Behavioral and Psychological Symptoms of Dementia (BPSD) Leon Kraybill MD CMD

Behavioral and Psychological Symptoms of Dementia (BPSD) Leon Kraybill MD CMD

Behavioral and Psychological
Symptoms of Dementia
(BPSD)
Leon Kraybill MD CMD
Lancaster General Hospital Geriatric Fellowship
February 4, 2009
“Agitated” behavior
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What is the challenging behavior?
Whose problem is it?
Is it just not doing what “we” want “them”
to do?
Behavioral and Psychological Symptoms of
Dementia (BPSD)
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A heterogeneous range of psychological
reactions, psychiatric symptoms, and
behaviors occurring in people with dementia
of any etiology.
Any verbal, vocal, or motor activities not
judged to be clearly related to the needs of the
individual or the requirements of the situation
An observable phenomena (not just internal)
Objectives
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Identify the range of behaviors in dementia
Discuss possible causes of these behaviors
Review types of nonpharmacological responses
Review medications used for emotional relief
Prevalence of BPSD
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Present in all types of dementia
80-90% of patients develop at least 1
distressing symptom during the course of
their dementia
60% of community dwelling patients with
dementia
80% of dementia patients in nursing homes
BPSD – distressing for all
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Individual – distress is key to tx decisions
Family - noncognitive symptoms are most
distressing, could cope with a 'memory'
disorder. Unpredictable violence or
aggression = desperation
LTC staff need to understand and have tools
for response
Consequences of BPSD
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Caregiver stress
Increased ER visits
Prolonged hospital stays
Increased use of medications
Placement in LTC
Increased financial costs
**Decreased quality of life for patient and
caregiver**
The “unmet needs” model (Cohen-Mansfield)
There is an underlying unmet need that is causing the inappropriate
behavior.
This need is frequently not apparent to the observer or the caregiver,or
else caregivers do not feel able to fulfill this need (example -sensory
deprivation, boredom, and loneliness)
Ideally can identify and prevent the resident from reaching the point of
unmet need
Possible responses:
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Providing sensory stimulation, activities, and social contacts -The provision
of hearing aids may decrease isolation due to sensory deprivation
Easily accessible outdoor area
Reduced levels of restraints
Sufficient levels of light
Good toileting procedures, better
Proper treatment of pain
Learning/behavioral models
(Cohen-Mansfield)
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Behavior is a learned connection between antecedents,
behavior, reinforcement
Many problem behaviors are learned through reinforcement
by staff members, who provide attention when problem
behavior is displayed.
ABC approach
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A = antecedent or triggering event that precedes the problem behavior
B= the behavior of concern
C= the consequence of that behavior
Changing either the antecedent or the consequence may
change the behavior
Learning/behavioral models
(Cohen-Mansfield)
1)
2)
3)
4)
5)
Identify precisely the problem. The more clearly it is defined,
the easier it is implement an effective response
Gather information about the circumstances surrounding the
problem immediately before and after. There may be several
triggers
Set realistic goals, and make plans to achieve them. Seek to
be creative, realistic and tailored to the individual and
caregivers. "Increasing pleasant activity" is more realistic
than "be happy all the time.“
Encourage rewards (to all) for small successes. Changing
behavior is hard work for everyone.
Continually evaluate and modify plans. Consistency but
flexibility. Strategies may need to change.
Environmental vulnerability/reduced
stress-threshold model (Cohen-Mansfield)
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The dementia process results in greater vulnerability to
surroundings and a greater chance that an event will affect
behavior.
Persons with dementia progressively lose their coping
abilities and therefore perceive their environment as more and
more stressful.
Concurrently, their likelihood of being bothered by the
environment increases, resulting in anxiety and inappropriate
behavior when the environmental stimuli exceed the
threshold for tolerating the stress
An environment of reduced stimulation is supposed to limit
the stress experienced and thereby reduce the level of
inappropriate behavior
Relaxation will reduce the stress and thereby decrease the
undesirable behavior.
