Transcript Steinberg – Medication Management of Behaviors in RCFEs

Psychotropic Medications in RCFE
Karl Steinberg, MD, CMD, HMDC
About Me
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Harvard, Ohio State, UCSD (Family Medicine)
In North County full-time since 1992
Mission ParkSharp Mission ParkScripps
Mobile Physicians, Kindred Village Square, Life Care Center
of Vista, Hospice by the Sea
Post-Acute & Long-Term Care (PA/LTC) Geriatrics
Hospice & Palliative Care
Medical Ethics
Expert Consultation
Lots of Boards, Committees, etc.
Faculty at CSUSM, Case Western Reserve University
Volunteer Faculty at UCSD, Camp Pendleton, others
Love My Work!
Pets Are Great Therapy!
Definition of Dementia
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Chronic Loss of Cognitive Functioning
Usually Progressive
Multiple Types and Natural History
Common, and Increases with Age
4% at 60
More like 40% at 85
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Huge Public Health Issue
$100B annually in US estimated, will rise
Common Reason for SNF Admission
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Alzheimer’s Disease
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By far the most common type of dementia
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Gradual, Insidious, Progressive, Terminal
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Generally thought to be at least 60% of all cases
But can show sudden decompensation
Usual time course 8-10 years (can range 2-20)
Starts with Memory Problems, progresses into
Behavioral, Language, ADL, Perceptual Problems
Diagnosis Made on Clinical Grounds
~85% accurate
May Co-Exist with other Dementing Conditions
Differential Diagnosis of Alzheimer’s
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Depression (“pseudodementia”): Apathy, Psychomotor
Retardation—antidepressants can be remarkably effective
Vascular Dementia (“multi-infarct”):
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Dementia with Lewy Bodies
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Behavioral Problems, Visual Hallucinations, Parkinsonian Appearance,
Unresponsive Spells. Worsened by traditional antipsychotics.
Frontal Lobe Dementias
Normal Pressure Hydrocephalus
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More stutter-step type progression described, but not always
Gait Problems, Urinary Incontinence, Dementia
Hypothyroidism, B-12 Deficiency, Tertiary Syphilis, HIV
Other neurodegenerative conditions (PML, PSP, vCJD, MS)
Structural Anomalies: Subdural, Neoplasm
Delirium: More of an alteration of attention/sensorium, acute Δ
Toxic/Metabolic Syndromes
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EtOH, anticholinergics, opioids, benzos, NH3, hypoxemia, drug
withdrawal, etc.
Behavioral & Psychiatric Symptoms of
Dementia (BPSD)
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Commonplace (Close to 100% lifetime prevalence)
Exacerbate Physical/Functional Deficits
Often Predictable
Often Multiple Sx Coexist (e.g., Psychosis &
Agitation)
Often Persistent (60-80% in 1 Year for Agitation,
40-60% for Psychosis)
However, usually resolve in time as dementia
becomes advanced/end-stage
Tariot & Blazina 1993, Lyketsos et al 2000, Levy et al 1996, Devanand et al 1997, McCarty et al 2000,
Haupt et al 1999, Hope et al 1999
Behavioral & Psychiatric Symptoms of
Dementia (BPSD)
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Affective (Depression & Mania) Problems
Anxiety/Fear
Psychotic (Thought Disorder, Loss of Reality Testing)
Symptoms
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Hallucinations (Auditory, Visual, Tactile, Olfactory)
Delusions (Beliefs that are contrary to Reality)
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Paranoid Delusions Are Common: Poisoning, Held Captive, etc.
Delusions of Grandeur
Capgras Syndrome (think a relative is an ‘impostor’)
Many Other Variations
Agitation/Aggression
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Many Forms: Pacing, Repetitive Vocalizations, Abusive
Language, Sexual Aggression, Physical Assault
Quiz Question:
How many types of medication are approved for
treating dementia-related behaviors (BPSD)?
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FDA-Approved Meds for Behavioral and
Psychiatric Symptoms of Dementia:
Antipsychotics
in dementia:
1 in 100
DIE from
adverse effects
Overuse of
antipsychotic
medication can
be essentially a
CHEMICAL
RESTRAINT
#14
-18%
Pharmacotherapy Basics
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Assess Specific Target Symptoms &
Monitor Them
If Initial Rx Ineffective, can either taper/DC and Start
New Agent, or Add Second Agent
Empiric Trials of Medication—Not Always EvidenceBased Decisions in geriatrics/LTC Medicine
Start Low, Go Slow, But Go!
Medications Don’t Always Help!
Weigh Risks/Benefits/Alternatives & Document
Thought Process, Consent
Person-Centered!!
