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5 minute soap box

5 minute soap box . Old Age Psychiatry. Who gets anti-dementia drugs?. Diagnosis must be AD MMSE 10-20 Or Moderate severity on clinical grounds Likely to comply 6 monthly review of MMSE, function, behaviour, carer views - ? Overall “worthwhile effect” MMSE remains above 10.

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5 minute soap box

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  1. 5 minute soap box Old Age Psychiatry

  2. Who gets anti-dementia drugs? • Diagnosis must be AD • MMSE 10-20 • Or Moderate severity on clinical grounds • Likely to comply • 6 monthly review of MMSE, function, behaviour, carer views - ? Overall “worthwhile effect” • MMSE remains above 10

  3. Who doesn’t get anti-dementia drugs? • People suffering from other dementias • Mild AD • Severe AD • No memantine

  4. BENEFIT Mild to moderate AD Parkinson’s Disease VaD Memantine for moderate to severe AD NONE PROVEN Mild Cognitive Impairment FTD LBD What does Cochrane say?

  5. Treatment of Behavioural Disturbance in Dementia

  6. Risperidone and Olanzapine • Risk of CVA ^ from 1% to 3% in 12 weeks • Risk ^ in “old old” and if CVA risk factors • No evidence that other atypicals and typicals safer

  7. Treatment of BPSD • Pharmacological • Behavioural • Environmental Evidence base for all is poor

  8. Non-drug strategies • Day- time activity • Reminders • Reassurance • Regular orientation • Distraction • Respite – longer or shorter periods • Help with care tasks • Is 24-hour care necessary? – and if so is it the right kind of place?

  9. Non–Pharmacological Therapies • Behavioural analysis and therapy • Aromatherapy • Bright light therapy • Homeopathy • Pets • Music therapy • Staff training

  10. Some causes of agitation • Depression • Anxiety • Psychotic symptoms • Physical ill health

  11. Drug Groups used in BPSD • Neuroleptics • Benzodiazepines • Anti-convulsants • Anti-depressants • AcetylCholine-Esterase Inhibitors

  12. Where BPSD is treatable in people without dementia – treat this Eg: • Psychosis (risperidone, others, not olanzapine) • Depression • Hypomania • Anxiety • Insomnia

  13. Reasons to use neuroleptics • Continuing BPSD despite alternatives • Severe symptoms • Clear risk to self or others (document)

  14. The “three Ts” • Target symptom (and record it) • Start low and titrate slowly • Time limited

  15. Withdrawal of neuroleptics • In double-blind r.c.t. no significant difference in behavioural symptoms between those continuing neuroleptic and switching to placebo • A small number of people withdrawn show worsening

  16. The other NICE document of 2006Dementia CG 42 • Use antipsychotics (neuroleptics) only for severe BPSD in AD and DLB • Discuss risks • Document target symptoms • Monitor - ? 3 monthly

  17. The other NICE document of 2006Dementia CG 42 • Donepezil, rivastigmine or galantamine may be used for BPSD in LBD • And in AD if causing significant harm or distress and if antipsychotics are ineffective or inappropriate

  18. Summary 1) Is the behaviour intolerable? 2) Would it be tolerable in a different setting? 3) Are there non-drug options? 4) Aim to target drug to clinical features, e.g. depression, psychotic symptoms. 5) Low dose 6) Slow increases 7) Review – and consider withdrawing when stable

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