Treatment protocols for BPSD

1. Treatment protocols for BPSD Professor Clive HolmesMemory Assessment and Research Centre University of Southampton & Hampshire Partnership Foundation Trust

2. Declaration of interest I have received research grants, consultancy fees and honoraria from: Lundbeck Novartis

3. The need for local treatment protocols Confusion about (often) conflicting information Academic literature; pharmaceutical industry; national guidelines; local experts Concerns about litigation Safety in numbers Cost Commissioners

4. Problems with developing local treatment protocols Compromise Local experts v.s. local experts Local experts v.s. National guidelines Cost v.s. effectiveness Primary care v.s. Secondary care Loss of clinical autonomy Audit

5. BPSD local treatment protocols: influences National guidelines Evidence base Local experts PCTs/ Trusts Licensing issues

6. National guidelines NICE technology appraisal guidance NICE-SCIE guideline SIGN guideline Royal College Psychiatry British Association of Psychopharmacology National Dementia strategy The use of anti-psychotic medication for people with dementia – Time for action

7. National guidelines Advantages Influential Cost considerations often implicit Safe Disadvantages Conflicting advice with other guidelines In some areas of BPSD advice non specific Committee driven Representation Political agendas NICE GUIDELINES SAY USE ACHE IN MILD MOD SEVERE AD FRO BPSD C.F. GUIDEIDANCE Helplessness…can make a clinician into a stae of helpless ness..told what not to do …don’t prescribe antispychotics but not given realistic alternatives because alternatievs often not allowed under other gudeianceNICE GUIDELINES SAY USE ACHE IN MILD MOD SEVERE AD FRO BPSD C.F. GUIDEIDANCE Helplessness…can make a clinician into a stae of helpless ness..told what not to do …don’t prescribe antispychotics but not given realistic alternatives because alternatievs often not allowed under other gudeiance

8. Evidence based approach Levels of evidence base Metanalysis Randomised placebo controlled trials Other studies Expert opinion

9. Evidence based approach Advantages Can see bigger picture e.g. side effects; effect size Politically neutral Safe Disadvantages In BPSD often woefully inadequate Often level 4 anyway Time consuming to review

10. Local expert opinion Advantages Ownership In some areas of BPSD as good or better than published evidence Disadvantages Opinions can vary widely and can be esoteric The halo effect May be influenced by local pharmaceutical exposure Can’t see the bigger picture Side effects e.g. mortality and antipsychotics May not be cost effective

11. PCTs and other commissioners Primary concerns Adherence to governmental guidelines Including restrictions of the initiation of cholinesterase inhibitors and memantine Use of antipsychotics Cost

12. Licensing issues Risperidone is the only licensed drug for the treatment of BPSD (aggression)* Antidementia drugs are licensed for treatment of cognition not behaviour in restricted severity groups Cholinesterase inhibitors for mild to moderate AD Rivastigmine for mild to moderate Parkinson’s Disease Dementia Memantine for moderate to severe AD

13. BPSD local treatment protocols: influences National guidelines Evidence base Local experts PCTs/ Trusts Licensing issues

14. Developing treatment guidelines in HPFT Request by Southampton City PCT for guidance Nov 2008 Medicine Management Committee HPFT Dec 2008 Existing national guidelines RCPsych; NICE; NICE-SCIE; BAP; CSM; SIGN Licensing indications BNF Evidence base literature search First draft consultation with Consultant OAP’s/CMN’s teams Approval by MMC HPFT March 2009 Approval by Basingstoke; Southampton and Winchester DPC Aug 2009 Adopted by Portsmouth APC Aug 2009 Next review Aug 2010

17. Things to consider before reaching for the prescription pad Exclude delirium Manage or treat non disease specific factors Pain; carer specific; iatrogenic; environmental factors Consider non pharmacological management Only consider pharmaceutical treatment if symptoms severe; harmful to others or the patient

18. Things to consider before reaching for the prescription pad Identify the dominant target symptom* Depression Apathy Psychosis Aggression Moderate agitation/anxiety Severe agitation/anxiety Poor sleep Other symptoms e.g. vocalisations; hypersexuality Consider your dementia differential diagnosis Dementia with Lewy bodies/Parkinson’s disease dementia Vascular dementia or stroke related dementias Other dementias e.g. Frontotemporal lobe dementia

19. BPSD treatment protocols: influences National guidelines Evidence base Local experts PCTs/ Trusts Licensing issues

20. Pharmacological choices A patient with Alzheimer’s disease has evidence of moderate to severe depression. You believe that pharmacological intervention is warranted. What would be your first drug of choice?

