pharmacological management of behavioral & psychological
TRANSCRIPT
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PharmacologicalManagementof
Behavioral&PsychologicalSymptomsofDementia
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Investigate:TenKeyPoints1. Neworrapidlyworseningbehavioralsymptomsinapatientwith
dementiashouldbeconsideredasignofanunderlyingmedicalillnessuntilprovenotherwise.
2. Thefirststepinevaluationistoassesswhetherunderlyingmedicalfactorsmaybeinvolved.
3. Problembehaviorsareoftentriggeredbyanticholinergicmedsandsuboptimalprescribing.
4. Obtainacarefulhistoryfocusedonanychangesinthepatient’smedicalstatusandmedications.
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Investigate:TenKeyPoints
5. Therearedifferencesbetweenthepsychoticsymptomstypicallyseeninpatientswithdementiaversusthepsychosisseenotherconditions.
6. “Psychobehavioralmetaphor”mayhelpselectaclassofmedicationmosthelpful.
7. Incertainsituationsarisk-to-benefitanalysismaystillfavortheuseofantipsychoticmedications.
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Investigate:TenKeyPoints
8. Otherpossiblyhelpfulstrategies:prazosin(Minipress®)anddextromethorphan-quinidine(Nuedexta®).
9. Theuseofbothpharmacologicalandbehavioralstrategiesleadstothebestresults.
10. Symptomsevolveoverthestagesofdementiaandmaydecreaseordisappear.
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CommonBehavioralProblems•FoodRefusal •Wandering •Restlessness
•Sleepdisturbances •Combativeness
•Disinhibition•Hypersexuality •Irritability
•Depression •Psychosis •ADLrefusal
•Socialwithdrawal •Medicationrefusal
•Anxiety •Agitation •Aggression
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11
Types of Agitation
Agitation
Verbal
Aggressive e.g. Threats, name calling, profanity
Nonaggressive e.g. Repetitive requests, moaning
Physical
Aggressive e.g. Hitting, biting, scratching,
hair pulling, shoving
Nonaggressive e.g. Pacing, tapping, pounding
Cohen-Mansfield J, Marx MS, Rosenthal AS. A description of agitation in a nursing home. Journal of Gerontology: Medical Sciences 1989;44(3):M77–M84.
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AppropriateEvaluationBehavioralsymptomsinapatientlivingwithdementiashouldbeviewedasaformofcommunication• Symptomsoftenrepresenttheperson’sbestattempttosignalaproblem
• Developmentofsymptomsshouldtriggeracarefulinvestigationtodeterminecause(s)
• Symptomsoftenanindicationofunderlyingmedicalproblem
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DifferentialDiagnosis:PatientRelated
Causesrelatedtothepatientcategorizedas:• Medical:suboptimalprescribing,uncorrectedsensory
deficits,hypoglycemia,pain• Psychiatric:depression,anxiety,paranoia• Psychological:frustration,boredom,TVviolence,
loneliness• Other:thirst,hunger,fatigue,noise,movement
restriction
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DifferentialDiagnosis
• Newmedicalconditions• Pre-existingmedicalconditions• Sub-optimalprescribing• Poly-pharmacology• Medicationnonadherence• Newpsychiatriccondition• Pre-existingpsychiatricconditionre-emerging• Useofdrugsand/oralcohol
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RecognizingDelirium•Havetherebeenanyrecentmedicationchanges?•Doesthepatientlookphysicallyillorphysicallyuncomfortable?•Arethepatient’svitalsignsreasonable?•Arethevitalsignsaroundtheirusualbaseline?•Arethepatient’slabvaluesreasonable?•Hasmentalstatuschangedrathersuddenlyordramatically?•Isthepatientsuddenlybehavinginwaysthathaveneverbeencharacteristicforthepatient?•Isthepatient‘slevelofalertnessand/orattentionwaxingandwaning?