Pharmacotherapy Basics
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Omit Unnecessary Drugs
Use Non-Pharmacological Measures
“Start Low, Go Slow, But Go”
Anticholinergics, Benzodiazepines = Bad News
2012 Update of Beers List (AGS)
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Antipsychotics for Dementia are on it
So is Sliding Scale Insulin
When Possible, be sure Informed Consent is obtained
Treatment of Agitation
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No Drug is FDA approved for Dementia with Agitation,
but it is a common problem! (Nuedexta may get it soon)
First consider other causes and non-Rx treatment
(pain, noise, constipation, etc.)
Determine whether there is psychosis
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Determine whether there are affective (especially
manic/hypomanic) features
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If so, consider an antipsychotic
Psychosis without distress does not require Rx
If so, consider mood stabilizer (Divalproex) or antidepressant
In severe/acute cases, consider antipsychotic, or a
benzodiazepine for emergency treatment
Treatment of Agitation/Psychosis
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Antipsychotics
(also called Neuroleptics or Major Tranquilizers)
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Traditional Antipsychotics
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Haloperidol—Haldol, Chlorpromazine—Thorazine,
Fluphenazine—Prolixin, Thiothixene—Navane, Thioridazine—
Mellaril, many others.
High risk of Tardive Dyskinesia in elderly!! (Do AIMS)
May require anticholinergic coverage (e.g. Cogentin, Artane)
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Adds insult to injury as far as cognition in the elderly
Intramuscular Depot forms available
For acute delirium, antipsychotics are drug of choice
Treatment of Agitation/Psychosis
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Atypical Antipsychotics
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Commonly used off-label for agitation of dementia
Clozapine (Clozaril), Risperidone (Risperdal), Olanzapine (Zyprexa),
*Quetiapine (Seroquel), Ziprasidone (Geodon), *Aripiprazole (Abilify),
Paliperidone (Invega), Iloperidone (Fanapt), Asenapine (Saphris),
Lurasidone (Latuda)
Major Black Box Warning, definitely increase risk of serious
cardiovascular/ cerebrovascular events, death
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Weight Gain, Hyperglycemia, Metabolic Effects
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even in short run (12 weeks of therapy)
Not always a bad thing for the LTC population
Many available in oral and immediate-release injectable forms
Some available in Depot form (IM)
Some available in ODT (Oral Dispersing Tablet) form
* Approved for major depressive disorder
Drug Treatment of Alzheimer’s
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2 General Classes of Approved Drugs
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Cholinesterase Inhibitors
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NMDA Antagonist (Mod.-Severe)
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Donepezil (Aricept) (Mild to Severe)
Rivastigmine (Exelon) (Mild to Moderate)
Galantamine (Razadyne) (Mild to Moderate)
Memantine (Namenda)
Acts on glutamatergic neurons
Most effective when one from each class used
together
May show limited utility for BPSD, delirium
Drug Treatment of Alzheimer’s
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Controversy as to Effectiveness
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They Probably Slow Progression
Allow Maintenance of Function for additional
6-12 months
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Underwhelming Results
May be well worth it if it allows patient to remain
at home or lower level of care
Some Patients actually Improve
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Cognitive and Behavioral Parameters
What antipsychotic use is necessary ??
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Antipsychotics are the drug of choice for agitated
delirium, although it is off-label
Antipsychotics are approved and effective for bipolar
disorder (mania)
(Some) antipsychotics are approved and effective
for refractory major depressive disorder
Antipsychotics can be helpful (mostly off-label) for
nausea and hiccups
Distressing psychotic features (paranoid delusions,
disturbing hallucinations, negative ideas of reference,
etc.)
Care Considerations: Quality of Life
What else works? Evidence?
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No drug approved for BPSD/agitation of dementia
Antipsychotics clearly carry significant risks in this
population, and limited (but some) benefits
Physician availability to explain risks and benefits is
of key importance
Nonpharmacological interventions can be very
helpful, although evidence is limited
Systematic Review 2011 done for Veterans Affairs
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Less than 20 good studies (see next slide)
No magic bullet
Resident-specific, individualized strategy can work
What else works? Evidence?
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Reminiscence Therapy: No support
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Simulated Presence Therapy: No support
Validation Therapy: Insufficient evidence
Acupuncture: No quality evidence of benefit or harm
Aromatherapy: Insufficient evidence
Light Therapy: Some beneficial effect on agitation and
nocturnal restlessness, but poor quality. Insufficient
evidence to support its use.
(Hand) Massage and Touch: May have beneficial effect
Music Therapy: Limited evidence, may be of benefit
Snoezelen (Multi-Sensory Stimulation): Insufficient evid.
