Managing Behavioral and Managing Behavioral and Psychological Symptoms Psychological Symptoms

of Dementia (BPSD)of Dementia (BPSD)

Carol Ward M.D., U of OttawaCarol Ward M.D., U of Ottawa

May 2005May 2005

Participants will be able Participants will be able to:to:

Identify target BPSD symptoms that may be amenable to medication and those that are not

Use the PIECES framework with their nursing colleagues to evaluate Long-term care residents with challenging BPSD

Select appropriate pharmacological interventions for the management of BPSD unresponsive to non-pharmacological interventions

I

ReferencesReferences

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, www.DementiaEducation.ca

‘A.D.E.P.T – A Dementia Education Physician Teaching Program for Family Physicians’, Janssen-Ortho

BPSDBPSD

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.

(Mega et al. 1996)

Causes of BPSDCauses of BPSD

Intellectual and cognitive changes - amnesia, agnosia, apraxia,

aphasia, apathy Neurotransmitter dysfunction - dopamine, serotonin, cholinergic,

adrenergic, GABA Instinctual behaviors under stress - territoriality - defensiveness

Estimated frequency of Estimated frequency of common BPSDcommon BPSD

Agitation up to 75% Wandering up to 60% Depression up to 50% Psychosis up to 30% Screaming up to 25% Aggression up to 20% Sexual Disinhibition up to 10% (Mega, Cumming

et al. 1996)

BPSDBPSD

50 – 90% of caregivers considered 50 – 90% of caregivers considered physical aggression as the most physical aggression as the most serious problem they encountered and serious problem they encountered and a factor leading to institutionalization a factor leading to institutionalization (Rabins et al. 1982) (Rabins et al. 1982)

Front-line staff working in LTC report Front-line staff working in LTC report that physical assault contributes to that physical assault contributes to significant work related stress (Wimo significant work related stress (Wimo et al. 1997)et al. 1997)

Course of BPSDCourse of BPSD

50% of patients may have resolution of some symptoms but may develop new ones

Activity disturbance is common and persistent in early Alzheimer

Verbal aggression is the most common and longest lasting

Aggressive resistance most likely to persist until death

((Keene et al. 1999)

BPSD that will not respond BPSD that will not respond to medicationto medication

Wandering Inappropriate urination/defecation Inappropriate dressing/undressing Annoying repetitive activities

(perseveration) or vocalization Hiding/hoarding Eating inedibles Tugging at/removal of restraints Pushing wheelchair bound co-residents

Problems that Problems that maymay respond respond to medicationto medication

AnxietyAnxiety Depressive symptomsDepressive symptoms Sleep disturbance Sleep disturbance Manic-like symptomsManic-like symptoms Persistent and distressing delusions Persistent and distressing delusions

or hallucinationsor hallucinations Persistent verbal and physical Persistent verbal and physical

aggressionaggression Sexually inappropriate behaviorSexually inappropriate behavior

PIECES: a framework for PIECES: a framework for evaluation and interventionevaluation and intervention

Most BPSD can be understood if we look Most BPSD can be understood if we look systematically for the ‘reasons behind the systematically for the ‘reasons behind the behavior’behavior’

To understand BPSD, one must understand To understand BPSD, one must understand the illness the illness andand the person who lives with the person who lives with dementiadementia

Look for possible causes/hypotheses for Look for possible causes/hypotheses for BPSDBPSD

PIECES framework to PIECES framework to understand BPSDunderstand BPSD

PPhysical problem or discomfort IIntellectual/cognitive changes EEmotional CCapacities EEnvironment SSocial/cultural

PPhysical Factorshysical Factors

Acute medical problem – DeliriumAcute medical problem – Delirium Drugs and alcoholDrugs and alcohol Diseases (chronic, unstable)Diseases (chronic, unstable) PainPain Primitive reflexes – graspPrimitive reflexes – grasp ParatoniaParatonia

IIntellectualntellectual

Type of dementia (Alzheimer, Type of dementia (Alzheimer, Vascular, Lewy-Body, Frontal-Vascular, Lewy-Body, Frontal-temporal)temporal)

The ‘A’sThe ‘A’s Developmental stage: retro-genesisDevelopmental stage: retro-genesis

EEmotionalmotional

DepressionDepression AnxietyAnxiety PsychosisPsychosis Adjustment difficultiesAdjustment difficulties AggressionAggression

CapabilitiesCapabilities

If remaining capabilities not utilized If remaining capabilities not utilized enough:enough:

- boredom- boredom

- anger- anger Demands exceed capabilities: Demands exceed capabilities:

frustration and catastrophic frustration and catastrophic reactionsreactions

EEnvironmentnvironment

Relocation, feeling lost, “needing to Relocation, feeling lost, “needing to go home”go home”

Ambiance - excessive or distressing Ambiance - excessive or distressing noise, unfriendly, confusing noise, unfriendly, confusing environmentenvironment

Non-pharmacological Non-pharmacological approachesapproaches

Derived from hypotheses generated from trying to understand the contributing factors and understanding the person

A Showy Doctor Cannot Provide Enough Empathy

(A.D.E.P.T.)

