Transcript BPSD PPT lecture for resident cases - 4.78 MB

Nonpharmacologic
Management of BPSD*
*Behavioral and Psychological Symptoms of Dementia
Christine Chang, MD
Brookdale Dept of Geriatrics and Palliative Medicine
October 2015
Objectives
Participants will be able to:
1. Define BPSD
2. Evaluate BPSD
3. Discuss the Guidelines for Management
of BPSD
Nonpharmacologic Interventions
What Is BPSD?
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
Case 1: Part 1
1. How would you approach this case?
Evaluation of BPSD
1. Obtain a 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
2. Careful Physical & Neurologic Exam
Assess Mental Status
Pay attention to:
• Appearance and Behavior
• Speech
• Mood
• Thoughts and Perceptions
• Cognitive Function
• Attention
Evaluation of BPSD
3. Lab Studies
•
CBC, metabolic panel and drug levels 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 acute infection
like pneumonia and UTI, angina, electrolyte
imbalance, endocrine abnormality, pain
and constipation
• Medication Toxicity or adverse effects of
medications due to new or existing
medications
Evaluation of BPSD
R/O Environmental Causes
1. Make sure 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
Case 1: Part 1 continued
2. What is the most appropriate treatment?
Case 1: Part 2
3. What is the most appropriate approach?
Guidelines for Management of BPSD
2007 American Psychiatric Association practice guideline for the
treatment of pts with Alzheimer's disease and other
dementias. Second edition1
2012 Nonpharmacologic mgt of BPSD by Gitlin LN, Kales HC,
Lyketsos CG2
2013 Management of the BPSD (the National Resource Center
for Academic Detailing) with support AHRQ3
1 Am
J Psychiatry. 2007; 164 (Suppl 12): 5-56
2 JAMA. 2012 Nov 21; 308 (19): 2020-9
3 NaRCAD with support from a grant from the Agency for Healthcare Research and Quality
December 28, 2013
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
Guidelines for Management of BPSD
4 Effective Nonpharmacologic Interventions
1.
2.
3.
4.
CG Interventions
Unmet Needs Interventions
Behavioral Interventions
Psychosocial Interventions
Worldviews evidence based nursing. 2015;12 (2):108-15
JAMA. 2012; 308 (19):2020-2029
Ont Health Technol Assess Ser. 2008
Arch Intern Med. 2006;166:2182-2188
Am J Psychiatry 2005; 162:1996–2021
Guidelines for Management of BPSD
4 Effective Nonpharmacologic Interventions
1. CG Interventions
CG education about
•
•
Disease, prognosis, realistic expectations
Techniques to minimize development of BPSD
–
–
–
–
–
Maintain a structured daily routine
Environmental modifications
Communication Techniques
Encourage independence in ADLs
Patient –Centered Care
JAGS 2010; 58:1465–1474: ACT-Advancing Caregiver Training
JAMA.2010; 304 (9):983-991: COPE: Care of Persons with Dementia in their Environments
Gerontologist 2003; 43:908–15: Savvy Caregiver, STAR-C, REACH II
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 warm water or no-rinse soap
• Use gentle massage to cleanse
• Modify shower spray
www.bathingwithoutabattle.unc.edu
Guidelines for Management of BPSD
4 Effective Nonpharmacologic Interventions
2. Unmet Needs Interventions
Cohen-Mansfield J et al RCT of UNMET NEEDS protocol-TREA
(TX Routes for Exploring Agitation). Clin Psychiatry. 2012
Guidelines for Management of BPSD
4 Effective Nonpharmacologic Interventions
3. Behavioral Interventions
–
3 R’s (Repeat, Reassure, Redirect)
• Positive reinforcement for desirable behaviors by praising,
encouraging or reassuring
• Distraction technique-redirection
–
Be a Sleuth: Do the “ABC’s”-Avoid triggers
Guidelines for Management of BPSD
4 Effective Nonpharmacologic Interventions
4. Psychosocial Interventions
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–
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Preferred Calming Music
Aromatherapy-lavender
Thermal bath
Bright Light and Pet Therapy
Snoezelen-Multisensory:
light, sound, aroma, massage
Exercise and Structured activity therapies
***PHYSICAL RESTRAINTS SHOULD BE AVOIDED
Aging & Mental Health. 2009, 512–520
Evidence for Guidelines
Ont Health Technol Assess Ser. 2008
Evidence for Guidelines
Ont Health Technol Assess Ser. 2008
Evidence for Guidelines
•
Effectiveness of 4 interventions: nonpharmacologic behavior management
intervention, haloperidol (1.8mg), trazodone (200mg), and placebo1.
