Management of Agitation in Dementia. Kimberly Triplett Ferguson, MS4

Transcription

1 Management of Agitation in Dementia Kimberly Triplett Ferguson, MS4

2 Objectives 1. Review recommended evaluation of agitated patients with dementia. 2. Discuss evidence concerning nonpharmacologic management. 3. Understand risks and benefits of pharmacologic management of the agitated patient with dementia. 4. Review medications to avoid in the treatment of agitated patients with dementia.

3 Evaluation Assess safety Consider physical causes Infection Medications Pain/discomfort Sensory deficits Sleep disorders Consider psychological causes Delusions Confusion Depression

4 Nonpharmacologic Management Person-centered communication Avoidance of physical restraints unless ABSOLUTELY necessary Music therapy Pet therapy Massage/ sensory therapy Aromatherapy 1 Exercise training 2

5 2014 Review of Nonpharmacologic Methods Published in British Journal of Psychiatry 3 33 total RCTs Methods found to be efficacious Music therapy (3 RCTs) Specialized activities (5 RCTs) Sensory interventions (5 RCTs) person -centered care, dementia care mapping (5 RCTs) Not efficacious: aromatherapy, light therapy Insufficient evidence: exercise, training caregivers without supervision,

6 Pain Management Relies heavily on caregiver observation Efficacy of stepwise approach: Acetaminophen, low-dose morphine, buprenorphine patch, pregabalin RCT published in patients Reduction in agitation scores by 17% in treatment group over control after 8 weeks Suggestion that acetaminophen use improved ADLs

7 Pharmacologic Management Anti-dementia drugs Antidepressants Antipsychotics

8 Anti-dementia Medications Cholinesterase inhibitors Small benefit for mild neuropsychiatric symptoms 5 Potentially greater benefit in Dementia with Lewy Bodies rather than AD rivastigmine 6 Questionable efficacy of memantine to diminish aggression/agitation 7

9 Antidepressants SSRIs, especially citalopram 8 Some evidence of reduction in neuropsychiatric symptoms, reduction in caregiver stress Risk of QT prolongation 9 (max dose 20 mg) Weigh risks and benefits

10 Antipsychotics Reserved only for patients with symptoms of psychosis Severe or unsafe delusions, hallucinations Increased mortality- stroke, MI FDA Black Box warning includes all antipsychotics as of Retrospective case control study of > 90,000 pts showing increased mortality risk at 180 days treatment 11 Haloperidol-3.8% (NNH 26) Risperidone-3.7% (NNH 27) Olanzapine-2.5% (NNH 40) Quetiapine-2% (NNH 50)

11 Drugs to avoid Benzodiazepines Especially long-acting Anti-histamines Think sleep disturbances on the hospital floor

12 Summary Agitation is common in elderly patients with dementia and can be difficult to recognize. All possible non-pharmacologic methods should be attempted prior to implementing targeted medications. Understand risks associated with antidepressants, antipsychotics. Best practices and physician treatment preferences should be instilled in all hospital care team members as well as at-home caregivers.

13 References 1. Aromatherapy for dementia. Forrester LT, Maayan N, Orrell M, Spector AE, Buchan LD, Soares-Weiser K Cochrane Database Systematic Review Exercise plus behavioral management in patients with Alzheimer disease: a randomized controlled trial. Teri L, Gibbons LE, McCurry SM, Logsdon RG, Buchner DM, Barlow WE, Kukull WA, LaCroix AZ, McCormick W, Larson EB. JAMA Non-pharmacological interventions for agitation in dementia: systematic review of randomized controlled trials. Livingston G, Kelly L, Lewis- Holmes E, Baio G, Morris S, Patel N, Omar RZ, Katona C, Cooper C. Br Journal Psychiatry Efficacy of treating pain to reduce behavioural distrubances in residents of nursing homes with dementia: cluster randomized clinical trial. Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. BMJ Pharmacological treatment of neuropsychiatric symptoms in Alzheimer s disease: a systematic review and meta-analysis. Wang J, Yu JT, Wang HF, Meng XF, Wang C, Tan CC, Tan L. Journal Neurology Nuerosurgery Psychiatry

14 References 6. Efficacy of rivastigmine in dementia with Lewy bodies: a randomized, double-blind, placebo-controlled international study. McKeith I, Del Se T, Spano P, Emre M, Wesnes K, Anand R, Cicin-Sain A, Ferrara R, Spiegel R. Lancet Memantine for agitation/aggression and psychosis in moderately severe to severe Alzheimer s disease: a pooled analysis of 3 studies. Wilcock GK, Ballard CG, Cooper JA, Loft H. Journal of Clinical Psychiatry Comparison of citalopram, perphenazine, and placebo for the acute treatment of psychosis and behavioral disturbances in hospitalized, demented patients. Pollock BG, Mulsant BH. American Journal of Psychiatry Effect of citalopram on agitation in Alzhemier disease: the CitAD randomized clinical trial. Porsteinsson AP, Drye LT, Pollock BG, Devanand DP, Frangakis C, Ismail Z, CitAD Research Group. JAMA The American Psychiatric Association Practice Guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Reus VI, Fochtmann LJ. American Journal of Psychiatry Antipsychotics, other psychotropics, and the risk of death in patients with demential number needed to harm. Maust DT, Kim HM, Seyfried LS, Chiang C, Kavanagh J, Schneider LS, Kales HC. JAMA Psychiatry