How I Treat Aggression in Outpatients With Dementia. C. Omelan MD, FRCP(C)

Transcription

1 How I Treat Aggression in Outpatients With Dementia C. Omelan MD, FRCP(C)

2 Conflict of Interest I have no potential conflicts of interest to declare

3 Overview Outline the prevalence of aggression Review management of responsive beh s Non-pharmacologic pharmacologic Discuss resources for family MD s Discussion/questions

4 Prevalence Of Aggression Community (%) 1 Nursing home (%) 2 Care facilities (%) 3 Overall prevalence Clinically significant Delusions Hallucinations Depressed mood Activity disturbance Aggression/agitation (aggression only) 42 (total agitation) Apathy Lyketsos CG et al. Am J Psychiatry 2000; 157: Brodaty H et al. Int J Geriatr Psychiatry 2001; 16: Ballard C et al. J Clin Psychiatry 2001; 62: 631 6

5 NPS Clusters Apathy Withdrawn Lack of interest Amotivation Aggression Aggressive resistance Physical aggression Verbal aggression Depression Sad Tearful Hopeless Low self-esteem Anxiety Guilt Psychosis Hallucinations Delusions Misidentifications Agitation Walking aimlessly Pacing Trailing Restlessness Repetitive actions Dressing/undressing Sleep disturbance McShane R. Int Psychogeriatr 2000; 12 (Suppl 1):

6 From Gauthier & Thal, 1999

7 Aggression Verbal threats Physical striking-out Often targeted against spouse or family May precipitate an ER visit or hospitalization

8 What Aggression Means... A opportu ity has usua y bee missed The sweet spot for relocating has come & gone Aggression occurring in the community generally makes placement more difficu t

9 Approach to Behavioral Issues Ask ho has the prob em? Ask ho da gerous is the behavior (rather than ho a oyi g) Concentrate on those behaviours which affect safety

10 Approach to Behavioral Issues Identify possible precipitants e.g.spouse s communication style Think about u met eeds Try non-pharmacologic interventions first Reserve medications for when behavior is u safe

11 Approach to Behavioral Issues If emerge t safety issues: call the Mobile Crisis Team or have family pursue a warrant for exam (FORM 1) through the magistrate

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13 GMHT If non-emergent, consider consulting the GMHT Open referral through central intake Not a crisis service Can provide an in-home assessment Have tip sheets regarding aggression or improving communication

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15 Non-Pharm Interventions Proven effective for severe agitation: Me ta hea th assessme t (e.g. GMHT) Exercise Se sory stimu atio Commu icatio ski s trai i g staff & fami y Care mappi g Schedu ed p easa t activities Livingston G. The British Journal of Psychiatry (2014) 205,

16 Alzheimer Society Provides caregiver support & educatio groups Enhanced programs with additional expertise as required Have o i e resources available Special groups for you ger o set deme tia (teleconference & in person)

17 Drug Therapy Drugs used for aggressive behaviors in dementia have limited benefits and significant side effects

18 Can Fam Physician 2006;52:

19 Drug Therapy Only ~18% of pts respond to a given antipsychotic Schneider, LS. et al. JAGS 1990;38: 553. Medications increase falls & hip # Major tranquilizers double the risk of death in demented pts ~1% absolute death rate increase in 8-12 weeks Schneider LS. et al JAMA. 2005; 294(15):

20 Drug Related Mortality Compared with matched nonusers, pts receiving: haloperidol had an d mortality risk of 3.8% (95% CI, 1.0% 6.6%; P <.01) NNH of 26 for 1 excess death/year (95% CI, 15 99) risperidone, d mortality risk of 3.7% (95% CI, 2.2% 5.3%; P <.01) NNH of 27 for 1 excess death/year (95% CI, 19 46) Maust DT. JAMA Psychiatry May 1; 72(5):

21 CCCD (2012) Recommendations Risperido e, o a zapi e and aripiprazo e be used for severe agitation, aggression and psychosis associated with dementia where there is risk of harm to the patient and/or others. The potential benefit of all antipsychotics must be weighed against the significant risks, such as cerebrovascular adverse events and mortality. (Grade 2A) Hermann N. Alz Research & Therapy 2013;5(suppl):55

22 Antidepressants CCCD (2012) concluded: There is insufficient evidence to recommend for or agai s the use of SSRI s or trazodone in the management of agitated patients. (Grade 2B) Hermann N. Alz Research & Therapy 2013;5(suppl):55

23 Trazodone Citalopram Risperidone Quetiapine* Occasionally: Gabapentin* Valproic Acid* Prazosin* Dextromethorphan* Olanzapine Methotrimeprazine* Medications I Use * limited RCT evidence

24 How Long To Treat? Numerous studies have shown that antipsychotics can later be withdrawn ithout cha ge i behaviour Ballard et al J.Clin Psych 2004; 65:

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26 Take Home Points Ask: Who eeds treatment? Use behavioral & environ l interventions first Reserve Rx for behaviors which pose a safety risk or marked distress I generally use non-neuroleptics first trazodone, citalopram, prazosin

27 Antipsychotic Take Home Points Ask: Who needs to stay on tx? Use lowest effective dose for shortest possib e time

28 Resources for Primary Care Geriatric Mental Health Teams (GMHT) through WRHA central intake In community or PCH Psychiatric consultation is available Community-living patients may be referred to SBGH Outpatient department

29 Resources for Primary Care Transitional panel for behavioral issues Behaviour units at Tache Riverview DLC