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Reminiscence is a Good Thing
What else works? Evidence?
TENS: Insufficient evidence
 Animal-assisted therapy: Potential for benefit but no
rigorous evidence
 Exercise: Improvement in sleep and other parameters
but no consistent effect on behavior
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 Wandering: Exercise, Walking not helpful. Tracking
devices, alarms, motion detectors effective.
 Agitation: some benefit in some studies from hand
massage, aromatherapy, thermal bath, calming music
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From British Columbia (Canada)
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There is evidence to suggest that risperidone and
olanzapine are useful in reducing aggression, and
risperidone is more effective in reducing psychosis. (In
Canada,) Risperidone is the only atypical antipsychotic
medication approved for the short-term treatment of
aggression or psychosis in patients with severe dementia.
Despite the modest efficacy, the significant increase in
adverse events suggests that neither risperidone nor
olanzapine should be used routinely to treat residents
with aggression or psychosis unless there is marked risk
or severe distress.
Best Practice Guideline for Accommodating and Managing Behavioural and Psychological Symptoms of
Dementia in Residential Care (Province of British Columbia, 2012)
From British Columbia (Canada)
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Carefully weigh the potential benefits of pharmacological
intervention versus the potential for harm.
Recognize that the evidence base for drug therapy is
modest.
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(Number needed to treat that ranges from 5-14)
Engage the resident/family/substitute decision-maker in
the health care planning and decision-making process.
Obtain consent for health care treatment from the
appropriate decision-maker before administering
antipsychotic medication.
Regularly review the need (or not) for ongoing
antipsychotic therapy for BPSD and trial withdrawal.
Continue non-pharmacological interventions.
Best Practice Guideline for Accommodating and Managing Behavioural and Psychological
Symptoms of Dementia in Residential Care (Province of British Columbia, 2012)
From British Columbia (Canada)
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Table 2- Examples of BPSD Usually not
Amenable to Antipsychotic Treatment
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wandering
vocally disruptive behaviour
inappropriate voiding
hiding and hoarding
inappropriate dressing /undressing
eating inedible objects
repetitive activity
tugging at seatbelts
pushing wheelchair bound residents
Best Practice Guideline for Accommodating and Managing Behavioural and Psychological Symptoms of Dementia in
Residential Care (Province of British Columbia, 2012)
Everything Ages~!
Some Things (and People) Age Better Than Others
Other Useful Medications
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Antidepressants can be helpful—some evidence that
citalopram (Celexa) can reduce agitation symptoms
when given regularly
Trazodone, an old, sedating antidepressant, can be
helpful for sleep and acute agitation at doses well
below antidepressant dose (25-50 mg)
Female hormones, SSRIs sometimes used successfully
for hypersexual behavior
SNRIs (e.g. duloxetine [Cymbalta]) can help for pain
and depression
Nuedexta (dextromethorphan/quinidine) can help for
PBA “emotional incontinence”
Take-Home Messages
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No drug is approved for treating dementia with agitation,
because nothing has ever been demonstrated to be
consistently effective—individualize care decisions!
Much of what we do in LTC is trial-and-error, not necessarily
evidence-based
Off-label use does not mean inappropriate use. Some offlabel use is absolutely appropriate.
Treat people like you would want your own family members
to be treated—but be mindful that not everyone will agree on
specific treatment plans, etc.
Take-Home Messages
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Psychotropic medications can be extremely valuable and
improve the quality of life of our residents
Non-pharmacological measures should be tried first whenever
possible
In general, dose reduction is a good idea, but not for everyone
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Especially longstanding psychotic disorders
(For depression with 2 more more lifetime episodes,
definitely a bad idea!)
The less medications, the better! Always!
Antipsychotic drugs are dangerous
Antipsychotic drugs are very useful for psychotic disorders
Summary
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Antipsychotics are not always poison
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Nonpharmacologic measures are always better,
if they work! Individualize these, be creative.
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Your caregivers may have the best ideas
Consider other kinds of medication
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Risperidone, olanzapine probably best for BPSD
Especially Pain Meds
Insist on prescriber involvement and active
engagement, and document in chart notes—these
drugs are under a lot of scrutiny, AL included
Take-Home Messages
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We all agree that reducing the unnecessary use of these drugs
is a good idea!
Documentation of risks, benefits, alternatives and informed
consent is important to obtain—especially for antipsychotics.
Doc Needs to Participate!
Good idea document informed consent forms and have a
process to ensure physician participation
You need an engaged medical consultant and/or psychiatrist
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Thank you for working in long-term care!
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I Wish You Smooth Sailing