•
Training programs for family CG (Savvy Caregiver, STAR-C, REACH II)2,3
•
ACT-Advancing Caregiver Training4 and Prospective 2-group randomized
trial COPE: Care of Persons with Dementia in their Environments
(community-living dyads) 5
Found no significant differences in outcomes, but fewer adverse events
(e.g., bradykinesia and parkinsonian gait)
1 Neurology. 2000 Nov 14;55(9):1271-8
2 Gerontologist 2003; 43:908–15
3 Ageing Res Rev. 2012 Jul 20
4 JAGS 58:1465–1474, 2010
5 JAMA. 2010; 304(9):983-991
Evidence for Guidelines
ACT-Advancing Caregiver Training
•DESIGN: Two-group randomized trial
•PARTICIPANTS: 272 CGs and people with dementia at home
•INTERVENTION (ACT-Advancing Caregiver Training):
– <11 home and telephone contacts over 16 wks by professionals
• Identified potential triggers of BPSD
– Communication factors
– Environmental factors
– Undiagnosed medical conditions (by blood and urine samples)
• Trained caregivers in strategies to modify triggers and reduce their upset
– 3 telephone contacts reinforced strategy use btw 16 and 24 weeks
JAGS 58: 1465–1474, 2010
Evidence for Guidelines
ACT-Advancing Caregiver Training
•RESULTS at 16/24 wks :
– 67.5% (cf with 45.8% (P=0.002) of intervention CGs reported
improvement in targeted problem behavior
– Reduced upset with problem behavior (P=0.03)
– Enhanced confidence managing (P=0.01) the behavior
– Less upset with all problem behaviors (P=0.001)
– Less negative communication (P=0.02),
– Less burden (P=0.05) + Better well-being (P=0.001) c/w CGs had
depressive sxs (53.0% cf 67.8%, P=.02).
– Intervention CGs perceived more study benefits (P=0.05), including
ability to keep family members home, than controls.
JAGS 58: 1465–1474, 2010
Evidence for Guidelines
Care of Persons with Dementia in their Environments
Design
• Prospective 2-group randomized trial COPE: Care of Persons with
Dementia in their Environments (community-living dyads) recruited from
March 2006 -June 2008 in Pennsylvania.
Interventions
• Up to 12 home or telephone contacts over 4 months by health
professionals
– Assessed patient capabilities and deficits
– Trained families in home safety, simplifying tasks, and stress reduction
– Obtained blood and urine samples
• Control group CGs- 3 telephone calls and educational materials
JAMA. 2010; 304(9):983-991
Evidence for Guidelines
Care of Persons with Dementia in their Environments
Results At 4 months, COPE patients had
• Less functional dependence
(adjusted mean difference, 0.24; 95% CI, 0.03-0.44; P=.02; Cohen d=0.21)
• Less dependence in instrumental activities of daily living
(adjusted mean difference,0.32; 95% CI, 0.09-0.55; P=.007; Cohen d=0.43), measured by a 15-item scale modeled after
the Functional Independence Measure;
• Improved engagement
(adjusted mean difference, 0.12; 95% CI, 0.07-0.22; P=.03; Cohen d=0.26), measured by a 5-item scale.
• Improved in their wellbeing
(adjusted mean difference in Perceived Change Index, 0.22; 95% CI, 0.08-0.36; P=.002; Cohen d=0.30) and confidence
using activities (adjusted mean difference, 0.81; 95% CI, 0.30-1.32; P=.002; Cohen d=0.54), measured by a 5-item scale.
By 4 months, 64 COPE dyads (62.7%) vs 48 control group dyads (44.9%) eliminated 1 or more caregiver-identified
problems (21=6.72, P=.01).
*No group differences were observed at 9 months for patients, though
COPE caregivers perceived greater benefits.
JAMA. 2010; 304(9):983-991
Resources for Providers & Family
• Alz.org
• www.agingbraincare.org/ABC Care
Protocols by Dr. Callahan at IU
• Gitlin LN, Kales HC, Lyketsos CG.
NPI mgt of BPSD. JAMA. 2012
• Books
– International Psychogeriatric Assoc
– Peter V. Rabins, Constantine G.
Lyketsos and Cynthia D. Steele
Resources for Providers & Family
Resources for Providers & Family
Resources for Providers & Family
Resources for Providers & Family
Resources for Providers & Family
Resources for Providers & Family
Resources for Providers & Family
Case 2
4. What is your first intervention?
a.
b.
c.
d.
e.
f.
