Dementia – managing behavioural and psychological symptoms Dr. Jonathan Hare Consultant Old Age Psychiatrist Barnet, Enfield & Haringey Mental Health Trust Dr Robert Tobiansky

Dementia A syndrome due to disease of the brain usually of a chronic or progressive nature Multiple disturbances of higher cortical function Global impairment: intellect, memory, personality Changes in emotional control, social behaviour, motivation In clear consciousness Decline in usual functional abilities

Dementia Many causes but commonest are: Alzheimer’s Disease Vascular Dementia Lewy Body Dementia Alcohol related dementia Frontotemporal dementia

Dementia: general signs & symptoms Early stages: memory impairment, loss of planning, judgement, difficulty with administrative tasks etc intermediate impaired basic ADL can’t learn new information, increasing disorientation time & place increased risk of falls and accidents due to confusion and poor judgment

Dementia: signs & symptoms severe dementia: no ADL skills, totally dependent for feeding, toileting, & mobilising. Severe global cognitive impairment risk of malnutrition and aspiration poor mobility & malnutrition increases risk of pressure sores Seizures, dehydration, malnutrition, aspiration, pressure sores death from infection (resp., skin, UTI etc)

Dementia: signs & symptoms Behavioural problems (BPSD): Persecutory delusions, suspiciousness in c. 25% wandering, aggression, agitation Depressive symptoms in c. 60% Depression in c. 25%

Delirium: DSM 4 criteria Disturbance of consciousness with reduced ability to focus, sustain or shift attention Change in cognitive function not due to pre-existing or evolving dementia Development over short period of time – usually hours or days & tendency to fluctuate during course of day

Delirium: causes Infection Drugs (prescribed & illicit, intoxication or withdrawal) Organ failure (cardiac, resp., hepatic, renal) Electrolyte disturbance (dehyd. Na/Ca/K) Endocrine & metabolic – thyroid, glucose CNS- CVA, subdural, SOL Nutritional – thiamine deficiency Malignancy Hypothermia

Delirium: management Clarify history Assessment of physical & mental state Identify & treat underlying cause May need to treat neuropsychiatric symptoms with modest doses of sedatives or antipsychotics Well-lit, quiet room, address sensory impairment

Levels of evidence Metanalysis Randomised placebo controlled trials Other studies Expert opinion, National guidance, local protocols, expert opinion etc

BPSD Behavioural and Psychological Symptoms in Dementia

BPSD symptoms include: Agitation Aggression Repetitive vocalisations Sexual disinhibition Wandering Shadowing Depression Anxiety Apathy Delusions Hallucinations Irritability Restlessness & overactivity

BPSD Very common in people with dementia Almost all will have at least one symptom at some point in illness Distress to patient & carers Associated with increased institutionalisation Faster rate of decline Increased mortality Increased stress for care staff

NICE guidance CG42 1.7.1.1 assess PWD who develop behaviour that challenges the person's physical health depression possible undetected pain or discomfort side effects of medication individual biography, including religious, spiritual & cultural psychosocial factors physical environmental factors Individually tailored care plans, recorded & reviewed regularly 1.7.1.2 Approaches that may be considered include: aromatherapy multisensory stimulation therapeutic use of music and/or dancing animal-assisted therapy.

Aetiology of BPSD (after Brodarty) Biological Psychosocial Environmental

Biological potential causes Frontal pathology – disinhibition, depression Basal ganglia lesions-delusions Temporal lobe pathology – delusions, hallucinations Locus coeruleus – psychosis, depression Previous / current psychiatric disorder: depression / anxiety / psychosis

Biological causes Acute medical illness eg UTI, RTI causing delirium Medication Pain syndromes Constipation Urinary retention Sensory impairment Basic needs – tiredness, hunger, thirst

Psychological causes Previous psychiatric illness Premorbid personality- no meaningful correlations Frustration fear Interpersonal / reaction of others

Environmental factors Overstimulation Understimulation (boredom) Overcrowding Inconsistent care givers, high staff changes Provocation by others

“Something must be done” Who’s problem is it? What is the behaviour? When does it occur? Where does it occur? Try to understand the behaviour, why is this person presenting like this at this time? Intervene if behaviour results in distress or risk to patient or others

Before intervening Clarify the nature of the problem Document /keep ABC chart of behaviour Confirm most difficult challenging behaviour Are there triggers? Exclude non-dementia causes treat medical disorders & any causes of disability (mobility, vision, hearing etc ) NB PAIN!

