Behavioral Issues in Dementia March 27, 2014 Dylan Wint, M.D.
OVERVIEW Key points Depression Definitions and detection Treatment Psychosis Definitions and detection Treatment Agitation
SOME KEY POINTS Depression, psychosis, and agitation Common Often comorbid No treatments specific for behavioral problems in dementia
DEPRESSION NOT a reaction to illness Neurologic disability depression Insight into disability depression Rates of depression higher in neuro dz Pathological and anatomical correlates
RECOGNIZING DEPRESSION Gather reliable information Patient often not the best informant Caregivers may have their own biases Observation and gut sense Screening instruments GDS 30 q, yes/no, self, emotional PHQ-9 9 q, mult choice, self, DSM-IV HRSD (Ham-D) 17 q, mult choice, pro
RECOGNIZING DEPRESSION Diagnostic criteria for MDD Required: sadness or anhedonia Vegetative: sleep, appetite, energy Psychological: interest, concentration, guilt, thoughts of death In dementia, also consider Social withdrawal Irritability
RECOGNIZING DEPRESSION Distinguish from apathy Apathetic behaviors Reduced initiative Lack of persistence Apathetic thoughts and emotions Lack of caring Subdued reactions No neurovegetative symptoms No anhedonia or sadness
MANAGING DEPRESSION Optimize dementia care Psychotherapy Poorly studied for dementia Consider therapy for caregiver Behavioral changes Exercise Social stimulation
MANAGING DEPRESSION Antidepressant medications Generally safe Consider potential side effects Anticholinergic (paroxetine, tricyclics) Antihistaminic (mirtazapine, nefazodone, trazodone, tricyclics) Antiadrenergic (tricyclics, sertraline) Cytochrome P450 interactions
MANAGING DEPRESSION Muscarinic Alpha 1 Histaminic TRICYCLICS Amitriptyline ++++ +++ +++ Clomipramine +++ ++ + Desipramine + + + Doxepin ++ +++ ++++ Imipramine ++ + ++ Nortriptyline ++ + + Protriptyline + + + OTHERS Mirtazapine ++++ Nefazodone +++ ++ Paroxetine ++ Sertraline + Richelson 2002, Richelson 2003
MANAGING DEPRESSION Avoid common errors Choose target symptoms/signs wisely Strive for objective endpoints Caregiver information is vital Follow up Ask specifically about side effects Track the same symptoms that led to treatment Use rating instruments when possible
MANAGING DEPRESSION Avoid common errors Persist when appropriate Maximize doses Minimum trial of 8 weeks Desist when appropriate Discontinue ineffective medications Employ different mechanisms of action Communicate expectations to patient and caregiver
PSYCHOSIS Disturbed interaction with reality Delusions false beliefs Types Theft Phantom Boarder Impostor (Capgras) Paranoia Usually persist Severe caregiver burden Infidelity Persecution Nihilism Parasitosis
PSYCHOSIS Hallucinations false perceptions Auditory Most common modality Not just voices Visual Delirium Lewy Parkinson disease Tactile, olfactory, gustatory
PSYCHOSIS Abnormal thought processes Faulty logic Often driven by delusions Impaired cognition Unusual preoccupations Disconnection Derailment Irrelevancy Tangentiality
RECOGNIZING PSYCHOSIS Low threshold of suspicion Unusual thought process Inexplicable behavior Caregiver reports
RECOGNIZING PSYCHOSIS Possible precipitants Iatrogenic DA agonists Stimulants Steroids Benzodiazepines Withdrawal syndromes Medical illness Infection Nutrition Anticholinergics Muscle relaxants Anticonvulsants Opioids Electrolytes
MANAGING PSYCHOSIS Non-pharmacologic Diagnose and treat delirium Increase stimulation and activity Enhance sensory input Avoid arguing Recognize goals safety and comfort of the patient
MANAGING PSYCHOSIS Cholinesterase inhibitors (hallucinations) Alzheimer Lewy body Parkinson Antipsychotics Probably most effective treatment Probably most difficult treatment
MANAGING PSYCHOSIS Side effects Antidopaminergic Anticholinergic Dry mouth Constipation Antihistaminic Drowsiness Antiadrenergic Hypotension Dry eyes Confusion Confusion Dysrhythmia
MANAGING PSYCHOSIS Antipsychotics Side effects, cont Neuroleptic malignant syndrome Metabolic syndrome Weight gain Tardive dyskinesia Elder-specific Sudden death Stroke
MANAGING PSYCHOSIS Rules of thumb -dones (e.g., risperidone, ziprasidone) More specific (dopamine and serotonin) More intense DA blockade (EPS) -pines (e.g., quetiapine, olanzapine) Broader-acting More sedating Probably more beneficial mood effects
MANAGING PSYCHOSIS Serious Adverse Events Rochon et al, Arch Int Med 2008
MANAGING PSYCHOSIS Informed Consent Increase in sudden death in elderly Tardive dyskinesia Metabolic effects
AGITATION Heightened state of excitement / activity Physical Fighting Fidgeting, pacing Affective Crying Laughter Vocal Speaking Screaming
Causes Medical Pain Illness Medication AGITATION Psychiatric Social and situational Forced routines Surrounding activity
MANAGING AGITATION Non-pharmacologic Behavioral and environmental Redirect Decrease stimulation Exercise Music therapy Aromatherapy Inhalation Skin application Lavender, lemon balm
MANAGING AGITATION Pharmacologic General SSRI Memantine Atypical antipsychotics Ginkgo biloba Nocturnal Melatonin Trazodone
GENERAL PRINCIPLES Expect psychiatric disturbances Ask specifically about symptoms The first question is whether to treat Identify treatment goals Are goals achievable? Start low, go slow NOT start slow, go low Remission is the target
GENERAL PRINCIPLES Up-front investment pays off Clarify problem being addressed Communicate goals and expectations Understand the drugs you use At least three antidepressants At least two antipsychotics Continually assess treatment response Use the minimal treatment necessary