dementia
23FDA Blackbox on antipsychotics WARNING: INCREASED MORTALITY FOR ELDERLY PATIENTS WITH DEMENTIA RELATED PSYCHOSES. Elderly patients with dementia related psychoses are at increased risk for death compared to placebo. This drug is not approved for the treatment of dementia related psychoses.
24FDA Blackbox warningMeta-analysis of 17 double blind RCT’s in elderly dementia patients, April Atypicals associated with a times greater risk of mortality compared to placebo. Most deaths from cardiac or infectious etiology, in some studies – strokes.Extended to all antipsychotics in June 2008
25Common side-effects of antipsychotics Extrapyramidal symptoms (akathisia, dystonia, psuedoparkinsonism, and dyskinesia)SedationTardive dyskinesia – should screen regularlyDyskinesia Identification System: Condensed User Scale (DISCUS)Abnormal Involuntary Movement Scale (AIMS)Gait disturbancesFallsMeta-analysis shows a significant increase in respiratory tract and urinary tract infections and peripheral edema in patients treated with risperidone versus placebo (Ballard et al. 2006)
26StudyOlder adults with dementia: 20,682 in community, 20,559 in LTCControl: No antipsychoticsOutcomes: serious events in first 30 daysCommunity dwellers:Atypicals: 13.9% had a serious event (3.2 times higher than control)Typicals: 3.8 times higher serious eventLTCAtypicals: 1.9 times higher serious events than controlTypicals: 2.4 times higher serious eventRochon PA. Antipsychotic therapy and short-term serious events in older adults with dementia. Arch Intern Med. 2008;168:
27CATIE-AD TrialFirst cost-benefit analysis of second generation antipsychotics in treating non-cognitive symptoms in AD patients421 AD patients with psychosis and aggression where randomly assigned to olanzapine, quetiapine, risperidone, or placebo of “watchful waiting” over 9 monthsNo statistical differences between groups, although placebo most often superior in net health benefit analysisOlanzapine group – more impaired on ADL testing- ???sedation, gait disturbancePlacebo group – best ADL score, lower dependence score, lower total health care costs - $50-100Several methodological drawbacks:Subjects were outpatients, less impaired then some BPSD trialsHigh dropout rate compared to other RCTs (likely a design feature)No washout periodDosage likely too low for quetiapine (mean 56.5mg/day)Authors concluded adverse events offset advantages in efficacyClinical Antipsychotic Trial of Intervention Effectiveness – Alzheimer’s Disease. Rosenheck, Cost-benefit analysis…., Arch Gen. Psychiatry 2007; 64(11):
28Antipsychotics in LTCOnly 2 RCTs have examined antipsychotics in AD over 6 monthsBallard et al (2005) found no difference between quetiapine, rivastigmine, or placebo in agitation over 6 months
29Atypicals vs typicalsAtypicals block excessive dopamine transmission, which is beneficial in schizophrenics.Elderly patients (especially dementia) have accelerated dopamine loss and tend to experience more severe motor side effects than younger patients.Less likely to trigger extrapyramidal symptoms/tardive dyskinesiaNo difference in safety, efficacy
30Atypical dosesOlanzapine 5-10 mg/day and Risperidone 1mg/day appear to have low incidence of EPS, but somnolence remains a concernSee handout
31Recommendations Look for etiology of symptoms Use caution in these fragile and vulnerable patientsNeed shared decision making – staff, families, patientsIdentify target signs and symptoms, and set a limited time frame (many patients improve without treatment over 2-4 weeks)Treat only severe symptoms, emotional distress, physical safetyUse the lowest dosages for shortest timePossible doses used:Risperidone (Risperdal) mg/dayOlanzapine (Zyprexa) 5-10 mg/dayQuetiapine (Seroquel) mg/dayAripiprazole (Abilify) 7-12 mg/dayMonitor, assess regularlyTaper and trial discontinuation regularlyWhite paper of American College of Neuropsychopharmacology – reviewed July 18, 2007 in Neuropsychopharmacology
32Documentation Target behavior, duration and circumstances Emotional and physical consequences of the behaviorNonpharmacological interventionsTeam discussions and interventionsDiscussions with resident/POA/family regarding the circumstances, the risk of medication (death), and consent for treatmentCan someone else read your documentation and be able to explain what happened and why the treatments were chosen?