Terminology
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Agitation – abnormal behavior (ie aggression,
restlessness, etc.)
Psychosis – abnormal perceptions/beliefs that
may lead to agitated behavior (ie paranoid
delusions)
Dementia treatment principle: agitation
generally responds better than psychosis
Range of behavior
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Psychosis (delusions or hallucinations)
Agitation/aggression
Apathy/indifference
Depression/dysphoria
Anxiety
Elation/euphoria
Disinhibition
Irritability/lability
Aberrant motor behavior
Insomnia
Appetite disruption
From Neuropsychiatric Inventory (NPI) rating scale (Cummings et al. 1994)
Subtypes of BPSD (Cohen-Mansfield)
see handout
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Physically aggressive behaviors (hitting,
kicking, biting)
Physically nonaggressive behavior (pacing,
inappropriate touching)
Verbally nonaggressive agitation (repetitive
phrases or requests, calling out)
Verbally aggressive behaviors (cursing,
screaming)
BPSD vs other causes
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Acute/evolving/sudden is often med related or
other medical disease
Progression of underlying dementia –
generally more insidious and persistant
Evaluation
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Obtain a clear description of problem behavior, temporal
onset, course, circumstances
Assess ability to express basic needs (hunger, thirst, fatigue)
Look for delirium – acute/rapid change (dehydration, UTI,
pneumonia, angina, constipation, pain, uncontrolled DM)
Look for mood disturbance (sadness, irritability, withdraw)
Check med changes – always suspect the meds
Ask about environmental precipitants: change in routine,
roommate, caregiver, overstimulation/understimulation, other
disruptive patients, family illness
Framework for treating agitation:
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Important to adopt a pragmatic approach to
treatment
Most situations allow for an initial nonpharmacological approach to management
“Four D” Method
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Define and Describe
Decode
Design and Implement
Determine
Principles of restorative care
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Focus on bigger picture of health and emotional
wellbeing, rather than just “problem behavior”
Capitalize on the individual’s remaining abilities
and strengths
Create an enabling and motivating environment
Provide appropriate tasks and assistance (ie
activities that will be successful)
Practice and repetition are needed (repetition is
the mother of learning)
Staff Techniques
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Communicate face to face, speak slowly & clearly
Use verbal clues
Approach slowly and deliberately (don’t surprise)
Serve as a “calming force”
Humor and laughter
Know what makes the resident tick
Act as if they function at a higher level of cognition
Sensory experience: music, dance, visual contrast,
fragrances, foods, tactile stimulation
Distraction, redirection
Flexibility, “go with the resident’s pace”
Anticipate challenges and difficulties – they are the norm
Behavioral interventions
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Tx underlying medical illness
Correct sensory deficits
Remove offending medications
Keep environment comfortable, calm,
homelike
Regular daily activities and structure
Assess sleep and eating patterns
Educate and support caregiver
Nonpharmacologic interventions
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See handout - Specific
situations of agitation
Medication for BPSD
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Currently there are no FDA approved
treatments for agitation and psychosis in
dementia
FDA Blackbox on antipsychotics
WARNING: INCREASED MORTALITY
FOR ELDERLY PATIENTS WITH
DEMENTIA RELATED PSYCHOSES.
Elderly patients with dementia related
psychoses are at increased risk for death
compared to placebo. This drug is not
approved for the treatment of dementia
related psychoses.
FDA Blackbox warning
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Meta-analysis of 17 double blind RCT’s in
elderly dementia patients, April 2005.
Atypicals associated with a 1.6-1.7 times
greater risk of mortality compared to
placebo. Most deaths from cardiac or
infectious etiology, in some studies – strokes.