ApproachApproach Kind Unrushed Non-confrontational Face-to-face Distract – food, change environment,

triggers

(A.D.E.P.T.)

SchedulesSchedules

Patient-centered

Individualized care plan

(A.D.E.P.T.)

DemandsDemands

Reduce demands on the patient

Remember some domains may be more preserved than others may lead to wrong assumptions about capability

(A.D.E.P.T.)

CommunicationCommunication

Simple

Clear

One or two stage commands

(A.D.E.P.T.)

Personal CarePersonal Care Simple protocol

Preventive care – eyes, ears, mouth, bowels, bladder, skin and feet

Attention to mobility, comfort while seating, hydration, nutrition, exercise, sleep

(A.D.E.P.T.)

Activity and EnvironmentActivity and Environment Appropriate daytime activity

Compatible with patients level of function

Take into consideration physical environment

(A.D.E.P.T.)

SSocial/Culturalocial/Cultural

Life history Social network Life accomplishments Relationship with family Interaction with other residents

(A.D.E.P.T.)

When should we consider When should we consider pharmacologic treatment of pharmacologic treatment of

BPSD?BPSD? Behavior is dangerous, distressing, Behavior is dangerous, distressing,

disturbing, damaging to social disturbing, damaging to social relationships and persistentrelationships and persistent

ANDAND Has not responded to comprehensive non-Has not responded to comprehensive non-

pharmacologic treatment plan. Including pharmacologic treatment plan. Including removal of possibly offending drugsremoval of possibly offending drugs

OROR Requires emergency treatment to allow Requires emergency treatment to allow

proper investigation of underlying proper investigation of underlying problemsproblems

Approach to the Acutely Approach to the Acutely Agitated PatientAgitated Patient

Safety - of the patient, other residents and staff is number one concern

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 .

Treatment – of choice in urgent situations is oral atypical antipsychotics

Urgent situations – Atypical Urgent situations – Atypical AntipsychoticsAntipsychotics

M tab and Zydis are more quickly dissolved but do not have a more rapid onset of action

Time to peak plasma concentration for risperidone = 1.5 hrs, olanzapine = 5 hrs, quetiapine = 1.5 hrs

Urgent Situations – Atypical Urgent Situations – Atypical AntipsychoticsAntipsychotics

AtypicalAtypical DoseDose FrequencFrequencyy

Max Max dose/24 dose/24 hrshrs

Risperidone

0.25-1 mg, po tabs/liq /Mtab

Q2-4 hr prn

2 mg

Olanzapine

2.5-5 mg po tabs/Zydis

Q2-4 hr prn

10 mg

Quetiapine

12.5-25 po tabs

Q2-4 hr prn

150 mg

Urgent Situations – Urgent Situations – Second LineSecond Line

MedicatioMedicationn

DoseDose FrequencFrequencyy

Max Max dose/24 dose/24 hrshrs

Haloperidol

0.5-1 mg po/liq/im

Q2-4 hr prn

2 mg

Loxapine 2.5-5 po tabs/liq/im

Q2-4 hr prn

25 mg

Lorazepam

0.5-1 mg po tabs/im

Q2-4 hr prn

2 mg

Clopixol (Accuphase)

6.25-12.5 mg im

Q2-4 DAYS prn

?N/A in dementia

Urgent SituationsUrgent Situations

The previous medication suggestions are intended for acute/urgent situations only where safety is a concern, and must be reviewed promptly!

Not all patients will need to remain on the medication started in acute/urgent situations

Treatment of persistent Treatment of persistent psychotic symptoms and psychotic symptoms and

aggressionaggression Best choices are: risperidone, Best choices are: risperidone,

olanzapine, quetiapineolanzapine, quetiapine All have significant side-effectsAll have significant side-effects

- - Risperidone: watch for EPSRisperidone: watch for EPS- Olanzapine: sedation, anticholinergic SE, - Olanzapine: sedation, anticholinergic SE, increased vascular risk factorsincreased vascular risk factors- Quetiapine: hypotension, sedation, difficult to find - Quetiapine: hypotension, sedation, difficult to find therapeutic dosetherapeutic dose

?increased risk of cerebro-vascular ?increased risk of cerebro-vascular events reported with both olanzapine events reported with both olanzapine & risperidone& risperidone

