THE EXESSIVE USE OF NEUROLEPTICS IN DEMENTED PATIENTS

1. THE EXESSIVE USE OF NEUROLEPTICS IN DEMENTED PATIENTS Rasa Ruseckiene Old age psychiatrist psychotherapist University hospital of Vilnius Vilnius University Lithuania, 2013

2. Vilnius University, Lithuania What is dementia? • Deterioration from a previously obtained level of cognition and/or behaviour • Cognitive deterioration disproportionate to disturbance of arousal • Duration of at least several months • Deficits that interfere with daily life • The chronic confusional state

3. Vilnius University, Lithuania The impact of dementia • Dementia is one of the most severe and challenging disorders we face • Worldwide an estimated 36 million people are living with dementia • A new report predicts that number will increase to more than 115 million by 2025

4. Vilnius University, Lithuania The impact of dementia • The incidence of dementia and the prevalence of dementia rise exponentially with age • Dementia affects men and women in all social and ethnic groups • Dementia has negative effects not only on those with disorder, but also on family members who provide the majority of care

5. Vilnius University, Lithuania Number of hospitalized patients with dementia (psychogeriatric units, Lithuania, 2012)

6. Vilnius University, Lithuania Why are neuroleptics used in dementia? • Behavioural disturbances and mental symptoms are a frequent source of distress to demented patients at any stage of the illness • These non-cognitive symptoms are described as neuropsychiatric symptoms or “behavioural and psychological symptoms of dementia” (BPSD)

7. Vilnius University, Lithuania Why are neuroleptics used in dementia? • BPSD are distressing and problematic for carers, they make a large and independent contribution to caregiver strain and are a common precipitating factor for institutionalization • BPSD are very common and may occur in up to 90% of people with Alzheimer’s and Lewy body dementia

8. Vilnius University, Lithuania BPSD rate in dementia (psychogeriatric units, Lithuania, 2012)

9. Vilnius University, Lithuania Exposure to antipsychotics drugs • Antipsychotics are widely used as the first line pharmacological approach to treat neuropsychiatric symptoms in dementia • Up to 60% - 90% of demented patients in hospital may receive neuroleptics, and 13%-70% of elderly people in institutions receive neuroleptics within any 24 hours for at least one year

10. Vilnius University, Lithuania Exposure to antipsychotics drugs • Often used antipsychotic drugs include haloperidol, aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone, tiapridal (Eastern Europe c.), chlorprotixene (Eastern Europe c.) • Rare used antipsychotics include thioridazine, chlorpromazine, perphenazine, fluphenazine, acetophenazine, promazine, trifluoperazine, triflupromazine, loxapine, pimozide, thiothixene, sulpiridi.

11. Vilnius University, Lithuania Exposure medications in demented patients (psychogeriatric units, Lithuania, 2012)

12. Vilnius University, Lithuania Typical and atypical antipsychotics using (psychogeriatic units, Lithuania, 2012)

13. Vilnius University, Lithuania Positive effect of antipsychotic drugs in dementia • Antipsychotic drugs has minimal/modest efficacy for the treatment of BPSD • There is very limited evidence for the efficacy of typical or atypical neuroleptics for the treatment of symptoms of psychosis in dementia • No additional falls or fractures using atypical NL for less 12 week (risperidone, olanzapine) • There is some evidence to support slightly better improvement in aggression for risperidone (licensed for dementia) • A clinically significant degree of improvement has only been demonstrated for aripiprazole

14. Vilnius University, Lithuania Negative effect of antipsychotic drugs in dementia • All drugs have side effects as well as intended effects • People with dementia are in high-risk of group for adverse effects on the basis of age, frailty, physical co-morbity and interactions with other drugs • This means that people with dementia are much more sensitive to the side effects of typical/ atypical antipsychotics such Parkinsonism, disorders of movement and QT prolongation

15. Vilnius University, Lithuania Safety of antipsychotic drugs in dementia • In recent years, was clear that the use of antipsychotics in dementia is a drug safety issue as well • Food and Drug Administration issued an advisory warning in 2005 that atypical antipsychotics were associated with a 60%-70% increased risk of death among older patients with dementia • Subsequent studies found risks at least as high among users of conventional antipsychotics , and Food and Drug Administration issued a similar warning for such drugs in 2008

16. Vilnius University, Lithuania Safety of antipsychotic drugs in dementia • All cause mortality • There is a dose – response relation with side effects for all antipsychotic drugs except quetiapine • Patients, treated with haloperidol, compared with risperidone, had double the risk of mortality • Risperidone was found to be associated with an increased risk of stroke compared with olanzapine and quetiapine • Quetiapine is associated with the lowest risk of mortality

17. Vilnius University, Lithuania Circulatory system Others CAUSE SPECIFIC MORTALITY Respiratory system Cerebrovascular system