Extended to all antipsychotics in June 2008
Common side-effects of antipsychotics
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Extrapyramidal symptoms (akathisia, dystonia,
psuedoparkinsonism, and dyskinesia)
Sedation
Tardive dyskinesia – should screen regularly
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Dyskinesia Identification System: Condensed User Scale (DISCUS)
http://www.dhs.state.mn.us/main/groups/licensing/documents/pub/dhs_id_057837.pdf
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Abnormal Involuntary Movement Scale (AIMS)
www.cqaimh.org/pdf/tool_aims.pdf
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Gait disturbances
Falls
Meta-analysis shows a significant increase in respiratory
tract and urinary tract infections and peripheral edema in
patients treated with risperidone versus placebo (Ballard et
al. 2006)
Study - 2008
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Older adults with dementia: 20,682 in community,
20,559 in LTC
Control: No antipsychotics
Outcomes: serious events in first 30 days
Community dwellers:
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Atypicals: 13.9% had a serious event (3.2 times higher
than control)
Typicals: 3.8 times higher serious event
LTC
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Atypicals: 1.9 times higher serious events than control
Typicals: 2.4 times higher serious event
Rochon PA. Antipsychotic therapy and short-term serious events in older adults with dementia. Arch Intern Med.
2008;168:1090-1096.
CATIE-AD Trial
First cost-benefit analysis of second generation antipsychotics in treating noncognitive symptoms in AD patients
421 AD patients with psychosis and aggression where randomly assigned to
olanzapine, quetiapine, risperidone, or placebo of “watchful waiting” over 9
months
No statistical differences between groups, although placebo most often superior
in net health benefit analysis
Olanzapine group – more impaired on ADL testing- ???sedation, gait
disturbance
Placebo group – best ADL score, lower dependence score, lower total health
care costs - $50-100
Several methodological drawbacks:
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Subjects were outpatients, less impaired then some BPSD trials
High dropout rate compared to other RCTs (likely a design feature)
No washout period
Dosage likely too low for quetiapine (mean 56.5mg/day)
Authors concluded adverse events offset advantages in efficacy
Clinical Antipsychotic Trial of Intervention Effectiveness – Alzheimer’s Disease. Rosenheck, Cost-benefit
analysis…., Arch Gen. Psychiatry 2007; 64(11):1259-1268.
Antipsychotics in LTC
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Only 2 RCTs have examined antipsychotics
in AD over 6 months
Ballard et al (2005) found no difference
between quetiapine, rivastigmine, or placebo
in agitation over 6 months
Atypicals vs typicals
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Atypicals block excessive dopamine transmission,
which is beneficial in schizophrenics.
Elderly patients (especially dementia) have
accelerated dopamine loss and tend to experience
more severe motor side effects than younger
patients.
Less likely to trigger extrapyramidal
symptoms/tardive dyskinesia
No difference in safety, efficacy
Atypical doses
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Olanzapine 5-10 mg/day and Risperidone
1mg/day appear to have low incidence of
EPS, but somnolence remains a concern
See handout
Recommendations
Look for etiology of symptoms
Use caution in these fragile and vulnerable patients
Need shared decision making – staff, families, patients
Identify target signs and symptoms, and set a limited time frame (many
patients improve without treatment over 2-4 weeks)
Treat only severe symptoms, emotional distress, physical safety
Use the lowest dosages for shortest time
Possible doses used:
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Risperidone (Risperdal) 0.5-1.5 mg/day
Olanzapine (Zyprexa) 5-10 mg/day
Quetiapine (Seroquel) 50-200 mg/day
Aripiprazole (Abilify) 7-12 mg/day
Monitor, assess regularly
Taper and trial discontinuation regularly
White paper of American College of Neuropsychopharmacology – reviewed July 18, 2007 in
Neuropsychopharmacology
Documentation
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Target behavior, duration and circumstances
Emotional and physical consequences of the
behavior
Nonpharmacological interventions
Team discussions and interventions
Discussions with resident/POA/family regarding the
circumstances, the risk of medication (death), and
consent for treatment
Can someone else read your documentation and be
able to explain what happened and why the
treatments were chosen?
