Transcript Memory Problems – Clinical Assessment and Management

Emotional and Behavioural
Complications of Dementia –
Recognition, Assessment and
Management
Prof Philip Morris
MB BS, BSc(med), PhD, FRANZCP, FAChAM (RACP)
Consultant Psychiatrist/Psychogeriatrician
Medical Advisor – DBMAS NT
Medical Director
Gold Coast – Tweed Memory Clinic
36 Beryl St, Tweed Heads, NSW, Australia
Ph 07 55992220 and
Suite 2, Level 5, 123 Nerang St, Southport, Qld, Australia
Ph 07 55327655
www.drphilipmorris.com
Dementia ‘epidemic’ explodes
Main types of dementia
Alzheimer’s disease (35%)
Vascular dementia (20%)
Mixed Alzheimer’s/vascular (20%)
Dementia with Lewy bodies (10%)
Focal lobar atrophies (frontal variant FTD, semantic dementia,
progressive non-fluent aphasia, and motor neuron dementia) (5%)
Sub cortical dementias (Parkinson’s disease, progressive
supranuclear palsy, multiple system atrophy, Huntington’s disease)
(5%)
Alcohol related (3%)
Head injury (2%)
Memory loss a cardinal feature of dementia along with
either aphasia, apraxia, agnosia or a disturbance of
executive functioning (planning, organizing, sequencing,
abstracting) causing impaired function
Alzheimer’s disease
Most common. Inflammatory plaques of amyloid
outside neurones, and deposition of tau inside
neurones producing tangles. Initially
concentrated in hippocampus and acetylcholine
producing neurones in the basal forebrain. First
causes new learning problems and recent
memory recall problems, and attention
difficulties. Most later onset cases (over age 65)
are ‘sporadic’. Early onset Alzheimer’s disease
more often inherited (mutations on
chromosomes 14, 1, and 21 including Down’s
syndrome – trisomy 21)
Brain atrophy – general and hippocampus – coronal view
Peter Tori
Clinical Features of Alzheimer’s
Disease
Cognitive Symptoms
Attention problems
Memory – recent narrative recall
Language - dysphasia
Visuo-spatial dysfunction
Praxis - apraxia
Executive Dysfunction – planning,
organizing, abstraction, sequencing
Structure of Memory
Memory – 3 Rs: registration (encode - needs attention and arousal),
retain (store), and recall (retrieve)
Implicit/procedural
(unconscious)
Declarative/explicit
(conscious)
(learning of skills and
automatic behaviours)
(learning of information)
Motor/conditioning/priming
(over seconds)
Working/short term memory
(over seconds to minutes)
Phonological loop
Visuo-spatial sketch pad
Long term memory (over days)
Semantic memory
(knowledge and memory
about things)
Episodic memory
(narrative memories)
Clinical Features of Alzheimer’s
Disease
Cognitive Symptoms
Attention problems
Memory – recent narrative recall
Language - dysphasia
Visuo-spatial dysfunction
Praxis - apraxia
Executive Dysfunction – planning,
organizing, abstraction, sequencing
Clinical Features of Alzheimer’s Disease
Non-cognitive Neuropsychiatric Symptoms
– Emotional and Behavioural
Complications of Alzheimer’s Disease
Affective Disturbance
Psychotic Disturbance
Sleep Disturbance
Apathetic Syndrome
Executive Dysfunction Syndrome
Other Clinical Features
Clinical Features of Alzheimer’s Disease
Non-cognitive Neuropsychiatric Symptoms –
Emotional and Behavioural Complications of
Alzheimer’s Disease
Affective Disturbance
Depression 40% - mild to moderate dementia,
less symptoms of ‘sadness’, more of
frustration, anxiety and loss of interest
Irritability - anger, poor tolerance
Agitation 25% – verbal or motor behaviour not
directly related to the needs of the patient
Elation - unusual
Demoralization – despair, loss of control, not
depression, early stage problem
Clinical Features of Alzheimer’s Disease
Non-cognitive Neuropsychiatric Symptoms
– Emotional and Behavioural
Complications of Alzheimer’s Disease
Psychotic Disturbance
Delusions 23% – poorly developed
paranoid delusions (theft, infidelity) and
misidentification syndromes
(family/carers as imposters or strangers)
Hallucinations 15% - visual
misperceptions or misinterpretation (if
early onset – consider Lewy body
dementia)
Clinical Features of Alzheimer’s Disease
Non-cognitive Neuropsychiatric Symptoms – Emotional and
Behavioural Complications of Alzheimer’s Disease
Sleep Disturbance 60% at some time in course of illness
Insomnia, wandering/pacing, excessive daytime sleeping,
decreased REM sleep
Eating problems 40% - loss of interest in food, leads to poor
nutrition
Apathetic Syndrome 70% over the course of the illness
Anterior cingulate gyrus and adjacent medial frontal lobe
involved
Loss of motivation first, then gradual withdrawal from all
interaction
Executive Dysfunction Syndrome
Planning, organizing, abstraction, sequencing problems,
personality change, disinhibition, verbal and motor
perseveration
Other Clinical Features
Balance and gait problems, poor coordination, falls, subdural
