Antipsychotics and Dementia Management

• Dementia, or major neurocognitive disorder (MND), involves cognitive decline and functional loss.
• Alzheimer's, vascular, frontotemporal, Lewy body, and Parkinson's are causes of dementia.
• BPSD includes neuropsychiatric symptoms like delusions, hallucinations, apathy, anxiety, depression, or disinhibition.
• Supportive interventions and medications can help improve the associated symptoms.
• BPSD negatively affects prognosis, increases institutionalization, and strains caregivers.

Objectives:

• Identify psychosocial, medical, and environmental factors behind dementia-related behavioral issues.
• Use evidence-based interventions for treating BPSD.
• Strategize the evaluation and management of BPSD.
• Collaborative communication among the care team improves patient outcomes.

Introduction

• BPSD symptoms include emotional, perceptual, and behavioral disturbances.
• BPSD symptom domains: cognitive/perceptual, motor, verbal, emotional, and vegetative.

Etiology

• BPSD arises from interactions between biology, experiences, and environment, not a single etiology.
• Agitation, psychosis, and disinhibition stem from reduced brain volume and metabolism in emotional regulation, self-awareness, perception areas.
• Neurotransmission imbalances (cholinergic, dopaminergic, serotonergic etc.) can contribute to BPSD.
• Non-biological factors: pre-morbid neuroticism, caregiver communication issues, sensory over or under-stimulation, influence BPSD.
• Environmental contributors: unmet needs, patient-environment mismatch, and behavior/ learning issues can relate to BPSD.

Epidemiology

• In 2016, about 43.8 million people worldwide had dementia, a 117% increase from 1990.
• Up to 97% of community-dwelling dementia patients develop BPSD, symptom severity increases over time and correlates with institutional placement. Delusions are common in Alzheimer's, apathy/depression in vascular dementia, disinhibition and eating disturbances occur in frontotemporal dementia.

History and Physical

• History-taking prioritizes intervention urgency, symptom characterization, and identifying reversible exacerbating factors.
• Factors include environmental characteristics, medications, substance use, and pre-morbid psychiatric disorders.
• Physical examination confirms data and identifies alternate conditions.
• "Sundowning" affects up to 2/3 of patients, delusions are common, paranoid themes often occur.
• Common symptoms leading to hospital admissions: agitation, aggression, wandering, apathy, disinhibition, and sleep disturbances.
• The physical examination can highlight an altered level of consciousness, delirium features, and signs of pain.
• Signs like fever, abdominal tenderness, or neurological deficits may indicate delirium.

Evaluation

• Laboratory/imaging is unnecessary unless the history or physical exam indicates an alternative reason for dementia symptoms.
• Basic studies can reveal underlying causes of delirium.
• Long-term staff may wrongly attribute behavioral issues to UTIs.
• Over-diagnosis and unnecessary treatment can stem from routine testing
• Antibiotic resistance can become a problem
• Diagnostic evaluation and empiric therapy should be enacted for patients with fever, dysuria, suprapubic pain, or new/increased urinary frequency, urgency, or incontinence.

Establish Priorities

• Key is characterizing the severity and nature of the symptoms.
• Inpatient care is best for high risk dementia behaviors like aggression or refusal to eat.
• History should begin with safety assessment
• Prioritize safety and identify delirium, will require a full medical work up and the possibility of parenteral medications.

Characterize Symptoms

• Solicit caregivers describe what the patient is doing rather than using generic terms (ie: agitated, depressed, etc)

Review Medications

• Clinicians should ask about medication changes and the time line of the changes leading up to BPSD signs
• CNS effects of medications should be considered
• Even medication withdrawal can have effects.

Assess Comfort

• Address Pain and painful conditions of the patient
• PAINAD or FLACC scales are reliable for objectively evaluating and tracking pain

Create a Baseline

• Use standardized instrument such as the Neuropsychiatric Inventory ( NPI) and the Behavioral Pathology in Alzheimer Disease Rating Scale ( Behave-AD)
• NPI evaluates delusions, hallucinations, agitation, aggression, depression, dysphoria, anxiety, elation, euphoria, apathy, indifference, etc.
• BEHAVE-AD include delusions, hallucinations, activity disturbances, aggression, diurnal disturbances etc.

