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Rethinking Behavioral Problems Associated with Dementia Joel E. Streim, M.D. Professor of Psychiatry University of Pennsylvania Philadelphia VA Medical.

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Presentation on theme: "Rethinking Behavioral Problems Associated with Dementia Joel E. Streim, M.D. Professor of Psychiatry University of Pennsylvania Philadelphia VA Medical."— Presentation transcript:

1 Rethinking Behavioral Problems Associated with Dementia Joel E. Streim, M.D. Professor of Psychiatry University of Pennsylvania Philadelphia VA Medical Center Pennsylvania Medical Directors Association

2 Overview (of an evolving landscape) How will the new MDS 3.0 change assessment of behavioral symptoms of dementia? How can we identify more effective interventions based on an understanding that behaviors are triggered both by — Cognitive deficits due to dementia, as well as — Internal and external factors? How should we interpret recent research to inform the use of medications to treat behavioral disturbances in dementia?

3 Overview of Changes from MDS 2.0 to MDS 3.0 Revised sections based on pilot studies : Cognitive Patterns Delirium Mood Behavior Pain Gait / falls Bladder and bowel Health conditions

4 Minimum Data Set (MDS) Behavior Section Required completion on admission and at least quarterly Includes section on behavior problems in NH residents MDS 2.0 based on staff observations and ratings MDS 3.0 proposes a shift to the patients’ experience — Patients’ voice in depression assessment — Patients’ perspective / values in behavior assessment

5 Overview of Item Content in Behavior Section of MDS 3.0 CATEGORIES Psychotic Symptoms Behavioral Symptoms Rejection of Care Wandering DOMAINS Presence Frequency Alterability Impact on resident Impact on others Change from previous assessment

6 Domains of Behavior in MDS 3.0

7 What makes this behavior a “problem”? Impact on the resident = clin. significant

8 What makes this behavior a “problem”? Impact on Others

9 Rejection of Care: shifting emphasis to resident’s own values and goals

10 E6 - E9. Rejection of Care - Assessment Protocol Assess whether care rejection behavior is easily addressed or altered by modifying the approach If not easily addressed or altered, determine whether care rejection behavior interferes with receipt of care that is necessary to meet resident’s (or proxy’s) goals for health and well-being. — Advance healthcare directives — Previously stated goals or preferences — Choices made by proxy on behalf of the resident

11 Wandering: impact and frequency determines whether problematic

12 E11a-b. Wandering - Impact Does the wandering place the resident at significant risk of getting to a dangerous place? — Stairs, hazmat exposure, risk of getting lost, inadvertant exiting Does the wandering significantly intrude on the privacy or activities of others? — Interferes with ADLs, leisure activities, or staff restrict programming (group walks, other outings)

13 MDS 3.0 Field Testing and Validation Study Conducted in — 70 community nursing homes (n = 418 residents) — 20 VA nursing homes (n = 296 residents) “Gold standard” nurses administered MDS 3.0 Facility nurses administered MDS 2.0 Cohen-Mansfield Agitation Inventory (CMAI) was gold standard for validation of presence of behavioral symptoms Neuropsychiatric Inventory (NPI) was gold standard for validation of presence of psychosis

14 Comparison of Kappa Coefficients for MDS 2.0 vs 3.0 and CMAI CMAIMDS 2.0MDS 3.0 Factor ( ) ( ) Factor ( ) ( ) Factor ( ) ( )

15 Factors that cause or contribute to behavioral problems associated with dementia

16 Assessment of behavioral symptoms in patients with dementia Behavioral symptoms are multiply determined by — Cognitive deficits due to dementia — Internal and external factors 1.How does cognitive impairment lead to behavioral disturbances? 2. What other factors contribute to behavioral disturbances?

17 Cognitive Domains Impaired in Dementia Syndrome of memory loss (amnesia) Decline in other cognitive functions — Use of language (aphasia) — Visual-spatial function — Recognition (agnosia) — Performing motor activities (apraxia) — Initiating/executing sequential tasks (abulia, executive dysfunction)

18 How does memory impairment lead to behavioral problems? Example Patient is able to dress himself, but can’t remember where his clothes are kept Walks naked into hallway

19 How does language impairment (aphasia) lead to behavioral problems? Example Patient who can’t verbally communicate her dislike of milk Throws milk carton across the room

