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Management of BPSD

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

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  1. Management of BPSD Shahla Baharlou, MD and Christine Chang, MD Brookdale Dept of Geriatrics and Adult Development March 5, 2008

  2. Objectives Participants will be able to: • Define BPSD • Evaluate BPSD • Discuss the Guidelines for Management of BPSD • Nonpharmacologic Interventions • Pharmacologic Interventions

  3. What Is BPSD?

  4. What Is BPSD? Behavioral and Psychological Symptoms of Dementia

  5. What Is BPSD? Non-cognitivemanifestations of dementia Behavioral Symptoms Psychological Symptoms

  6. What Is BPSD? Behavioral Symptoms “Agitation” Related to resistiveness to care Physical vs Verbal Aggressive vs Nonaggressive

  7. What Is BPSD? Psychological Symptoms Mood Symptoms Psychotic Symptoms Sleep Disturbances

  8. Why Is BPSD Important? • Lifetime risk is nearly 100% • Associated with increased morbidity and nursing home placement • Potentially treatable

  9. Case: Part 1A

  10. 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

  11. 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

  12. Evaluation of BPSD • Careful Physical & Neurologic Exam Assess Mental Status Pay attention to: • Appearance and Behavior • Speech • Mood • Thoughts and Perceptions • Cognitive Function • Attention

  13. 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

  14. Evaluation of BPSD R/O Delirium • Acute Conditions such as acute infection like pneumonia and UTI, pain, angina, constipation, endocrine abnormality, electrolyte imbalance • Medication Toxicity or adverse effects of medications due to new or existing medications

  15. 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

  16. 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

  17. Case: Part 1B

  18. Case: Part 2

  19. 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

  20. 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

  21. 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

  22. Nonpharmacologic Strategies:To Minimize Development of BPSD • Maintain a structured daily routine • Environmental modifications • Utilize good communication skills • Encourage independence in ADLs

  23. 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

  24. Nonpharmacologic Strategies: Agitation/Aggression (<1/wk) • Identify the precipitating factor and avoid the triggers • Distraction Techniques • Behavior Modification • Positive reinforcement of desirable behavior

  25. 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

  26. Case: Part 3

  27. 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

  28. Matching Target Symptoms Sleep-wake Cycle Disturbance >1 Month After R/O depression + 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

  29. 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

  30. 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

  31. Case: Part 4

  32. 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

  33. 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

  34. 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

  35. 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

  36. Case: Part 5

  37. 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)

  38. Matching Target SymptomsMood Symptoms: Depression Depression of 2 weeks’ duration resulting in significant distress or sustained depressive features lasting more than 2 months Consider Antidepressants –1st line: SSRIs • Citalopram • Sertraline (improved depressive symptoms and ADLS w/o improving cognition) • Avoid fluoxetine and paroxetine

  39. Case: Part 6

  40. 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

  41. Matching Target SymptomsMood Symptoms: 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)

  42. Matching Target Symptoms Mood Symptoms: Depression For partial responders to an antidepressant, consider augmentation strategies Methylphenidate ????

  43. Matching Target Symptoms Mood Symptoms: 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

  44. Case: Part 7

  45. 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

  46. 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: 1st line for psychotic features • SSRI’s : 1st line for depression Systematic reviews, Meta analysis, Randomized controlled trials 2004+

  47. Psychosis in Dementia Clinical criteria for diagnosis of AD with psychosis: Presence of intermittent delusions or hallucinations occur for at least 1 month and must cause distress

  48. Pharmacologic Interventions • If nonpharmacologic interventions fails or if “agitated” behaviors are too harmful to patient or others, consider pharmacologic agents • What to prescribe?

  49. Matching Target Symptoms Psychosis in Dementia • Antipsychotics Atypical (Risperidone, Aripiprazole, Olanzapine) vs Conventional (Haloperidol) • Memory Enhancers Cholinesterase Inhibitors (ie. Donepezil) NMDA receptor antagonists (Memantine) • Anticonvulsants/Mood Stabilizers • Antidepressants SSRI, Trazodone

  50. Conventional Antipsychotics Haloperidol • Might be effective in treating aggression in patients with dementia but side effects limits its use; extrapyramidal symptoms • Risk for neuroleptic malignant syndrome, tardive dyskinesia, orthostasis, and prolong QTc Cochrane Database of Systematic Reviews. 4, 2007

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