[PPT] Managing Behavioural and Psychological Symptoms of ...


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[PPT] Managing Behavioural and Psychological Symptoms of ...

  1. 1. Managing Behavioral and Psychological Symptoms of Dementia (BPSD) Carol Ward M.D., U of Ottawa May 2005
  2. 2. Participants will be able to: <ul><li>Identify target BPSD symptoms that may be amenable to medication and those that are not </li></ul><ul><li>Use the PIECES framework with their nursing colleagues to evaluate Long-term care residents with challenging BPSD </li></ul><ul><li>Select appropriate pharmacological interventions for the management of BPSD unresponsive to non-pharmacological interventions </li></ul>I
  3. 3. References <ul><li>Rivard M.F., LeClair K., Ward C. ‘Understanding and Managing Behavioral and Psychological Symptoms of Dementia’, Ontario’s Strategy for Alzheimer Disease and Related Dementia: Initiative #2, Physician Education, </li></ul><ul><li>www.DementiaEducation.ca </li></ul><ul><li>‘ A.D.E.P.T – A Dementia Education Physician Teaching Program for Family Physicians’, Janssen-Ortho </li></ul>
  4. 4. BPSD <ul><li>90% of patients affected by dementia will experience Behavioral and Psychological Symptoms of Dementia (BPSD) that are severe enough to be labeled a problem at some time during the course of their illness. </li></ul><ul><li>(Mega et al. 1996) </li></ul>
  5. 5. Causes of BPSD <ul><li>Intellectual and cognitive changes </li></ul><ul><li>- amnesia, agnosia, apraxia, aphasia, apathy </li></ul><ul><li>Neurotransmitter dysfunction </li></ul><ul><li>- dopamine, serotonin, cholinergic, adrenergic, GABA </li></ul><ul><li>Instinctual behaviors under stress </li></ul><ul><li>- territoriality - defensiveness </li></ul>
  6. 6. Estimated frequency of common BPSD <ul><li>Agitation up to 75% </li></ul><ul><li>Wandering up to 60% </li></ul><ul><li>Depression up to 50% </li></ul><ul><li>Psychosis up to 30% </li></ul><ul><li>Screaming up to 25% </li></ul><ul><li>Aggression up to 20% </li></ul><ul><li>Sexual Disinhibition up to 10% </li></ul><ul><li>(Mega, Cumming et al. 1996) </li></ul>
  7. 7. BPSD <ul><li>50 – 90% of caregivers considered physical aggression as the most serious problem they encountered and a factor leading to institutionalization (Rabins et al. 1982) </li></ul><ul><li>Front-line staff working in LTC report that physical assault contributes to significant work related stress (Wimo et al. 1997) </li></ul>
  8. 8. Course of BPSD <ul><li>50% of patients may have resolution of some symptoms but may develop new ones </li></ul><ul><li>Activity disturbance is common and persistent in early Alzheimer </li></ul><ul><li>Verbal aggression is the most common and longest lasting </li></ul><ul><li>Aggressive resistance most likely to persist until death </li></ul><ul><li>( Keene et al. 1999) </li></ul>
  9. 9. BPSD that will not respond to medication <ul><li>Wandering </li></ul><ul><li>Inappropriate urination/defecation </li></ul><ul><li>Inappropriate dressing/undressing </li></ul><ul><li>Annoying repetitive activities (perseveration) or vocalization </li></ul><ul><li>Hiding/hoarding </li></ul><ul><li>Eating inedibles </li></ul><ul><li>Tugging at/removal of restraints </li></ul><ul><li>Pushing wheelchair bound co-residents </li></ul>
  10. 10. Problems that may respond to medication <ul><li>Anxiety </li></ul><ul><li>Depressive symptoms </li></ul><ul><li>Sleep disturbance </li></ul><ul><li>Manic-like symptoms </li></ul><ul><li>Persistent and distressing delusions or hallucinations </li></ul><ul><li>Persistent verbal and physical aggression </li></ul><ul><li>Sexually inappropriate behavior </li></ul>