bleeds, skin ulcers, chest and urinary infection, delirium
Pharmacological Management of Emotional and Behavioural
Complications of Alzheimer’s Disease
Psychotropic Medications
Antipsychotic agents
‘Typical’ antipsychotics (haloperidol, chlorpromazine)
‘Atypical’ or new generation antipsychotics (risperidone, olanzapine,
quetiapine, aripriprazole)
Cognitive enhancers (‘nootropics’)
Acetyl cholinesterase inhibitors (donepezil, galantamine, rivastigmine
patches)
Glutamate (NMDA) antagonist
Antidepressants
Tricyclics
SSRIs
SNRIs
Mirtazapine, agomelatine
Mood stabilizers
Valproate
Carbamazepine
Lithium
Others
Pharmacological Management of Emotional and Behavioural Complications of
Alzheimer’s Disease
Psychotropic Medications
General approach
Target specific symptoms or behaviours
First try non-pharmacologic methods
Then choose psychotropic agent – start with low dose
Review response
Monitor progress for adverse effects
Consider drug withdrawal
Antipsychotic agents
For psychotic symptoms and severe agitation
‘Typical’ antipsychotics (haloperidol [high potency], chlorpromazine [low
potency])
‘Atypical’ or new generation antipsychotics (risperidone, olanzapine,
quetiapine, aripriprazole)
No significant differences between types in effectiveness at small doses
Side effects differ between classes and within classes (sedation, EPS,
raised prolactin, postural hypotension, anticholinergic effects, weight gain)
Clinical effects modest
Safety concerns – cerebrovascular incidents, death
Pharmacological Management of Emotional and Behavioural Complications of
Alzheimer’s Disease
Psychotropic Medications
Cognitive enhancers (‘nootropics’)
Acetyl cholinesterase inhibitors (donepezil, galantamine, rivastigmine
patches)
For mood (depressive) symptoms, psychotic symptoms, agitation, apathy
Modest benefit on emotional and behavioural problems
Also helpful to enhance attention and cognitive symptoms
Give in usual doses
Glutamate (NMDA) antagonist – memantine
Few studies
Reduced agitation
Improved appetite/eating behaviours
Watch for over-sedation
Reduce dose in renal impairment
Pharmacological Management of Emotional and Behavioural
Complications of Alzheimer’s Disease
Psychotropic Medications
Antidepressants
For depression, agitation, aggression, anxiety, psychotic
symptoms
Tricyclic antidepressants
Avoid due to anticholinergic effects
SSRIs, SNRIs, mirtazapine and agomelatine
A small number of studies have shown effect for treatment of
agitation, aggression, and psychotic symptoms in nondepressed patients with dementia
Use as usual for depressive illness complicating dementia
Mirtazapine is sedative, improves appetite and is anxiolytic
Caution with agomelatine in liver impairment
Pharmacological Management of Emotional and Behavioural Complications of
Alzheimer’s Disease
Psychotropic Medications
Mood stabilizers
No information on lithium
Negative trials for valproate
Carbamazepine
Improved agitation and behavioural disturbance in two studies
Other medications
Benzodiazepines – can induce calming and sedation for short periods,
beware ‘paradoxical’ response
Beta blockers
Hormones (estrogen, anti androgen agents)
Stimulants (dexamphetamine, methylphenidate, modafinil)
Parkinson’s disease medications (selegiline)
Effects of treatment on target
symptoms
Pharmacological Management of Emotional and Behavioural Complications of
Alzheimer’s Disease
Non-pharmacological methods
Reduce agitation and problem behaviours
Theoretical framework
Behavioural model
Environmental vulnerability model
Unmet needs model
Behavioural model
Antecedents (triggers) and consequences shape and can modify behaviour
‘Carrot and stick’ – reward and discourage approach
Environmental vulnerability model
Dementia results in increased vulnerability to the environment and lowers
threshold of response to environmental or stressful stimulus
Unmet needs model
Behaviours arise out of difficulty of person with dementia to control their
environment and to communicate needs – problem behaviours emerge as
attempts to communicate those needs
Pharmacological Management of Emotional and Behavioural Complications of
Alzheimer’s Disease
Non-pharmacological methods
An approach to using non-pharmacological methods for managing emotional
and behavioural complications of Alzheimer’s disease involves Determining the problem behavious to be addressed
Sets out measurable goals
Analyzes the problem behaviours from the behavioural perspective, the
environmental vulnerability perspective, and the unmet needs perspective
Develops a plan that takes into account the unique individual characteristics
and circumstances of the patient and the caring environment
Implements the plan
Monitors the response
Revises the plan as needed