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Management of BPSD. Shahla Baharlou, MD and Christine Chang, MD Brookdale Dept of Geriatrics and Adult Development March 5, 2008. Objectives. Participants will be able to: Define BPSD Evaluate BPSD Discuss the Guidelines for Management of BPSD Nonpharmacologic Interventions
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Management of BPSD Shahla Baharlou, MD and Christine Chang, MD Brookdale Dept of Geriatrics and Adult Development March 5, 2008
Objectives Participants will be able to: • Define BPSD • Evaluate BPSD • Discuss the Guidelines for Management of BPSD • Nonpharmacologic Interventions • Pharmacologic Interventions
What Is BPSD? Behavioral and Psychological Symptoms of Dementia
What Is BPSD? Non-cognitive manifestations of dementia Behavioral Symptoms Psychological Symptoms
What Is BPSD? Behavioral Symptoms “Agitation” Related to resistiveness to care Physical vs Verbal Aggressive vs Nonaggressive
What Is BPSD? Psychological Symptoms Mood Symptoms Psychotic Symptoms Sleep Disturbances
Why Is BPSD Important? • Lifetime risk is nearly 100% • Associated with increased morbidity and nursing home placement • Potentially treatable
1. What Do You Do Next? • Start haloperidol 0.5 mg at night • Start risperidone 1 mg at night • Increase donepezil to 10 mg • Increase oxybutynin to 10 mg twice a day • Increase acetaminophen to 1000 mg twice a day • Clarify the history and perform a careful physical and neurologic exam
Evaluation of BPSD • Obtaina History- clear description of the behavior from the patient & others • Temporal onset, course • Associated circumstances • Relationship to key environmental factors • In context of the patient’s medical, family and social history
Evaluation of BPSD • Careful Physical & Neurologic Exam Assess Mental Status Pay attention to: • Appearance and Behavior • Speech • Mood • Thoughts and Perceptions • Cognitive Function • Attention
Evaluation of BPSD • Lab Studies • CBC and metabolic panel in all cases of new onset BPSD • Brain imaging, EKG, CXR, and urinalysis based on the history and exam
Evaluation of BPSD R/O Delirium • Acute Conditions such as pneumonia, UTI, pain, angina, constipation, poorly controlled diabetes, electrolyte imbalance • Medication Toxicity or adverse effects of medications due to new or existing medications
Evaluation of BPSD R/O Environmental Causes 1. Make sure pt’s basic physical needs are met 2. Environmental Precipitant • Disruptions in routine • Over Stimulation • Under Stimulation
Evaluation of BPSD After medical, environmental, and care giving causes are excluded, it can be concluded that the primary cause is progression of the dementia
2. What Do You Do Next? • Start haloperidol 0.5 mg at night • Start risperidone 1 mg at night • Increase donepezil to 10 mg • Start citalopram 10 mg daily • Start valproate 250 mg daily • Start carbamazepine 100 mg daily • Review nonpharmacologic, patient-centered interventions
Guidelines for Management of BPSD 1997 Consensus statement from the American Psychiatric Association 2003 Consensus statement from the American Geriatrics Society and American Association for Geriatric Psychiatry
Guidelines for Management of BPSD Nonpharmacologic Interventions First • 40% of BPSD symptoms spontaneously resolve; “they come and go” • Placebo response can be quite substantial • No FDA approved medications for psychosis in AD
Nonpharmacologic Strategies:To Minimize Development of BPSD • Maintain a structured daily routine • Environmental modifications • Utilize good communication skills • Encourage independence in ADLs
Nonpharmacologic Strategies:To Minimize Development of BPSD Person-Centered Showers and Towel Baths • Create environment based on patient comfort and preference • Cover with towels to maintain warmth and modesty • Use no-rinse soap and warm water • Use gentle massage to cleanse • Modify shower spray www.bathingwithoutabattle.unc.edu
Nonpharmacologic Strategies: Agitation/Aggression (<1/wk) • Identify the precipitating factor and avoid the triggers • Distraction Techniques • Behavior Modification • Positive reinforcement of desirable behavior
Nonpharmacologic Strategies: Agitation/Aggression (<1/wk) • Environmental Modifications • Preferred music • Aromatherapy-lavender • Light and pet therapy • Exercise and structured activity therapies ***Physical restraints should be avoided
3. What Do You Do Next? • Prescribe zolpidem 5 mg • Recommend melatonin 0.3 mg • Prescribe triazolam 0.125 mg • Prescribe trazodone 25 mg • Prescribe mirtazapine 7.5 mg • Counsel about nonpharmacologic interventions to promote sleep
Matching Target Symptoms Sleep-wake Cycle Disturbance >1 Month After R/O depression and other psychiatric conditions: Consider: Nonpharmacologic Interventions • Only Guidelines for patients with primary sleep disorders exist • No RCT of newer agents tested in this population • McCurry SM et al. Nighttime insomnia treatment and education for Alzheimer's disease: a RCT. JAGS. 2005
Matching Target Symptoms Sleep-wake Cycle Disturbance >1 Month Nonpharmacologic Interventions • Follow Structured sleep and rising times that were not to deviate no more than 30 minutes from the selected times • Encouraged patients not to nap after 1 PM and limit naps to 30 minutes or less • Walk for 30 minutes exercise daily • Reduce light/noise levels in their sleeping areas