33Serotonergic agents (2005) Well toleratedBeneficial for depressionNot clearly effective in tx of other sxPharmacological treatment of Neuropsychiatric symptoms of dementia: A review of the evidence. JAMA 2005;293(5);
34Citalopram vs risperidone study (2007) To alleviate severe agitation and psychotic symptoms associated with dementia in nondepressed elderly (aggression, agitation, hostility, suspiciousness, hallucinations, or delusions)Efficacy:Citalopram overall 32% reduction of symptomsRisperidone - 35% reductionTotal adverse-event scoresIncreased 19% with risperidoneDecreased by 4% with citalopramCitalopram worked on psychotic symptoms like hallucinations and delusions!Suggests agitation and psychosis in younger and older populations have different neurochemistry.A double-blind comparison of citalopram and risperidone for the treatment of behavioral and psychotic symptoms associated with dementia. Am J Geriatr Psychiatry Nov;15(11): Epub 2007 Sep 10. (53 patients were randomized to citalopram and 50 to risperidone)
35Haldol for agitation in dementia (2005 Cochrane review) No significant improvement in agitation, compared with controlsAggression decreased (not other aspects of agitation)Dosages mg/dayRecommendationsHaloperidol was useful in reducing aggression, but was associated with adverse effectsNo evidence to support the routine use of this drug for other manifestations of agitation in dementiaHaloperidol should not be used routinely to treat patients with agitated dementia
36Trazodone for agitation in dementia (2004 Cochrane review) Rationale: BPSD may be due to serotonergic dysfunctionA sedating atypical serotonergic antidepressant with a lower rate of adverse effects may helpLimited data from two small studiesConclusions: Insufficient evidence to recommend the use of trazodone
37Valproate preparations for BPSD (2004 Cochrane review) No evidence of efficacy of valproate preparations for treatment of BPSDAdverse reactionsSedation occurred more frequently than in controlsUrinary tract infection was more than in controlsLow dose with valproate preparations is ineffective in treating BPSDHigh dose therapy is associated with an unacceptable rate of adverse effects
38Cholinesterase inhibitors Initial studies focused on cognition, yet there is increasing evidence of a possible behavioral benefit as wellMeta-analysis of ChEI studies - Modest but significant behavioral benefit compared with placebo Trinh et al. (2005)Several post-hoc analyses of studies with galantamine and donepezil suggest beneficial effects on psychosis, agitation, mood, apathy, and aberrant motor behaviors(Mega et al. 1999; Herrmann et al. 2005; Cummings et al. 2006)
39Cholinesterase inhibitors Data review suggest a statistically significant differenceBut magnitude of effect is small, and of questionable clinical significance
40Memantine3 studies have examined the effect of memantine on BPSD in moderate-severe ADPost-hoc analysis suggests benefits, particularly for aggressive, agitated behaviors (Gauthier S et al 2005; Cummings et al. 2006)Memantine also appears to delay emergence of agitation and reduce caregiver distress (Cummings et al 2006)Other reviewers question the clinical significance of the benefit
41Carbamazepine The Good News: 4 RCTs demonstrate benefit for aggression and agitation (Tariot el al. 1994; Cooney et al. 1996; Tariot et al. 1998; Olin et al. 2001)Tariot et al. (1998) completed a nursing home study where 72% of patients improved versus only 21% placeboOne of the largest effect sizes of all BPSD trialsThe Bad News: Concerns about tolerability in elderly, drug-drug interactions, and adverse events unfortunately limit its use
42Benzodiazepines Several studies support efficacy Main concern is high rate of adverse events in the elderlyExcessive sedation, falls, cognitive impairment, paradoxical agitationGuidelines support only short-term as-needed use
43What if we stop meds?3 placebo controlled withdrawal studies indicated no worsening of behavior when long-term administration of neuroleptics were stopped(Cohen-Mansfield et al. 1999; Bridge-Parlet. 1997; Ballard et al. 2004)
44Sexually inappropriate behaviors Likely more due to disinhibition, than hypersexualityOccurs in 7-25% of significantly impaired olderSSRIAntiandrogenProgesterone 5 mg po daily (10 mg IM weekly)Leuprolide 5-10 mg IM monthly
45Parkinsonian motor disturbances & meds Dementia with Lewy bodies (DLB), Parkinson disease (PD) and up to 50% of Alzheimer disease (AD)Neuroleptic antipsychotics are dopamine receptor antagonistSevere motor deterioration (neuroleptic sensitivity)Small trial (9 subjects) Quetiapine ( daily, mean 120) vs placeboNo difference in cognitive or behavioral scoresAdverse reactions – similar, except ↑ dizziness in quetiapineQuetiapine for agitation or psychosis in patients with dementia and parkinsonism. Neurology - Volume 68, Issue 17 (April 2007)Quetiapine - dosages of 200 mg/day or higher may be needed to control agitation in demented patientsZhong K, Tariot PN, Mintzer J, et al. Quetiapine for the treatment of agitation in elderly institutionalized patients with dementia: a randomized, double-blind trial. Presented at the American College of Neuropsychopharmacology Annual Meeting; December 12–16, 2004; San Juan, Puerto Rico.
46Manic-like syndromesSx: pressured speech, disinhibition, elevated mood, intrusiveness, hyperactivity, reduced sleepLikely secondary to the dementiaCoexist with confusional stateIrritable/hostile > euphoriaConsider divalproex 125 BID
47Apathy or depression?Often confused with depression, since symptoms overlap (diminished interest, hypersomnia, fatigue, lack of insight, psychomotor retardation)Apathy traits: emotional indifference, denying feelings of depression, reduced ability to initiate in multiple domains (cognitive, motor, gait)Meds to increase dopaminergic transmission: Bupriopion, amantadine, psychostimulants (Ritalin,etc), rivastigmine (Exelon), donepezil (Aricept). SSRIs may help but produce agitation.
48What don’t meds help?Meds don’t help general agitation – especially wandering
50F-tag 329The facility must assure that residents who are undergoing antipsychotic drug therapy receive adequate monitoring for significant side effects of such therapy with emphasis on the following:Tardive dyskinesia;Postural (orthostatic) hypotension;Cognitive/behavior impairment;AkathisiaParkinsonism.
51F-tag 329 (12/06 update)During the first year in which a resident is admitted on a psychopharmacological medication (other than an antipsychotic or a sedative/hypnotic), or after the facility has initiated such medication, the facility should attempt to taper the medication during at least two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a tapering should be attempted annually, unless clinically contraindicated. The tapering may be considered clinically contraindicated, if:The continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder; orThe resident’s target symptoms returned or worsened after the most recent attempt at tapering the dose within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder.
52Summary for gradual dose reduction (GDR) – F-tag 329 Within 1st year after admission on antipsychotic or after initiation: GDR in 2 separate quarters, with at least one month between attemptsAfter 1st year - GDR annually