Treatment / Management

• BPSD treatment involves setting, discomfort management, non-pharmacological interventions, and pharmacological therapies.
• Interventions begin after establishing a baseline, identifying, and quantifying target symptoms, unless patients are a danger to themselves or others.

Choose an Appropriate Setting

• First is safety and deciding on treatment setting.
• Delirium patients should be in a hospital for evaluation, parenteral meds might be needed.
• Geropsychiatry units are for medically stable self or other endangering patients

Treat Discomfort

• Assess and treat causes of discomfort (pain, constipation, room temp), treatment should address appropriately after.

Non-Pharmacological Interventions for BPSD

• Next step: non-pharmacological interventions.
• Non-pharmacological interventions may suffice for mild BPSD, should always accompany pharmacotherapy.
• Meta-analysis of 10 randomized controlled trials in patients with moderate to severe dementia found no benefit, except music therapy in reducing overall BPSD and massage therapy in reducing depression.
• Caregiver training: reduces BPSD and caregiver wellbing
• Alzheimer's Association offers help to carergivers
• Bathing reduction training can help

Pharmacologic Interventions for Agitation and Aggression

• Psychotropic medications are often employed for managing BPSD
• Wandering/repetitive vocalizations will not respond to meds, rather addressed via non pharmacological interventions,
• Pharmacologic approaches vary on the severity and nature of the symptoms, should always include pain and psychosis, if needed.
• Acetaminophen is a good start for painful BPSD and analgesics if needed

Antipsychotics

• Risperidone and olanzapine are used for agitation and aggression, effect sizes are small
• Adverse effects include cerebrovascular events, somnolence, urinary tract problems, and death, thus, the FDA issued a black box warning of death
• Should only resort to it when everything else has failed
• Aripiprazole can be taken for doses up to 15mg daily, Olanzapine 10mg, Quetiapine 100mg
• Avoid the use of antipsychotics as they can negatively affect symptoms, especially in Lewy body dementia and dementia w/ parkinsons

Complications of Meds

• Patients who take such meds should be closely monitored and have periodic checks to make sure they are effective, must discontinue if there are signs.
• SSRIs; Citalopram and sertraline were associated with improvement, but trazodone wasnt effective.
• 30mg of Citalopram resulted in needed benefit
• Meds such as Dextromethorphan, Quinidine, and Prazonsin, can have side effects, so should be carefil

Combination Meds

• Dextromethorphan and Quinidine has been known to help with BPSD
• Prazosin can be helpful, average of 6mg daily
• Don't use Cholinesterase inhibitors, Memantine, Valproate, and benzodiazepines
• Exception- patients with Lewy body/Parkinson's w/ small effect but increased motor symptoms
• Use Haloperidol for aggression and Ginkgo at 240mg
• While depression and apathy are known be the common BPSD, studies have yet to give an effective study's w/ phamacotherapy
• No benefits were noted for depression or apathy.

Neurostimulation therapies

• Refractory patients may respond to Neurostimulation therapies
• electroconvulsive therapy is highly effective for both depression and aggression

Differential Diagnosis

• Always assess the true diagnosis
• Includes Delirium, Schizophrenia, Bipolar disorder, Depression, trauma, etc
• Delirium is more of rapid incident, whereas BPSD occurs over time

Prognosis

• Shorter life expectancy in patients with BPSD than those without.

Complications

• BPSD increases the overall risks to dementia
• Risk includes long hospital stay, infections, falls, and possible death

Deterrence and Patient Education

• Some strategies have been show decrease risks
• Risk includes cognitive decline and development of dementia
• Combo dietary w/ DASH or diet and exercise can help.

Enhancing Healthcare Team Outcomes

• To be most effective requires a well put together team on patient
• Nurses have front lines
• PT and OT can make physical changes
• Pharm and physicians can track/change meds and oversee the treatment.

Addresses the precautions for prescribing clozapine, dosage management, and effects of antipsychotic discontinuation. Highlights treatments to avoid in Lewy body dementia, optimal dosing for pimavanserin, side effects of Citalopram, and the use of SSRIs. Includes management for agitation and aggression in older adults.