Matching Target Symptoms Sleep-wake Cycle Disturbance >1 Month Nonpharmacologic Interventions • Switch to decaffeinated drinks and reduce evening fluid consumption • If nocturia affected sleep, encourage toileting schedules at night, use of incontinence pads, exclude urinary tract infections • Eliminate triggers for nighttime awakenings ie control night time pain, give nightly snack, take activating meds in the AM
4. Which Is the Most Appropriate Pharmacologic Treatment? • Prescribe diphenhydramine 25 mg • Prescribe zolpidem 5 mg • Prescribe melatonin 0.3 mg • Increase donepezil to 10 mg • Prescribe trazodone 25 mg • Prescribe mirtazapine 7.5 mg
APPROVED Hypnotics for INSOMNIA BZO R Agonists a. BZO Temezepam, Triazolam b. Non-BZO Zolpidem Zaleplon Eszopiclone Melatonin R Agonist Ramelteon NON-APPROVED for INSOMNIA Sedating Antidepressant Trazodone Mirtazapine Antipsychotics Anticonvulsants NONPRESCRIPTION AGENTS Sedating Antihistamines Melatonin Matching Target Symptoms Sleep-wake Cycle Disturbance >1 Month
Matching Target Symptoms Sleep-wake Cycle Disturbance >1 Month GRS 6 Recommends: • Trazodone • Mirtazapine • Zolpidem and zaleplon Avoid: • Benzodiazepines • Antihistamines especially diphenhydramine Associated with high risk for falls, hip fractures, disinhibition, and cognitive disturbance when prescribed for patients with dementia
Matching Target Symptoms Sleep-wake Cycle Disturbance >1 Month Pharmacologic Therapy for primary sleep disturbances when nonpharmacologics fail • Benzodiazepine receptor agonists • Atypical Antipsychotics • Cholinesterase inhibitors • Melatonin as a hypnotic in this population appears equivocal *Pandi-Perumal SR, et al. Melatonin and sleep in aging population. Exp Gerontol. 2005
5. What Is the Most Effective Initial Management Strategy for This Patient? • Enrollment in Adult Day Health Care Center • Caregiver education and training in coping skills • Prescribe nortriptyline 25 mg • Prescribe sertraline 25 mg • ECT (Electroconvulsive Therapy)
Matching Target Symptoms Mood Symptoms in AD: Depression Depression of 2 weeks’ duration resulting in significant distress or sustained depressive features lasting more than 2 months Consider: Antidepressants –first line: SSRIs • Citalopram • Sertraline (improved depressive symptoms and ADLS w/o improving cognition in patient with AD and depression) • Avoid fluoxetine and paroxetine
6. What Would You Do Next? • Switch to another agent in same class • Switch to another agent in another class • Titrate dose of initial medication • Add methylphenidate 5 mg
Matching Target SymptomsMood Symptoms in AD: Depression If a first agent has failed an adequate therapeutic dose for 8 to 12 weeks, consider alternatives: • Bupropion • Mirtazapine • Venlafaxine • Tricyclic agents (desipramine and nortriptyline)
Matching Target Symptoms Mood Symptoms in AD: Depression For partial responders to an antidepressant, consider augmentation strategies • Methylphenidate ????
Matching Target Symptoms Mood Symptoms in AD: Depression If depression remains and patient is in danger of serious weight loss or suicidal ideas despite several antidepressant trials, consider ElectroConvulsive Therapy *No RCT in BPSD or geriatric pts
Matching Target Symptoms Mood Symptoms in AD: Manic-like Behavioral Syndromes Mood syndromes characterized by: • Pressured speech, disinhibition, elevated mood, intrusiveness, hyperactivity, and reduced sleep Consider: • Mood-stabilizing agents • Carbamazepine, lamotrigine, or ?lithium
Matching Target Symptoms Mood Symptoms in AD: Hypersexuality If hypersexuality occurs in association with a recognizable syndrome such as a mania-like state, treat the specific syndrome first First, try Nonpharmacologic Interventions: • Separating pt from others during social situations • Change dinner table assignment • Switch staffing to male attendants when possible • Redirection and distraction
Matching Target Symptoms Mood Symptoms in AD: Hypersexuality Consider: Antiandrogen • Progesterone-MPA • Leuprolide acetate • Cyproterone acetate, Cimetidine, Spironoloctone, Ketoconazole Estrogen Serotinergics:SSRIs, Effexor, Clomipramine, TCA Gabapentin Antipsychotics
Matching Target Symptoms Mood Symptoms in AD: Hypersexuality Caveat: Fronto-Temporal Dementia is often associated with prominent disinhibition and perseveration. In severe cases, a syndrome of hyperphagia, hyperactivity and hypersexuality may occur related to bilateral temporal lobe atrophy
7. What Is Your Recommendation? • Refer for nursing home placement • Do a time-limited trial of haloperidol 0.5 mg • Do a time-limited trial of risperidone 0.5 mg • Do a time-limited trial of olanzapine 5 mg • Do a time-limited trial of valproate 250 mg
Guidelines for Management of BPSD 1997 Consensus statement from the American Psychiatric Association endorse: • Matching target symptoms to relevant drug class 2003 Consensus statement from the American Geriatrics Society and American Association for Geriatric Psychiatry recommends: • Atypical antipsychotic as 1st line for treatment of severe behavioral symptoms with psychotic features in patients with dementia • SSRI’s are first recommended treatment for patients with dementia presented with depression Systematic reviews, Meta analysis, Randomized controlled trials 2004+