  11. 11. PIECES: a framework for evaluation and intervention <ul><li>Most BPSD can be understood if we look systematically for the ‘reasons behind the behavior’ </li></ul><ul><li>To understand BPSD, one must understand the illness and the person who lives with dementia </li></ul><ul><li>Look for possible causes/hypotheses for BPSD </li></ul>
  12. 12. PIECES framework to understand BPSD <ul><li>P hysical problem or discomfort </li></ul><ul><li>I ntellectual/cognitive changes </li></ul><ul><li>E motional </li></ul><ul><li>C apacities </li></ul><ul><li>E nvironment </li></ul><ul><li>S ocial/cultural </li></ul>
  13. 13. P hysical Factors <ul><li>Acute medical problem – Delirium </li></ul><ul><li>Drugs and alcohol </li></ul><ul><li>Diseases (chronic, unstable) </li></ul><ul><li>Pain </li></ul><ul><li>Primitive reflexes – grasp </li></ul><ul><li>Paratonia </li></ul>
  14. 14. I ntellectual <ul><li>Type of dementia (Alzheimer, Vascular, Lewy-Body, Frontal-temporal) </li></ul><ul><li>The ‘A’s </li></ul><ul><li>Developmental stage: retro-genesis </li></ul>
  15. 15. E motional <ul><li>Depression </li></ul><ul><li>Anxiety </li></ul><ul><li>Psychosis </li></ul><ul><li>Adjustment difficulties </li></ul><ul><li>Aggression </li></ul>
  16. 16. Capabilities <ul><li>If remaining capabilities not utilized enough: </li></ul><ul><li>- boredom </li></ul><ul><li>- anger </li></ul><ul><li>Demands exceed capabilities: frustration and catastrophic reactions </li></ul>
  17. 17. E nvironment <ul><li>Relocation, feeling lost, “needing to go home” </li></ul><ul><li>Ambiance - excessive or distressing noise, unfriendly, confusing environment </li></ul>
  18. 18. Non-pharmacological approaches <ul><li>Derived from hypotheses generated from trying to understand the contributing factors and understanding the person </li></ul><ul><li>A S howy D octor C annot P rovide E nough E mpathy </li></ul><ul><li>(A.D.E.P.T.) </li></ul>
  19. 19. Approach <ul><li>Kind </li></ul><ul><li>Unrushed </li></ul><ul><li>Non-confrontational </li></ul><ul><li>Face-to-face </li></ul><ul><li>Distract – food, change environment, triggers </li></ul><ul><li>(A.D.E.P.T.) </li></ul>
  20. 20. Schedules <ul><li>Patient-centered </li></ul><ul><li>Individualized care plan </li></ul><ul><li> (A.D.E.P.T.) </li></ul>
  21. 21. Demands <ul><li>Reduce demands on the patient </li></ul><ul><li>Remember some domains may be more preserved than others may lead to wrong assumptions about capability </li></ul><ul><ul><ul><ul><ul><li>(A.D.E.P.T.) </li></ul></ul></ul></ul></ul>
  22. 22. Communication <ul><li>Simple </li></ul><ul><li>Clear </li></ul><ul><li>One or two stage commands </li></ul><ul><li>(A.D.E.P.T.) </li></ul>
  23. 23. Personal Care <ul><li>Simple protocol </li></ul><ul><li>Preventive care – eyes, ears, mouth, bowels, bladder, skin and feet </li></ul><ul><li>Attention to mobility, comfort while seating, hydration, nutrition, exercise, sleep </li></ul><ul><li>(A.D.E.P.T.) </li></ul>
  24. 24. Activity and Environment <ul><li>Appropriate daytime activity </li></ul><ul><li>Compatible with patients level of function </li></ul><ul><li>Take into consideration physical environment </li></ul><ul><li>(A.D.E.P.T.) </li></ul>
  25. 25. S ocial/Cultural <ul><li>Life history </li></ul><ul><li>Social network </li></ul><ul><li>Life accomplishments </li></ul><ul><li>Relationship with family </li></ul><ul><li>Interaction with other residents </li></ul><ul><li>(A.D.E.P.T.) </li></ul>
  26. 26. When should we consider pharmacologic treatment of BPSD? <ul><li>Behavior is dangerous, distressing, disturbing, damaging to social relationships and persistent </li></ul><ul><li>AND </li></ul><ul><li>Has not responded to comprehensive non-pharmacologic treatment plan. Including removal of possibly offending drugs </li></ul><ul><li>OR </li></ul><ul><li>Requires emergency treatment to allow proper investigation of underlying problems </li></ul>