Environment Modify environment (nidotherapy) Adequate space Privacy available Personalised space Avoid over / under stimulation Lighting, colours, furnishing, architecture Size of unit Mix of residents staff

Possible Interventions Bright light therapy- weak evidence Aromatherapy (lemon balm, lavender) moderate evidence, cochrane review Snoezelen:multisensory stimulation (modest evidence) Music therapy Person centred / dementia care mapping My life package Cognitive stimulation therapy

Interpersonal Staff education, support & training Dementia care mapping Person centred care (Kitwood) individualised care planning, fairly good evidence can reduce BPSD Psychoeducation for carers Behaviour management techniques

Therapeutic approaches Reminiscence groups Relaxation training Behavioural management techniques

Medication Medication for Behavioural & Psychological Symptoms in Dementia (BPSD)

Medication: Antidementia drugs -cholinesterase inhibitors: donepezil (Aricept) rivastigmine (exelon) galantamine (reminyl) -Memantine (Ebixa)

Licenced drugs Risperidone is the only licensed drug for the treatment of BPSD (aggression) Antidementia drugs are licensed for treatment of cognition not behaviour in restricted severity groups Cholinesterase inhibitors for mild to moderate AD Rivastigmine for mild to moderate Parkinson’s Disease Dementia Memantine for moderate to severe AD

Other medication for BPSD Antidepressants Anxiolytics Hypnotics Antipsychotics Anticonvulsants

Cholinesterase inhibitors for BPSD Systematic review & meta-analysis Statistically significant vs placebo Modest clinical benefit Biggest response on individual symptoms, apathy, hallucinations,

Memantine for BPSD Several RCTs vs placebo (eg Reisberg,et al; Tariot et al; Van Dyck et al; Gauthier et al) Small effect aggression, agitation

Depression in dementia: Cochrane review Antidepressant Dose Study N Duration Outcomes Sertraline 25-150mg Lyketos et al 2003 44 12 wks Positive Clomipramine 25-100mg Petracca et al 1996 21 6 wks Positive Imipramine 50 -150mg Reifler et al 1989 61 8 wks n.s.

Antidepressants in dementia Study of Antidepressants for Depression in Dementia (SADD) study: Banerjee et al Lancet 2011 Mirtazapine & sertraline vs placebo No significant benefits

CATIE-AD study Citalopram effects on BPSD Siddique et al 2009 Trend reduced irritability & apathy Reduced hallucinations

Antidepressants in dementia: conclusion Modest evidence efficacy May benefit agitation

Antipsychotics in dementia RCT evidence: Haloperidol Risperidone Quetiapine Olanzapine Aripiprazole

CATIE-AD: 42 sites, 421 pts randomised to olanzapine, quetiapine, risperidone, placebo

Antipsychotics in dementia Meta-analysis evidence: medium effect size Benefit for severe aggression, delusions

Antipsychotics in dementia 2-3 x increased risk cerebrovascular adverse events 1-2% increased risk death

Defensible prescribing of antipsychotics in Dementia Consider non-pharmacological alternatives Address vascular risk factors Consent / capacity / best interests Discuss risks & benefits with patients or carers Identify target symptoms (psychosis, hostility, aggression) Choose effective drug & dose Choose time-frame during which to assess benefits (discontinue if no evidence benefit or if harm) review need & aim to withdraw in c 3/12 if possible

Doses of antipsychotics start range Risperidone 0.25mg 0.5 to 2mg/day Olanzapine 2.5mg 2.5-10mg /day Quetiapine 25mg 25-100mg Aripiprazole 2mg 5-10mg

Anticonvulsants in dementia Review of RCTs Weak to modest evidence carbamazepine further trials needed Poor evidence / negative for valproate mostly no significant difference Adverse events more frequent in treatment groups

Benzodiazepines RCTs: Benzos reduce agitation Adverse effects: falls, sedation, worsen cognition

Using medication in BPSD Pharmacotherapy can be effective for BPSD First step: identify target symptoms Correct reversible factors Try environmental & psychological approaches first unless high risk of harm to self / others Use medication carefully, “start low go slow” Review treatment

Thank you