Management of Agitation in Dementia Christina Trevino MD

Disclosures Nothing to disclose

Objectives Review common presentations of behavioral disturbance in dementia Evaluation of the agitated patient with dementia Review efficacy for pharmacologic interventions (No FDA approved agents) Briefly discuss nonpharmacologic interventions

Terminology Neuropsychiatric symptoms (NPS) Behavioral Disturbance Behavioral and Psychological Symptoms of Dementia (BPSD) Discussion relates to Alzheimer’s Dementia

Neuropsychiatric symptoms (NPS) Most pressing treatment issue for patients/families presenting for care Distressing for patients Primary factor in caregiver burden Catalyst for longterm placement

Neuropsychiatric symptoms Affect more than 90% of patients Very difficult to treat lack of insight communication and cognitive barriers sensitivity to adverse effects of psychotropic medication symptoms are fluctuating

Symptom clusters of NPS Mood symptoms- apathy, depression, irritability, anxiety Psychosis- delusions, hallucinations Agitation-aggression, motor restlessness, verbal, resistiveness to care Disinhibition Sleep disturbance

Evaluation Define and describe target behaviors (e.g. reactive v. spontaneous) Evaluate for environmental/unmet physical needs/psychological triggers Rule out medical causes Track symptoms with rating scale NPI-Q Behavioral assessment scale

Pharmacological interventions Psychotropics should be given only when non pharmacological interventions have failed, with 3 exceptions : Major depression with or without suicidal ideation Psychosis causing harm or with great potential of harm Aggression causing risk of harm to self or others Kales et al, J Am Geriatr Soc, 2014 Apr;62(4):762-769

Antidepressants Citalopram: CitAD study- doses of 30 mg Citalopram v. Risperidone RCT When mood symptoms are prominent: SSRI- citalopram/lexapro; sertraline Sleep concerns: low dose trazodone, low dose mirtazapine 1 2 Portiensson et al, 2014 Pollock et al, 2007

Dementia Medications Inconclusive and mixed data Meta-analyses of cholinesterase inhibitors and memantine suggested benefit for agitation in dementia RCTs of memantine v. placebo, and donepezil v. placebo did not show benefit May be beneficial for nonaggressive agitation 1,2 4 3 1 McShane R, Cochrane Database Syst Rev, 2006 2 Trinh N, JAMA, 2003 3 Fox C, PLoS One, 2012 4 Howard R, N Engl J Med, 2007

Antipsychotics For aggression, risk of harm, or distressing psychotic symptoms in Alzheimer’s Dementia Atypical antipsychotic Risperidone- 0.25 mg qhs, max 2 mg qhs Olanzapine- 2.5 mg qhs, max 7.5 mg qhs Abilify- 2 mg qd, max 10 mg qd

Adverse effects of Antipsychotics Movement side effects Metabolic CNS effects- sedation, cognitive decline, delirium Orthostasis Neuroleptic sensitivity in Lewy Body Dementia

FDA Black box warnings, 2005 Increased risk of cerebrovascular events in atypicals 1.6-1.7 fold higher rate mortality for people with AD treated with atypicals compared to placebo Important to consent patient and family to these risks, and document target symptoms

Anticonvulsants Valproic Acid/Depakote- not recommended Gabapentin- open label studies and case reports Carbamazepine- two small studies of 6 week duration showed benefit drug interactions and adverse effects complicate use 1,2 1 Tariot PN, Am J Psychiatry, 1998 2 Olin JT, Am J Geriatr Psychiatry 2001

Other medications Prazosin- Wang 2009 Dextromethorphan/quinidine-Cummings 2015 Stepwise pain management- Husebo 2011 Cannabinoids/THC compounds, brexpiprazole- being studied currently

Behavioral Interventions Education of family re: progressive nature of illness, strong likelihood of behavioral symptoms at some point Caregiver/staff support and education predictable routine, low stimulation, structure Social interaction, pleasurable activity, exercise

Summary Define target behaviors, document what has been tried, track symptoms Rule out reversible causes/medical contributors Treat pain Environmental/Behavioral interventions All medications are off label

Resources For providers: Alzheimer’s Association- alz.org IA-ADAPT-University of Iowa GEC NPI-Q:http://www.medafile.com/cln/NPI-Qa.htm Kales HC, Assessment and management of behavioral and psychological symptoms of dementia, BMJ 2015 For caregivers alz.org ‘36 hour day’- Peter Rabins MD Savvy caregiver-DVD course A Caregiver’s Guide to Dementia- Laura Gitlin