Best medications for Best medications for anxiety symptomsanxiety symptoms

SSRI antidepressants are now first line treatment for anxiety disorders

- Will take a few weeks to work fully

- Watch for GI symptoms, headaches, hyponatremia

May consider a cholinesterase inhibitor if patient not already taking

- Will take a few weeks to work fully

- Screen for bundle branch block- Watch for GI symptoms, sleep disturbance,

worsening of agitation

Best medications for Best medications for anxiety symptomsanxiety symptoms

May also consider Trazodone for its sedating effects

- Watch for hypotension, over-sedation, priapism

If anxiety is specific to occasional situations, consider punctual use of lorazepam (ie. Weekly bath)

- - May cause falls, worsening of disinhibited May cause falls, worsening of disinhibited behaviour, confusion and memory problemsbehaviour, confusion and memory problems

Best medication for Best medication for depressiondepression

SSRIs (eg. Citalopram, sertraline), moclobemide, venlafaxine, or buproprion usually considered first

- Low anticholinergic activity and low potential for drug interactions

Selection based on previous response to treatment, medical problem list and drug interactions.

Other treatments for Other treatments for depressiondepression

For very severe or psychotic depression consider electroconvulsive therapy.

For recurrent depression of bipolar illness, patient will require a mood stabilizer first (to avoid switch into mania)

Treatment with Treatment with antidepressantsantidepressants

Titration according to therapeutic benefits and side effects: usually takes at least one month

Adequate trial: 4 weeks at maximum tolerated or recommended dose if no response; 6-8 weeks if partial response

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

2 years or more (?) if recurrent depressive disorder

Treatment of manic-like Treatment of manic-like symptoms (very limited symptoms (very limited

data)data) 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

For new onset of manic-like symtoms, consider valproic acid or carbamazepine

Rx of behavioral problems Rx of behavioral problems due to Lewy Body dementiadue to Lewy Body dementia

Cholinesterase inhibitors are now first line of treatment. Need to try over several weeks.

If ineffective or too early in treatment, consider trazodone (watch BP) and low doses of lorazepam or oxazepam

If antipsychotic medication necessary document risk with SDM and consider low doses of quetiapine.

When it is necessary to When it is necessary to decrease sexual drive (rare)decrease sexual drive (rare) Consider anti-androgens, SSRIs or

anti-psychotics with informed consent

Avoid benzodiazepines and remember that trazodone can cause priapism

SummarySummary

1.1. Identify target BPSD symptom/clusterIdentify target BPSD symptom/cluster2.2. Chart frequency and severity/monitor Chart frequency and severity/monitor

(rating scales)(rating scales)3.3. Consider possible new medical and Consider possible new medical and

psychiatric causespsychiatric causes4.4. Implement non-pharmacological approachImplement non-pharmacological approach5.5. Decide if BPSD needs pharmacological tx?Decide if BPSD needs pharmacological tx?

-severe, persistent and /or dangerous?-severe, persistent and /or dangerous?-urgent?-urgent?-target symptoms likely to respond?-target symptoms likely to respond?

SummarySummary

6. Start appropriate initial urgent pharmacotherapy for BPSD

7. Monitor effectiveness of tx., side effects, titrate dose

8. Decide if therapeutic goals are met9. Consider initiating a trial of weaning if

the patient is on an atypical antipsychotic and if BPSD is stable for 3 to 6 months

10. Monitor for recurrence/emergence of BPSD

Rating ScalesRating Scales

ScaleScale Cohen-Mansfield

Agitation Inventory (CMAI)

Neuropsychiatric Inventory-Nursing Home Version (NPI-NH)

AssessmentAssessment- Assesses frequency

of 29 agitated behaviors rated by caregiver on a 7-pt. scale

- Primary caregiver-related scale that assesses BPSD Consists of 12 items, each with a 1 – 12 possible score

Neuropsychiatric Clusters Neuropsychiatric Clusters in Dementia in Dementia (Ref: McShane R. (Ref: McShane R.

2000)2000)

AggressionAggression

Aggressive resistance Physical aggression Verbal aggression

ApathyApathy

Withdrawn Lack of interest amotivation

DepressionDepression

Sad Tearful Hopeless Low self-esteem Anxiety guilt

AgitationAgitation

Walking aimlessly Pacing Repetitive actions Dressing/undressing Sleep disturbance

PsychosisPsychosis

Hallucinations Delusions misidentification

Rx of severe agitation due Rx of severe agitation due to deliriumto delirium

Low dose haloperidol (po, im, liquid) may be considered for emergency, short-term use (days) while addressing cause(s) of delirium.

May consider risperidone (liquid, Mtab), loxapine (liquid, im)