Serotonergic agents (2005)
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Well tolerated
Beneficial for depression
Not clearly effective in tx of other sx
Pharmacological treatment of Neuropsychiatric symptoms of dementia: A review of the evidence. JAMA
2005;293(5); 596-608
Citalopram vs risperidone study (2007)
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To alleviate severe agitation and psychotic symptoms associated with
dementia in nondepressed elderly (aggression, agitation, hostility,
suspiciousness, hallucinations, or delusions)
Efficacy:
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Total adverse-event scores
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Citalopram overall 32% reduction of symptoms
Risperidone - 35% reduction
Increased 19% with risperidone
Decreased by 4% with citalopram
Citalopram worked on psychotic symptoms like hallucinations and
delusions!
Suggests agitation and psychosis in younger and older populations have
different neurochemistry.
A double-blind comparison of citalopram and risperidone for the treatment of behavioral and psychotic symptoms associated with
dementia. Am J Geriatr Psychiatry. 2007 Nov;15(11):942-52. Epub 2007 Sep 10. (53 patients were randomized to
citalopram and 50 to risperidone)
Haldol for agitation in dementia
(2005 Cochrane review)
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No significant improvement in agitation, compared with
controls
Aggression decreased (not other aspects of agitation)
Dosages 1.2-3.5 mg/day
Recommendations
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Haloperidol was useful in reducing aggression, but was associated
with adverse effects
No evidence to support the routine use of this drug for other
manifestations of agitation in dementia
Haloperidol should not be used routinely to treat patients with
agitated dementia
www.cochrane.org/reviews/en/ab002852.html
Trazodone for agitation in dementia
(2004 Cochrane review)
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Rationale: BPSD may be due to serotonergic
dysfunction
A sedating atypical serotonergic
antidepressant with a lower rate of adverse
effects may help
Limited data from two small studies
Conclusions: Insufficient evidence to
recommend the use of trazodone
www.cochrane.org/reviews/en/ab004990.html
Valproate preparations for BPSD (2004
Cochrane review)
No evidence of efficacy of valproate preparations
for treatment of BPSD
Adverse reactions
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Sedation occurred more frequently than in controls
Urinary tract infection was more than in controls
Low dose with valproate preparations is ineffective
in treating BPSD
High dose therapy is associated with an
unacceptable rate of adverse effects
Cholinesterase inhibitors
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Initial studies focused on cognition, yet there is
increasing evidence of a possible behavioral
benefit as well
Meta-analysis of ChEI studies - Modest but
significant behavioral benefit compared with
placebo Trinh et al. (2005)
Several post-hoc analyses of studies with
galantamine and donepezil suggest beneficial
effects on psychosis, agitation, mood, apathy,
and aberrant motor behaviors
(Mega et al. 1999; Herrmann et al. 2005; Cummings et al. 2006)
Cholinesterase inhibitors
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Data review suggest a statistically significant
difference
But magnitude of effect is small, and of
questionable clinical significance
Memantine
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3 studies have examined the effect of memantine on
BPSD in moderate-severe AD
Post-hoc analysis suggests benefits, particularly for
aggressive, agitated behaviors (Gauthier S et al 2005;
Cummings et al. 2006)
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Memantine also appears to delay emergence of
agitation and reduce caregiver distress (Cummings et al
2006)
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Other reviewers question the clinical significance of
the benefit
Carbamazepine
The Good News:
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4 RCTs demonstrate benefit for aggression and agitation
(Tariot el al. 1994; Cooney et al. 1996; Tariot et al. 1998;
Olin et al. 2001)
Tariot et al. (1998) completed a nursing home study
where 72% of patients improved versus only 21%
placebo
One of the largest effect sizes of all BPSD trials
The Bad News: Concerns about tolerability in
elderly, drug-drug interactions, and adverse events
unfortunately limit its use
Benzodiazepines
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Several studies support efficacy
Main concern is high rate of adverse events
in the elderly
Excessive sedation, falls, cognitive
impairment, paradoxical agitation
Guidelines support only short-term as-needed
use
What if we stop meds?