18. Vilnius University, Lithuania Adverse effects rate (psychogeriatric units, Lithuania, 2012)

19. Vilnius University, Lithuania The circulatory system complications risk using neuroleptics

20. Vilnius University, Lithuania Good practice recommendations • A proper assesment using may highlight the problem and appropriate intervention may be provide without the use of antipsychotics • Non – pharmacological interventions should be recommended as a first line treatment unless BPSD symptoms are severe, persistent or reccurent • First line treatment may include targeting the cause of the BPSD

21. Vilnius University, Lithuania Good practise recommendations • Carer training • Carer support • Staff training • Respite care

22. Vilnius University, Lithuania What to do in a suspected case of BPSD? EVALUATION EXPLANATION TREATMENT TREATMENT REVIEW

23. Vilnius University, Lithuania EVALUATIONPhysical factors

24. Vilnius University, Lithuania EvaluationIntellectual

25. Vilnius University, Lithuania EvaluationEmotional

26. Vilnius University, Lithuania Evaluation Capabilities Environment, social/cultural Any change of environment? Does patient feels lost? Is there exscessive noise? Is the environment unfreindly and confusing? Are there any cultural issues in meeting patients needs? How is the interaction with other residents? How is the relationship with family? • Is the patient bored? • Is the patient frustrated about something? • Is the patient angry about something?

27. Vilnius University, Lithuania Explanation • Discuss the current situation with the patient and family members • Explain possible choices of treatment and reasons for picking one • Risks and benefits have been fully clear • Assess cerebrovascular risk factors and explain possible increased risk of stroke and mortality • Patients/caregivers should be cautioned to immediately report signs and symptoms of potential strokes

28. Vilnius University, Lithuania Treatment • If BPSD is severe and complicated, then an atypical antipsychotic should be preferred over a typical one • Drug treatment should have a specific target symptom • Starting dose should be initially be low and then titrated upwards • Drug treatment should be time limited

29. Vilnius University, Lithuania Treatment review • Treatment is time limited and regularly reviewed (every two weeks or one month) and ideally used less than 12 weeks • Monitor for severe reactions, particularly neuroleptic malignant syndrome sensitivity reactions, development or worsening of extrapyramidal features • Changes in condition should be regularly assessed and recorded • Use psychosocial interventions as soon as possible instead of medications

30. Vilnius University, Lithuania Conclusions • Although non – pharmacological interventions are nearly universally recommended as first line treatment, they are commonly insufficient in people with severe and persistent/recurrent BPSD symptoms • Consequently, most patients will be given a psychotropic drugs at some point in their disease progression despite the clear data confirming their associated risk • It is very important to asses properly the patients state, when BPSD is suspected and to select marginally harmful method of treatment

31. Vilnius University, Lithuania Literature • Knapp M, Prince M, Albanese E, Banerjee S et al. Dementia UK: the Full report. London: Alzheimer Society,2007. • Black W, Almeida OP. A systematic review of the association between the behavioural and psychological symptoms of dementia and burden care. International Psychogeriartrics,2004 16(3), 295-315. • Zimmer JG, Watson N, Treat A. Behavioural problems among patients in skilled nursing homes. Am J Public Health 1984;74:1118. • Gillerd CJ, Morgan K, Wade BE. Patterns of neuroleptics use among the institutionalised elderly. Acta Psychiatr Scand 1983;68;419-25. • Huybrechts KF, Gerhard T, Olfson M, Lucas JA. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. 2012 12 (2), 344. • Scneider LS, Dagerman K Insel. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized trails. American Journal of Geriatric Psychiatry, 2006,14, 191-210. • Banerjee S. The use of antipsychotic medication for people with dementia: time for action. 2010, 25 (3.3), 1-59.

32. Vilnius University, Lithuania Literature • Ballard C, Howard R. Neuroleptic drugs in dementia: benefits and harm. Nat Rev Neurosi 2006;7:492-500. • FDA Public Health Advisory, Deaths with antipsychotics in elderly patients with behavioural disturbances. 2010 • Wang PS, Schneeweiss S, Avorn J, Fisher MA, Mogun H. Risk of deaths in elderly users of conventional vs atypical antipsychotics medications. N Engl J Med 2005; 353: 2335-41. • FDA. Information for Healthcare Professionals – antipsychotics.2011.www.fda.gov/Drugs/drug safety. • Setoguchi S, Brookhart A, Dormuth C, Wang PS. Risk of the death associated with the use of conventional versus atypical antipsychotics drugs among elderly patients. CMAJ 2007;176:627-32. • Maher A, Maglione M, Bagley S et al. Efficacy and comparative effectiveness of atypical medications for off-label uses in adults. JAMA 2011, 306:1359-69. • Cummings J. Behavioural and neuropsychiatric outcomes in AD. CNS Spectr 2005; 10: 22-5.