20 How does impaired recognition (agnosia) lead to behavioral problems? Example Patient can maneuver to pull down his pants, but can’t recognize that a toilet is a receptacle for urination Urinates on floor near nurses station

21 How does impairment in performance of motor tasks (apraxia) lead to behavioral problems? Example Patient is continent of bladder, but cannot unzip or unbutton to pull down her pants Wets her clothing

22 Apraxia, Disability, and Behavioral Change in Terminal Stages of Dementia Examples: 1. Patient no longer holds or manipulates objects (manual apraxia) 2. Patient sits all day; has difficulty bearing weight and ambulating, even with assistance (gait apraxia) 3. Patient can swallow, but cannot chew effectively (oral apraxia)

23 What other factors may contribute to behavioral changes in patients with dementia?

24 Common modifiable causes of behavioral disturbances Unmet needs (physical and psychological) Environmental / social irritants Adverse drug effects Medical conditions / somatic discomfort Psychiatric conditions

25 Unmet needs that can lead to behavioral disturbances Physical needs — Nutrition, hydration, toileting, exercise, rest Psychological needs — Security, autonomy, affection, self-worth

26 Environmental irritants that can lead to behavioral disturbances Physical — Noise — Confusing visual stimuli — Uncomfortable temperature — Unfamiliar surroundings Social — Changes in routines — Provocative social interactions

27 Adverse drug effects that can cause behavioral disturbances Nuisance symptoms Anticholinergic effects Antihistaminic effects Paradoxical excitation / disinhibition Intoxication or withdrawal states Akathisia

28 Medical conditions and somatic discomfort that can lead to behavioral disturbances Somatic discomfort — Pain — Constipation — Urinary urgency — Shortness of breath — Dizziness — Fatigue Medical condition — Arthritis — Dehydration — Prostatic hypertrophy — COPD — Cerebrovascular disease — CHF

29 Psychiatric conditions that can cause behavioral disturbances Delirium Depression Anxiety Psychosis

30 Psychotic symptoms and agitation in dementia 10% to 73% have delusions 21% to 49% have hallucinations Visual hallucinations characteristic in Lewy Body dementia Sensory deprivation increases risk 60% to 75% exhibit agitated behavior Finkel. J Clin Psychiatry. 2001;62(suppl 21):3. Cohen-Mansfield and Billig. J Am Geriatr Soc. 1986;34:711.

31 So… if the patient has dementia with agitated behaviors associated with psychosis, is it appropriate to use antipsychotic medication in 2008?

32 Prior Evidence for Efficacy and Safety of Antipsychotic Drugs Meta-analyses of conventional antipsychotic drug studies found significant efficacy, but small effect sizes (Schneider et al, 1990) Efficacy studies of atypical antipsychotic drugs showed drug significantly better than placebo for psychosis, agitation, aggression (Katz et al 1999, Street 2000, Mintzer 2008) Atypical antipsychotics associated with less Parkinsonism; but sedation, gait disturbance and falls occur at higher doses

33 Regulatory Interpretation of Risks FDA warning about risk of diabetes (Sept. 2003) — Applies to the class for all ages, conditions FDA warnings about CVAEs (April 2003, Jan. 2004, March 2005) — applies to risperidone, olanzapine, and aripiprazole in elders with dementia FDA advisories about mortality (April 2005, June 2008) — applies to atypical AND conventional antipsychotics in dementia — Includes a reminder that these drugs are not FDA- approved for this indication

34 Risk of Cerebrovascular Adverse Events (CVAEs) in Elderly Patients With Dementia In US, letters to healthcare professionals were sent and warning added in prescribing information UK Committee on Safety of Medicines guideline: — Avoid use in BPSD of dementia — Limited to short-term and under-specialist advice for the management of acute psychotic conditions with risperidone — Consider risk in treating patients with previous history of stroke or transient ischemic attack and assess cerebrovascular disease risk factors including hypertension, diabetes, smoking, and atrial fibrillation Health Canada Advisory for Health Professionals. Available at: dpt/risperdal1_e.html and Accessed May 26, 2004; Committee on Safety of Medicines. Available at: Accessed March 31, 2004. # of trials CVAEsNumbers Needed to Harm Active drugPlacebo Risperidone43.8% (29/764)1.5% (7/466)44 Olanzapine51.3% (15/1178)0.4% (2/478)118 Aripiprazole31.3% (8/595)0.6% (2/343)112

35 Cerebrovascular Adverse Events: Pooled Analyses of Dementia RCTs Sample Size CVAEsExposure RR (95% CI) subject-yrs (drug/PBO) (drug/PB0)(drug/PBO) Risperidone 1009/712 33/8171.8/ ( ) Olanzapine 1175/478 15/ / ( ) Aripiprazole 598/340 8/2 95.2/ ( ) Quetiapine 355/213 3/4 54.7/ ( ) Ziprasodone no available clinical trials data in dementia patients Haloperidol1.27 ( ) Adapted from Schneider L. Paper presented at Annual Meeting of the American Association for Geriatric Psychiatry, San Diego CA, March 5, NB: 95% CI includes 1 for nearly all drugs studied !!

