Neuropsychiatric Syndromes Susan Czapiewski,MD VAHCS December 10, 2015 Dr. Czapiewski has indicated no potential conflict of interest to this presentation. She does intend to discuss the off-label use of medications for dementia problem behaviors. Disclosures I have no financial relationships to discuss. Any mention of medications for agitation in dementia is off label. Views expressed in this presentation are mine & do not reflect the position or policy of the Veterans Administration or the US government.
What is good geriatric patient care? What are neuropsychiatric syndromes (NPS)? Neuropsychiatry: brain-behavior relationships Conceptualizing NPS When & how to treat NPS? Resources Questions Approach to patients Cognitive impairment/dementia Restore if not enhance function social IADL, ADL Collaborative care Family, caregiver Health care team Advocacy groups (alz.org/mnnd) Chronic disease vs acute care model/guidelines Patients care more about function & comfort than longevity Fried et al. Arch Intern Med. 2011; 171(20)1856-1858.doi:10.1001/archinternmed2011.424
Cognition Ability to perceive, think, communicate, solve problems Domains Attention Executive function Memory Language Visual-spatial Social Intact cognition: required for adaptive function Behavior Complicated, hard to predict Fluid Mediates association between cognition & disability Royall et al, J Neuropsychiatry Clin Neurosci 19:3, Summer 2007 Environmental independence vs dependency
Dementia Alzheimer s Chronic, progressive, debilitating & ultimately fatal Affects patient ability to Provide history Follow advice & medication instructions Remember appointments Judge need for care Organizing principle for care Lazaroff, Morishita et al, Minnesota Medicine, January 2013, 41-45. (CME credit) Behavior problems in Alzheimer s disease Common 90% Ballard et al. Nature Reviews Neurology 2009. 5:245 Predate cognitive impairment by years Masters et al. Neurology. 2015 February 10, Vol 84 Hard to categorize Increase morbidity, mortality, hospital stays, nursing home placement caregiver stress & depression Faster dementia progression
Categorizing behavior problems Neuropsychiatric Inventory (NPI) Cummings JL. Neurology. 1994 Dec;44(12):2308-14.
Neuropsychiatric syndromes Occur prior to onset of cognitive or motor symptoms Represent a change from baseline onset of primary psychiatric illness: 1 st 3 decades Neuropsychiatric syndromes per NPI Psychiatric symptoms Delusions/hallucinations Depression/dysphoria Elation/euphoria Apathy/indifference Agitation/aggression Impulsivity/disinhibition Irritability/lability Aberrant motor behavior Sleep disturbance
Depression v. apathy Van Reekum et al. J Neuropsychiatry Clin Neurosci 2005;17:7-19; Levy et al. J Neuropsychiatry Clin Neurosci 1998; 10:314-319 Depression Often diagnosed Pervasive feelings of sadness, anhedonia, hopelessness, guilt, suicidal thinking Improved with SSRIs Apathy Common in CI & dementia Lack of interest in activities, poor persistence, low social engagement, emotional indifference Worse with SSRIs Agitation & aggression Cohen Mansfield J Gerontol 1989;44:M77-84 Agitation Verbal vocal or motor activity not an obvious expression of need Any set of disruptive, dangerous or distressing behaviors Aggression Hostile physical, verbal or sexual action directed to objects or persons
http://www.uofmhealth.org/news/archive/201503/time- just-say-no -behavior-calming-drugs- alzheimer-patientshttp://www.uofmhealth.org/news/archive/201503/time- just-say-no - behavior-calming-drugs-alzheimer-patients Case Kales et al. JAGS 62:762-769,2014 80 y/o female, moderate dementia. CC: agitation, per daughter. Describe: At bathtime, mom curses at and strikes daughter. Pt: bathing hurts. Dau: not fearful of safety but mom doing this on purpose. Expects daily bathing. Investigate: Pt has arthritis, not on pain meds. It s painful when dau moves her quickly. Dau s communication overly complex. Doesn t understand link between dementia & behavior, harsh & confrontational, expects daily bathing. Has little respite.
Case, contd Create: Provider: rx pain medication, PT & OT referrals, educates daughter: take time out (maximize happiness/minimize frustration), calmer tones, simpler single step commands, light touch to reassure, avoid negative interactions, establish new normal routine: sponge baths, less frequent bathing Evaluate: Interventions: what was deployed, barriers; what was effective & helpful Medications Second line treatment OK to watch, wait At best, modest effects Can cause significant harm No FDA approved drugs Use for danger or distress. Acceptable balance between expected benefits & known risks Reassess frequently
antipsychotics Mainstay of treatment (APA guidelines 2006) Most studied Work within 3-4 days Use lowest effective doses for the shortest length of time Jeste 2007, Ballard 2010, Schneider 2005, JAGS 2011 Mortality increases with dose increase JAMA Psychiatry 2015 May;72(5)438-45 & longer term use Ballard & Corbett 2010 Increase rate of cognitive and functional decline Ballard & Corbett 2010 If drugs don t work on target symptoms within 1-4 weeks, stop Meds usually work with Psychiatric symptoms driving behaviors Delirium Mood disorders* Psychosis* Isolated sleep disorder *approved use of medications Agitation/aggression, irritability/lability causing significant distress or danger
Antipsychotic meds don t work with Apathy Aberrant motor behavior Hoarding Resistance to care Resource www.healthcare.uiowa.edu/igec/iaadapt Free training & education resources for providers Brief video lectures (CME credit) Clinical reference guides Managing problem behaviors & psychosis in dementia & families Shared decision making Managing a crisis Mobile app
IA-ADAPT Mobile Welcome to the Improving Antipsychotic Appropriateness in Dementia Patients app. This app contains pocket guides developed to help providers care for people with dementia and problem behaviors or psychosis. Overview of Step-by-Step Approach and Evaluation Recommendations Delirium Assessment and Management Drugs that May Cause Delirium or Problem Behaviors Non-Drug Management of Problem Behaviors Antipsychotic prescribing guide Antipsychotic guide for direct care providers Managing a Crisis Full IA-ADAPT Site - Iowa Geriatric Education Center https://www.healt hcare.uiowa.edu/igec/iaadapt/mobile/home 10/28/15, 7:25 AM Page 1 of 1
Questions?