  27. 27. Approach to the Acutely Agitated Patient <ul><li>Safety - of the patient, other residents and staff is number one concern </li></ul><ul><li>Assess competency - Except in an emergency the patient (if capable)/Substitute Decision Maker must be involved in treatment plan Communication with the family is key . </li></ul><ul><li>Treatment – of choice in urgent situations is oral atypical antipsychotics </li></ul>
  28. 28. Urgent situations – Atypical Antipsychotics <ul><li>M tab and Zydis are more quickly dissolved but do not have a more rapid onset of action </li></ul><ul><li>Time to peak plasma concentration for risperidone = 1.5 hrs, olanzapine = 5 hrs, quetiapine = 1.5 hrs </li></ul>
  29. 29. Urgent Situations – Atypical Antipsychotics 150 mg Q2-4 hr prn 12.5-25 po tabs Quetiapine 10 mg Q2-4 hr prn 2.5-5 mg po tabs/Zydis Olanzapine 2 mg Q2-4 hr prn 0.25-1 mg, po tabs/liq /Mtab Risperidone Max dose/24 hrs Frequency Dose Atypical
  30. 30. Urgent Situations – Second Line ?N/A in dementia Q2-4 DAYS prn 6.25-12.5 mg im Clopixol (Accuphase) 2 mg Q2-4 hr prn 0.5-1 mg po tabs/im Lorazepam 25 mg Q2-4 hr prn 2.5-5 po tabs/liq/im Loxapine 2 mg Q2-4 hr prn 0.5-1 mg po/liq/im Haloperidol Max dose/24 hrs Frequency Dose Medication
  31. 31. Urgent Situations <ul><li>The previous medication suggestions are intended for acute/urgent situations only where safety is a concern, and must be reviewed promptly! </li></ul><ul><li>Not all patients will need to remain on the medication started in acute/urgent situations </li></ul>
  32. 32. Treatment of persistent psychotic symptoms and aggression <ul><li>Best choices are: risperidone, olanzapine, quetiapine </li></ul><ul><li>All have significant side-effects </li></ul><ul><li>- Risperidone: watch for EPS </li></ul><ul><li>- Olanzapine: sedation, anticholinergic SE, increased vascular risk factors </li></ul><ul><li>- Quetiapine: hypotension, sedation, difficult to find therapeutic dose </li></ul><ul><li>?increased risk of cerebro-vascular events reported with both olanzapine & risperidone </li></ul>
  33. 33. Best medications for anxiety symptoms <ul><li>SSRI antidepressants are now first line treatment for anxiety disorders </li></ul><ul><li>- Will take a few weeks to work fully </li></ul><ul><li>- Watch for GI symptoms, headaches, hyponatremia </li></ul><ul><li>May consider a cholinesterase inhibitor if patient not already taking </li></ul><ul><li>- Will take a few weeks to work fully </li></ul><ul><li>- Screen for bundle branch block </li></ul><ul><li>- Watch for GI symptoms, sleep disturbance, worsening of agitation </li></ul>
  34. 34. Best medications for anxiety symptoms <ul><li>May also consider Trazodone for its sedating effects </li></ul><ul><li>- Watch for hypotension, over-sedation, priapism </li></ul><ul><li>If anxiety is specific to occasional situations, consider punctual use of lorazepam (ie. Weekly bath) </li></ul><ul><li>- May cause falls, worsening of disinhibited behaviour, confusion and memory problems </li></ul>
  35. 35. Best medication for depression <ul><li>SSRIs (eg. Citalopram, sertraline), moclobemide, venlafaxine, or buproprion usually considered first </li></ul><ul><li>- Low anticholinergic activity and low potential for drug interactions </li></ul><ul><li>Selection based on previous response to treatment, medical problem list and drug interactions. </li></ul>
  36. 36. Other treatments for depression <ul><li>For very severe or psychotic depression consider electroconvulsive therapy. </li></ul><ul><li>For recurrent depression of bipolar illness, patient will require a mood stabilizer first (to avoid switch into mania) </li></ul>