Prescribe zolpidem 5 mg
Recommend melatonin 1.5 mg
Prescribe triazolam 0.125 mg
Prescribe trazodone 25 mg
Prescribe mirtazapine 7.5 mg
Counsel about nonpharmacologic
interventions to promote sleep
4. What is your first intervention?
a.
b.
c.
d.
e.
f.
Prescribe zolpidem 5 mg
Recommend melatonin 1.5 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
Eval of insomnia Potential underlying causes
• Complete Medication list with timing
–
–
–
–
Diuretic (nocturia)
Stimulants/sympathomimetic (nicotine, caffeine, bronchodilators)
Anticholinergics, sedating (sinemet, analgesics)
SSRI-dec REM
• Sleep Diary
• R/O depression + other psychiatric cond’ts
• Physiologic changes with Age and AD:
Physiologic changes with Age and AD:
•
Suprachiasmic Nucleus Damage
(Sleep initiation/maintenance)
•
Circadian Rhythm Degeneration
(inc sleep fragmentation, inc light sleep (stage ½), less restorative sleep (stage ¾),
dec total sleep time
4 abnormal subtypes:
–
–
–
–
•
•
•
Aperiodic type
Free-running
Phase-delayed type
An ultradian rhythm type with an apparent cycle of about 3 to 4 hours; flattened amplitude type.
Rest/activity cycles in AD patients have been characterized by marked day-to-day variability
Decreased Melatonin secretion
Decreased REM (loss of cholinergic neurons in nucleus basalis)
XS hypersomnulence with some apoE4 subtypes
Matching Target Symptoms
Sleep-wake Cycle Disturbance >1 Month
Consider: Nonpharmacologic Interventions
•
The demented elder with insomnia. Clin Geriatr Med. 2008
•
Sleep disorders in Alzheimer's disease and other dementias.
Clin Cornerstone 2004
•
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
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
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
•
Bright light tx at dawn/dusk
5. What is your next approach if your
first intervention fails?
a.
b.
c.
d.
e.
f.
Prescribe diphenhydramine 25 mg
Prescribe zolpidem 5 mg
Prescribe melatonin 1.5 mg
Increase donepezil to 10 mg
Prescribe trazodone 25 mg
Prescribe mirtazapine 7.5 mg
5. What is your next approach if your
first intervention fails?
a.
b.
c.
d.
e.
f.
Prescribe diphenhydramine 25 mg
Prescribe zolpidem 5 mg
Prescribe melatonin 1.5 mg
Increase donepezil to 10 mg
Prescribe trazodone 25 mg
Prescribe mirtazapine 7.5 mg
Sleep-wake Cycle Disturbance >1 Month
APPROVED Hypnotics for
INSOMNIA
1.
BZO R Agonists
a. BZO
Temezepam, Triazolam
b. Non-BZO
Zolpidem*
Zaleplon*
Eszopiclone
2.
3.
Melatonin R Agonist
Ramelteon
Orexin R blocker
Suvorexant-Belsomra
NON-APPROVED for INSOMNIA
1.
2.
3.
Sedating Antidepressant
Trazodone *
Mirtazapine
Doxepin 10
Antipsychotics
Anticonvulsants
NONPRESCRIPTION AGENTS
1.
2.
3.
4.
Sedating Antihistamines
Melatonin
L-tryptophan-milk/honey
Valeria, Kava, St. John’s Wort
Sleep-wake Cycle Disturbance >1 Month
2007 APA + GRS 8 Recommends:
• Trazodone
• Zolpidem and zaleplon1
• Mirtazapine
REM-dyscontrol  clonazepam and cholinesterase inhibitors
(eg, rivastigmine, pramipexole, melatonin)
Avoid:
• Benzodiazepines
• Antihistamines esp diphenhydramine 2
1 GABAA receptor subtype binding in the prefrontal cortex
2 Associated with high risk for falls, hip fractures, disinhibition, and cognitive disturbance
Sleep-wake Cycle Disturbance >1 Month
Pharmacologic Therapy when nonpharmacologics fail
• Benzodiazepine receptor agonists
• Atypical Antipsychotics
• Cholinesterase inhibitors
• Melatonin
•
•
•
•
Pandi-Perumal SR, et al. Melatonin and sleep in aging population. Exp Gerontol. 2005
Paniagua MA, Paniagua EW. The demented elder with insomnia. Clin Geriatr Med. 2008
Bliwise DL. Sleep disorders in Alzheimer's disease and other dementias. Clin Cornerstone.