21. Graph of audience drug of choice for first line treatment of depression in AD

22. Prescribing guidelines HPFT

23. Depression in AD : influences National guidelines Not very helpful Local experts Strong steer for citalopram Some preference for sertraline/mirtazepine PCTs/ Trusts Cost Licensing issues Evidence base

24. Antidepressants: depression and related symptoms in AD larger studies with validated scales needed. 6 studies identified roth et al 1996 n = 694 exclued cos unable to identify the demented from the cog impaired,larger studies with validated scales needed. 6 studies identified roth et al 1996 n = 694 exclued cos unable to identify the demented from the cog impaired,

25. Prescribing guidelines HPFT

26. Pharmacological choices A patient with Alzheimer’s disease has evidence of moderate to severe apathy. You believe that pharmacological intervention is warranted. What would be your first drug of choice?

27. Graph of audience drug of choice for first line treatment of apathy in AD

28. Prescribing guidelines HPFT

29. Apathy in AD : influences National guidelines Not very helpful Cholinesterase inhibitors initiated in secondary care Local experts Steer for a cholinesterase inhibitor PCTs/ Trusts Cholinesterase inhibitor couldn’t be first line Licensing issues Evidence base Some retrospective evidence for cholinesterase inhibitors

30. NPI 12-item Total: Moderate to Severe ADNPI Individual Item Analysis In a subanalysis of NPI scoresby gauthier treatment benefits were most evident for depression, anxiety, and apathy. Athough relative effects are seen right across these sysmotms and it may well reflect the relative frquencies of these symtoms at baslien. In a subanalysis of NPI scoresby gauthier treatment benefits were most evident for depression, anxiety, and apathy. Athough relative effects are seen right across these sysmotms and it may well reflect the relative frquencies of these symtoms at baslien.

31. Prescribing guidelines HPFT

32. Pharmacological choices A patient with Alzheimer’s disease has evidence of moderate to severe aggression. You believe that pharmacological intervention is warranted but is not in need of rapid tranquillisation. What would be your first drug of choice?

33. Graph of audience drug of choice for first line treatment of aggression in AD

34. Prescribing guidelines HPFT

35. Aggression in AD : influences National guidelines Strong steer towards non-pharmacological management and dangers of antipsychotics. Slightly greater efficacy for risperidone Evidence base Risperidone Olanzapine; Quetiapine; Aripiprazole Anticonvulsants Memantine Cholinesterase inhibitors

36. Aggression in AD : influences Local experts Very variable; wide and esoteric range of atypical antipsychotics Some use of memantine PCTs/ Trusts major issue was to follow National Guidelines Licensing issues Risperidone is licensed for treatment of aggression in AD

37. Prescribing guidelines HPFT

38. Pharmacological choices A patient with Alzheimer’s disease has evidence of severe agitation. You believe that pharmacological intervention is warranted but is not in need of rapid tranquillisation. What would be your first drug of choice?

39. Graph of audience drug of choice for first line treatment of severe agitation in AD

40. Prescribing guidelines HPFT

41. Severe agitation in AD : influences National guidelines Avoidance of antipsychotics Local experts Strong steer for memantine PCTs/ Trusts Memantine couldn’t be first line Licensing issues Evidence base Antipsychotics Cholinesterase inhibitors Memantine Some retrospective evidence

42. NPI domains: improvement in baseline symptomsPooled data from six studies (MMSE <20), % of patients showing improvement, NPI single items (LOCF)

43. Prescribing guidelines HPFT

44. Pharmacological choices A patient with Alzheimer’s disease has evidence of vocalisations. You believe that pharmacological intervention is warranted. What would be your first drug of choice?

45. Graph of audience drug of choice for first line treatment of vocalisations in AD

46. HPFT : evidence based suggestions for the treatment of vocalisations

48. Graph of audience drug of choice for first line treatment of depression in AD

49. Thank you