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3 placebo controlled withdrawal studies
indicated no worsening of behavior when
long-term administration of neuroleptics
were stopped
(Cohen-Mansfield et al. 1999; Bridge-Parlet. 1997; Ballard et al. 2004)
Sexually inappropriate behaviors
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Likely more due to disinhibition, than
hypersexuality
Occurs in 7-25% of significantly impaired
older
SSRI
Antiandrogen
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Progesterone 5 mg po daily (10 mg IM weekly)
Leuprolide 5-10 mg IM monthly
Parkinsonian motor disturbances &
meds
Dementia with Lewy bodies (DLB), Parkinson disease (PD)
and up to 50% of Alzheimer disease (AD)
Neuroleptic antipsychotics are dopamine receptor
antagonist
Severe motor deterioration (neuroleptic sensitivity)
Small trial (9 subjects) Quetiapine (25-300 daily, mean 120)
vs placebo
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No difference in cognitive or behavioral scores
Adverse reactions – similar, except ↑ dizziness in quetiapine
Quetiapine for agitation or psychosis in patients with dementia and parkinsonism. Neurology - Volume 68, Issue 17 (April 2007)
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Quetiapine - dosages of 200 mg/day or higher may be
needed to control agitation in demented patients
Zhong K, Tariot PN, Mintzer J, et al. Quetiapine for the treatment of agitation in elderly institutionalized patients with dementia: a
randomized, double-blind trial. Presented at the American College of Neuropsychopharmacology Annual Meeting;
December 12–16, 2004; San Juan, Puerto Rico.
Manic-like syndromes
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Sx: pressured speech, disinhibition, elevated
mood, intrusiveness, hyperactivity, reduced
sleep
Likely secondary to the dementia
Coexist with confusional state
Irritable/hostile > euphoria
Consider divalproex 125 BID
Apathy or depression?
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Often confused with depression, since symptoms
overlap (diminished interest, hypersomnia, fatigue,
lack of insight, psychomotor retardation)
Apathy traits: emotional indifference, denying
feelings of depression, reduced ability to initiate in
multiple domains (cognitive, motor, gait)
Meds to increase dopaminergic transmission:
Bupriopion, amantadine, psychostimulants
(Ritalin,etc), rivastigmine (Exelon), donepezil
(Aricept). SSRIs may help but produce agitation.
What don’t meds help?
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Meds don’t help general agitation –
especially wandering
F-tag 329
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Doses above these milligrams trigger
scrutiny:
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Haloperidol (Haldol) 4 mg
Risperidone (Risperdal) 2 mg
Olanzapine (Zyprexa) 10 mg
Quetiapine (Seroquel) 200 mg
F-tag 329
The facility must assure that residents who are
undergoing antipsychotic drug therapy receive
adequate monitoring for significant side effects of
such therapy with emphasis on the following:
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Tardive dyskinesia;
Postural (orthostatic) hypotension;
Cognitive/behavior impairment;
Akathisia
Parkinsonism.
F-tag 329 (12/06 update)
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During the first year in which a resident is admitted on a
psychopharmacological medication (other than an antipsychotic or a
sedative/hypnotic), or after the facility has initiated such medication, the
facility should attempt to taper the medication during at least two separate
quarters (with at least one month between the attempts), unless clinically
contraindicated. After the first year, a tapering should be attempted
annually, unless clinically contraindicated. The tapering may be
considered clinically contraindicated, if:
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The continued use is in accordance with relevant current standards of practice
and the physician has documented the clinical rationale for why any
attempted dose reduction would be likely to impair the resident’s function or
cause psychiatric instability by exacerbating an underlying medical or
psychiatric disorder; or
The resident’s target symptoms returned or worsened after the most recent
attempt at tapering the dose within the facility and the physician has
documented the clinical rationale for why any additional attempted dose
reduction at that time would be likely to impair the resident’s function or
cause psychiatric instability by exacerbating an underlying medical or
psychiatric disorder.
www.cms.hhs.gov/transmittals/downloads/R22SOMA.pdf
Summary for gradual dose reduction
(GDR) – F-tag 329
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Within 1st year after admission on
antipsychotic or after initiation: GDR in 2
separate quarters, with at least one month
between attempts
After 1st year - GDR annually