  37. 37. Treatment with antidepressants <ul><li>Titration according to therapeutic benefits and side effects: usually takes at least one month </li></ul><ul><li>Adequate trial: 4 weeks at maximum tolerated or recommended dose if no response; 6-8 weeks if partial response </li></ul><ul><li>Duration of treatment: No specific evidence for duration of treatment in the presence of dementia but clinicians follow general recommendations unless there is good reason not to </li></ul><ul><li>2 years or more (?) if recurrent depressive disorder </li></ul>
  38. 38. Treatment of manic-like symptoms (very limited data) <ul><li>If well established diagnosis of bipolar illness prior to dementia, low dose lithium with appropriated geriatric blood levels (0.4-0.6 mEq/L) may be best treatment but requires close monitoring </li></ul><ul><li>For new onset of manic-like symtoms, consider valproic acid or carbamazepine </li></ul>
  39. 39. Rx of behavioral problems due to Lewy Body dementia <ul><li>Cholinesterase inhibitors are now first line of treatment. Need to try over several weeks. </li></ul><ul><li>If ineffective or too early in treatment, consider trazodone (watch BP) and low doses of lorazepam or oxazepam </li></ul><ul><li>If antipsychotic medication necessary document risk with SDM and consider low doses of quetiapine. </li></ul>
  40. 40. When it is necessary to decrease sexual drive (rare) <ul><li>Consider anti-androgens, SSRIs or anti-psychotics with informed consent </li></ul><ul><li>Avoid benzodiazepines and remember that trazodone can cause priapism </li></ul>
  41. 41. Summary <ul><li>Identify target BPSD symptom/cluster </li></ul><ul><li>Chart frequency and severity/monitor (rating scales) </li></ul><ul><li>Consider possible new medical and psychiatric causes </li></ul><ul><li>Implement non-pharmacological approach </li></ul><ul><li>Decide if BPSD needs pharmacological tx? </li></ul><ul><li>-severe, persistent and /or dangerous? </li></ul><ul><li>-urgent? </li></ul><ul><li>-target symptoms likely to respond? </li></ul>
  42. 42. Summary <ul><li>6. Start appropriate initial urgent pharmacotherapy for BPSD </li></ul><ul><li>7. Monitor effectiveness of tx., side effects, titrate dose </li></ul><ul><li>8. Decide if therapeutic goals are met </li></ul><ul><li>9. Consider initiating a trial of weaning if the patient is on an atypical antipsychotic and if BPSD is stable for 3 to 6 months </li></ul><ul><li>10. Monitor for recurrence/emergence of BPSD </li></ul>
  43. 43. Rating Scales <ul><li>Scale </li></ul><ul><li>Cohen-Mansfield Agitation Inventory (CMAI) </li></ul><ul><li>Neuropsychiatric Inventory-Nursing Home Version (NPI-NH) </li></ul><ul><li>Assessment </li></ul><ul><li>- Assesses frequency of 29 agitated behaviors rated by caregiver on a 7-pt. scale </li></ul><ul><li>- Primary caregiver-related scale that assesses BPSD Consists of 12 items, each with a 1 – 12 possible score </li></ul>
  44. 44. Neuropsychiatric Clusters in Dementia (Ref: McShane R. 2000)
  45. 45. Aggression <ul><li>Aggressive resistance </li></ul><ul><li>Physical aggression </li></ul><ul><li>Verbal aggression </li></ul>
  46. 46. Apathy <ul><li>Withdrawn </li></ul><ul><li>Lack of interest </li></ul><ul><li>amotivation </li></ul>
  47. 47. Depression <ul><li>Sad </li></ul><ul><li>Tearful </li></ul><ul><li>Hopeless </li></ul><ul><li>Low self-esteem </li></ul><ul><li>Anxiety </li></ul><ul><li>guilt </li></ul>
  48. 48. Agitation <ul><li>Walking aimlessly </li></ul><ul><li>Pacing </li></ul><ul><li>Repetitive actions </li></ul><ul><li>Dressing/undressing </li></ul><ul><li>Sleep disturbance </li></ul>
  49. 49. Psychosis <ul><li>Hallucinations </li></ul><ul><li>Delusions </li></ul><ul><li>misidentification </li></ul>
  50. 50. Rx of severe agitation due to delirium <ul><li>Low dose haloperidol (po, im, liquid) may be considered for emergency, short-term use (days) while addressing cause(s) of delirium. </li></ul><ul><li>May consider risperidone (liquid, Mtab), loxapine (liquid, im) </li></ul>