Cardinali DP, Furio AM, Brusco LI. Curr Neuropharmacol. 2010
Case 3
6. What are the Differential Diagnoses?
7. How would you treat this patient?
a. Enrollment in Adult Day Health Care Center
b. Caregiver education and training in coping
skills
c. Prescribe nortriptyline 25 mg
d. Prescribe citalopram 10 mg
e. ECT (Electroconvulsive Therapy)
7. How would you treat this patient?
a. Enrollment in Adult Day Health Care Center
b. Caregiver education and training in coping
skills
c. Prescribe nortriptyline 25 mg
d. Prescribe citalopram 10 mg
e. ECT (Electroconvulsive Therapy)
Matching Target Symptoms
Mood Symptoms: Depression
Depression of 2 weeks’ duration resulting in
significant distress or sustained depressive
features lasting more than 2 months
Treatment: due to lack of sufficient evidence to support
efficacy and serious side effects prescribe with caution
Consider Antidepressants –1st line: SSRIs
• Citalopram
• Sertraline
•
(improved depressive symptoms and ADLS w/o improving
cognition)
Avoid fluoxetine and paroxetine
JAGS 51;1287-1298,2003
Arch Gen Psychiatry. 2003 Jul;60(7):737-46
Lancet. Volume 378,Issue 9789,30 July–5 Aug 2011, 403–411
Cochrane Review, 2009
Matching Target Symptoms
Mood Symptoms: Depression
If a first agent has failed an adequate
therapeutic dose for 4 to 6 weeks,
consider alternatives:
•
•
•
•
Bupropion
Mirtazapine
Venlafaxine/cymbalta
Tricyclic agents (desipramine + nortriptyline)
Switch or add on –be careful for Serontonin syndrome
Am J Alzheimers Dis Other Demen. 2011
Matching Target Symptoms
Mood Symptoms: Depression
For partial responders to an antidepressant,
consider augmentation strategies
Methylphenidate ????
Modafinil??
The Journal of Neuropsychiatry and Clinical Neurosciences 1997
The Journal of Neuropsychiatry and Clinical Neurosciences 2007
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 geriatric patients with dementia
Case 4
8. When would you consider medications?
9. What medication would you consider in
treating his symptoms?
a.
b.
c.
d.
e.
f.
g.
h.
Increase donepezil to 10 mg daily
Start memantine 5 mg daily
Time-limited trial of risperidone 0.5 mg
Time-limited trial of haloperidol 0.5 mg
Time-limited trial of olanzapine 5 mg
Time-limited trial of valproate 250 mg
Time limited trial of sertraline 50 mg daily
Start a trial of prazosin 1mg daily
9. What medication would you consider in
treating his symptoms?
a.
b.
c.
d.
e.
f.
g.
h.
Increase donepezil to 10 mg daily
Start memantine 5 mg daily
Time-limited trial of risperidone 0.5 mg
Time-limited trial of haloperidol 0.5 mg
Time-limited trial of olanzapine 5 mg
Time-limited trial of valproate 250 mg
Time limited trial of sertraline 50 mg daily
Start a trial of prazosin 1mg daily
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
Pharmacologic Interventions
• If nonpharmacologic interventions fails or
if “agitated” behaviors are too harmful to
patient or others, consider pharmacologic
agents
• What to prescribe?
Guidelines for Management of BPSD
2013 Management of the BPSD
(National Resource Center for Academic Detailing) with support AHRQ
• Nonpharmacologics
• Pharmacologics:
• For Emergent BPSD
• Atypical antipsychotics-have a modest but significant beneficial
effect in the short-term TX of aggression (over 6-12 WKs) but limited
benefits in longer-term therapy
• For Nonemergent BPSD
•
•
•
•
Memantine
Carbamazepine
Citalopram
Prazosin
NaRCAD with support from a grant from the Agency for Healthcare Research and Quality December 28, 2013
Blackbox Warning
for Atypical Antipsychotics
• Increased risk of mortality. Rate of death
was 1.6 to 1.7 times that of placebo
• Death appeared to be heart related or from
infections (eg, pneumonia)
• Diabetes mellitus, hyperglycemia,
ketoacidosis, and hyperosmolar states
http://www.fda.gov/cder/drug/infopage/antipsychotics/default.htm
April 2005
Take Home Points
• Always obtain a thorough hx about the
“disturbance”
• Rule out delirium and other environmental factors
contributing to the disturbance
• Use nonpharmacologic interventions for BPSD first
• Consider “targeted,” time-limited pharmacologic
trials for severe or persistent BPSD symptoms given
modest evidence of efficacy and moderate potential
for harm
Thank You