36 Mortality in Dementia Trials: Meta-analysis of RCTs Schneider examined 15 randomized, placebo- controlled trials 6 were published Most were weeks duration Sample — 3353 patients randomized to atypical antipsychotics — 1757 patients randomized to placebo Death rates — 3.5% in treatment group — 2.3% in control group Risk difference = % Confidence Interval, (P=.01) Schneider LS, et al. JAMA 2005, 294:

37 Relative Risk of Death: Conventional vs. Atypical Antipsychotics Wang P et al. N Engl J Med. 2005;353: Model Hazard Ratio (95% CI) Unadjusted analysis1.51 ( ) Adjusted analysis* Use of any conventional APM1.37 ( ) Low dose of conventional APM (median)1.73 ( ) Adjusted analysis of death** <40 days after beginning therapy1.56 ( ) days after beginning therapy1.37 ( ) days after beginning therapy1.27 ( ) Adjusted analysis of patient subgroups** With dementia1.29 ( ) Without dementia1.45 ( ) In a nursing home1.26 ( ) Not in a nursing home 1.42 ( ) *APM=antipsychotic medication CI=confidence interval **Hazard ratios adjusted for age, sex, cardiovascular and cerebrovascular disease, psychiatric disorders, other medications used, and residential status.

38 Risk of Death in Elderly Patients: Atypical vs Conventional Antipsychotics Wang P et al. N Engl J Med. 2005;353: Days after initiation of medicine Deaths per person-year Conventional antipsychotics Atypical antipsychotics

39 CATIE-AD: Effectiveness of Atypical Antipsychotic Drugs in Outpatients with Alzheimer’s Disease 42-site, double blind, RCT N=421 patients with AD + psychosis, agitation or aggression Randomized to — Olanzapine (mean dose 5.5 mg/d) — Quetiapine (mean dose 56.5 mg/d) — Risperidone (mean dose 1.0 mg/d) — Placebo Primary outcomes: — Time to all-cause discontinuation — Number of patients with at least minimal improvement on CGIC at 12 weeks Schneider LS et al. N Engl J Med 2006;355:

40 CATIE-AD: Primary Outcomes No significant differences among groups on CGIC (P=0.22) No significant differences in time to discontinuation for any reason (P=0.52) Schneider LS et al. N Engl J Med 2006;355:

41 CATIE-AD: Summary of Results Time to discontinuation due to lack of efficacy favored olanzapine and risperidone (P=0.002) Time to discontinuation due to adverse events or intolerability favored placebo (P=0.009) Schneider LS et al. N Engl J Med 2006;355:

42 CATIE AD: Conclusions Atypical antipsychotic drugs appear more efficacious than placebo, but… Adverse events limit overall effectiveness Use may be appropriate for patients who have no or few adverse effects, and for whom benefits can be discerned Schneider LS. Presented at Annual Meeting of the AAGP, March 2, 2007, New Orleans LA.

43 Incorporating Risk Tolerance in Making Treatment Decisions When is the balance between expected benefits and known risks acceptable to the patient or surrogate decision-maker?

44 Documentation is Crucial Inform patient or proxy of benefits and risks Discuss acceptability of treatment Document discussion, including concurrence with treatment plan

45 Summary MDS 3.0 Behavior items — Perform better than MDS 2.0 at detecting presence of target behaviors — Clarify when behaviors are problems — Respect resident values and preferences Behavioral symptoms in dementia may be explained by — Deficits in various cognitive domains — Other factors such as unmet needs, environmental irritants, drug effects, medical and psychiatric conditions

46 Summary Antipsychotic drugs may benefit selected nursing home residents, but it is advisable to: — Discuss risks, including stroke and death — Document that balance between expected benefits and known risks is acceptable to patient or proxy

47 Questions ???

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