An#psycho#c Medica#on in People with Demen#a

Transcription

1 An#psycho#c Medica#on in People with Demen#a GERARD BYRNE BSc (Med), MBBS (Hons), PhD, FRANZCP, MFPOA School of Medicine, University of Queensland Mental Health Service, Royal Brisbane & Women s Hospital gerard.byrne@uq.edu.au

2 Prevalence of Demen#a By Age, Australia % Jorm et al. Acta Psychiatrica Scandinavica 1987; 76:

3 Propor#on Of Popula#on Aged 65+ Years Projec#ons, Australia

4 Probability Of Being In Permanent Aged Care By Age & Gender DoHA Technical Paper on the changing dynamics of residen#al aged care, April 2011

5 Behavioural & Psychological Symptoms of Demen#a (BPSD) Behavioural symptoms Noisy behaviour (screaming, calling out etc) Agita#on & aggression (hieng, kicking etc) Motor overac#vity (pacing, wandering) Appe#te & sleep disturbance Psychological symptoms Apathy, Anxiety, Depression, Delusions, Hallucina#ons, Misiden#fica#on

6 Behavioural & Psychological Symptoms Community Prevalence by Demen#a Severity (in Cache County, Utah) % NPI* Lyketsos et al. (2001) IJGP 16: *Neuropsychiatric Inventory

7 Persistence of Symptoms Maasbed Study (The Netherlands) % NPI* Aalten et al. (2005) Int J Geriatr Psychiatry 20: N = 199 ambulatory pa#ents with demen#a; 76.4yrs; 2yr persistence means presence of symptom at all 4 assessment periods over 2 years; 80.9% had one or more BPSD at baseline; NPI administered 4 #mes over 2 years *Neuropsychiatric Inventory

8 An#psycho#c Drug Use By Age & Gender, Australia PBS Data; Hollingworth et al. (2010) ANZ J Psychiatry 44,

9 An#psycho#c Use In Sydney Nursing Home Residents (2009) 690 (28%) of 2,465 residents of 44 Nursing Homes were taking an#psycho#c medica#on regularly 537 (21.8%) were taking modern atypical an#psycho#cs 286 (11.6%) were taking risperidone 180 (7.3%) were taking olanzapine 44 of 48 Nursing Homes in the catchment of the Sydney South- West Health Service par#cipated in this survey. Snowdon et al. (2011) Med J Aust 194,

10 Efficacy Of An#psycho#cs In clinical trials of an#psycho#c medica#on in people with demen#a complicated by psychosis, agita#on or aggression approximately 16 of every 100 persons treated showed some improvement this is considered a small effect size Trials generally went for 8-12 weeks only, so very limited knowledge of efficacy beyond this

11 Common Side- Effects Of An#psycho#cs In Older People Seda#on Parkinsonism Falls Weight gain Diabetes Increased lipids

12 Excess Mortality In NH Residents Treated With An#psycho#cs Meta- Analysis of clinical trials: An#psycho#c 4.5% mortality Placebo 2.6% mortality Rela#ve risk: 1.7 For every 100 people with demen#a treated with an#psycho#cs, one death will occur each weeks Chahine et al. (2010) Harvard Review of Psychiatry 18,

13 PBS Authority Rules Olanzapine (Zyprexa ) Schizophrenia Bipolar I disorder Risperidone (Risperdal ) Schizophrenia Bipolar I disorder Behavioural disturbances characterised by psycho#c symptoms and aggression in pa#ent with demen#a where non- pharmacological methods have been unsuccessful

14 An#psycho#c Drug Use By Age & Gender, Australia PBS Data; Hollingworth et al. (2010) ANZ J Psychiatry 44,

15 Survival Following An#psycho#c Discon#nua#on UK NH residents with AD Ballard et al. (2009) Lancet Neurology 8,

16 Behaviour Auer Discon#nua#on NH residents with mild to moderate behavioural disturbance (NPI 14) An#psycho#c vs Placebo difference = 0.49 (95% CI: ) [lixle difference but NS] NH residents with severe behavioural disturbance (NPI 15+) An#psycho#c vs Placebo difference = (95% CI: ) [favours an#psycho#c but NS] Ballard et al. (2008) PLoS Med 5(4): e76. doi: /journal.pmed

17 Non- Pharmacological Treatments For BPSD Two main evidence- based approaches: Behaviour management techniques to reduce frequency of problem behaviours Caregiver training to reduce burden, distress & depression and to increase coping Other specific interven#ons Mainly designed to temporarily modify behaviour (i.e. for 30 minutes or so) Ayalon et al. (2006) Arch Intern Med 166: ; Logsdon et al. (2007) Psychology & Aging 22: 28-36; Selwood et al. (2007) J Affect Dis 101: 75-89; Opie et al. (1999) Aust NZ J Psychiatry 33: ; Bird et al. (2002) Commonwealth Dept Health & Ageing; Turner S. (2005) Aging & Mental Health 9(2):

18 Alterna#ves To An#psycho#cs Ins#tute person- centred care Include rela#ves in the care of the resident Implement structured ac#vity programs Create domes#cally scaled environments Provide flexible care, not rigid rou#nes, thereby reducing resistance to care Improve professionalism of care staff Modified from Rosenwarne et al. (1997)

19 Summary Increased longevity & popula#on structure - > increased demen#a High probability of NH placement Challenging behaviours prevalent but tend not to persist Inappropriate use of an#psycho#c medica#on Increased mortality with an#psycho#cs Discon#nua#on ouen successful Insufficient use of non- drug interven#ons Problems with the funding model

20 Some Policy Sugges#ons Use rate of an#psycho#c drug use in people with demen#a as a quality indicator for NH audits Set targets for reduced use of an#psycho#cs in people with demen#a in Commonwealth- supported programs Support targeted training programs for Registered Nurses, General Prac##oners, Psychiatrists, Physicians, Psychologists (& students of these disciplines) Mandate a formal curriculum for non- pharmacological interven#ons by NH personal care staff & an annual training budget Improve access to clinical psychology input to people with demen#a at home and in RACFs

21 More Policy Sugges#ons Await Produc#vity Commission report on a new NH funding model - improved psychosocial treatment will have cost implica#ons Pursue vigorous pharmaceu#cal detailing via the Na#onal Prescribing Service (NPS) Augment exis#ng Demen#a Behaviour Management Advisory Service (DBMAS) Develop properly funded & supported psychogeriatric NHs in each region to manage the most challenging behaviours [Prosecute off- label prescribers]