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Sub-OptimalPrescribing• Prescribingamedicationfromanessentialcategoryofmedicationthatisnotseniorfriendly
• Prescribingadoseofanessentialmedicationthatislargerthanneeded
• Prescribingamedicationtobetakenatatimeofdaythatisnotoptimal(e.g.diureticsatbedtime)
• Notprescribinganeededmedication(e.g.apainmedication)
• Long-termuseofopiatepainmedicationinpatientsotherthanthosewithterminalcancer
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Sub-OptimalPrescribing
Poly-pharmacy• Avoidablemorbidityandmortality• Canbecausedbynumerousprescriberswithlimitedcommunications
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Sub-OptimalPrescribing
PrescribingCascade• Medicationaddressesproblembutcreatessideeffects
• Secondmedicationtreatssideeffectsbutmaycauseadditionalsideeffects
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Ifnomedicalissuesidentified
Lookforco-occurrenceofpsychiatricconditions
• Panicdisorder• Depression• Manicstate• Paranoidpsychosis
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PharmacologicalTreatmentofAgitation&Aggression
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BestPracticesforPrescribing
• Usemedicationsbettertoleratedbyolderadults• Olderpatientsoftenneedlowerdosages• Checktimingofmedicationdoseagainstotherissues,i.e.,diuretics
• Omissionofmedications• Opioidpainmedication–reducelongtermuse
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BestPracticesforPrescribing
Beer’sCriteriaorBeer’sList
• Listofmedicationsmoreharmfulthanhelpfulforolderpatients
• Originallydevelopedin1997• LatestversionsincooperationwithAmericanGeriatricsSociety
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UseofPsychotropicMedications• Trackimpactofmedication• Startlowdosage• Increaseslowly• Alwaysuselowestpossibledose• Incrementallyreducedoseandassessifbehaviorsreturn• Symptomsmayrecedeoverdiseaseprogressionanduseof
medsmaynotbenecessary• Maybepossibletodiscontinuemedication
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UseofPsychotropicMedications• Forallclassesofpsychotropics,preferenceformedications
thatarerenallyexcreted• Benzodiazapinerarelyhelpfulforolderpatientsandshould
generallybeusedinatime-limitedmannerforsituationalsymptoms
• Lookformedswithintermediatehalf-life• Preferredbenzodiazapines:
– Lorazepam(Ativan®)– Oxazepam(Serax®)– Temazepam(Restoril®)
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UseofPsychotropicMedications
UsePDRasreferencetoolfor:
• Appropriatestartingdosage• Maximumdosage• Sideeffects
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AntipsychoticMedicationsDrug Dose
Aripiprazole(Abilify) 4formsincludingtablets(2,5,10,15,20,30mg),DiscMelt(10and15mg),liquidandIM
Asenapine(Saphris) 2.5mg&5mgsublingual;q12hours
Cariprazine(Vraylar) Capsules(1.5,3,4.5and6mg)
Clozapine(Clozaril) Refertopsychiatrist
Iloperidone(Fanapt) Tablets(1,24,6mg);q12hours
Lurasidone(Latuda) Tablets(20,40,60,80mg)
Olanzapine(Zyprexa) 4formsincludingtablets(2.5,5,7.5,10,15,20mg)Zydis(5,10,1520mg),IM,IMER
Paliperidone(Invega) Tablets(1.5,3,6and9mg)Max=12mg,Renal=3mg
Pimavanserin(Nuplazid) Tablet17mg(FDAforParkinson’sdiseasepsychosis
Quetiapine(Seroquel) Tabs(25,50,100,200mg)q12hours;Extendedreleasetabs(50,150,200,300,400mg)
Risperidone(Risperdal) 4formsincludingtabletsandM-Tabs(0.25,0.5,1,2,3,4mg),liquid,RisperdalConsta(q2weeks)
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AntidepressantMedicationsDrug Dose
Citalopram 10,20and40mgtabs(20and40sarescored).Startingdoseis10mg.Maxdose=40mg.Dosesabove40mgnotrecommendedduetoQTcprolongation.
Escitalopram 5,10and20mg(10and20sarescored).Startingdoseis5mg.Maxdose=20.
Sertraline 25,50100tabsplusoralsolution.Startingdose=25mg.Maxdose=200mg.
Duloxetine 20,30,60mgtabs.Startingdose20mg.Maxdose=60mg.
NOTE:1) Thesearegenerallyconsideredthebestchoicesforolderadultsbutother
factorslikeprevioustreatmenthistoryorfamilyhistorymayinfluenceyourchoice. 2)Ifyouprescribedanytwoantidepressantmedicationsforaparticularpatient
withoutsuccess,thenareferraltoapsychiatristisrecommended.
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MoodStabilizingMedicationsDrug Dose
Divalproex Sprinkles125;,DR125,250500mg;ER250and500mg.Oralsolution:250mg/5ml.Startingdose=125to250mg.Doseisdeterminedbyclinicalresponseandbloodleveloftotalvalproicacid(50to100μg/ml).WhenconvertingtoER,increasedoseby20%.
Lithium Tablets,capsules,oralsolution;andER.300mgtabs.ERcomesin300and450s.Solution:8mEq/5ml.Recommendedtroughserumrangeis0.4to0.8mmol/L.Startingdose=300mg.
Gabapentin Capsules150,300,400mg;Tablets600and800;liquid.Startingdose150to300mg;Maxdose=3600mginadivideddose.
Pregabalin Caps:25mg,50mg,75mg,100mg,150mg,200mg,225mg,and300mg.OralSolution:20mg/mL.
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Benzodiazepines• Rarelyappropriateforlong-termuse• Helpfulforacuteagitation• Short-acting,renallyexcretedagentsarepreferred• Occasionallymayuseclonazepam(Klonopin®)• Smalldoses(e.g.lorazepam0.5mg)• Worrisomesideeffects:delirium,clumsiness,falls,depression,tolerance,dependenceandwithdrawal
• Rapidlydisintegratingformulationmaybehelpful
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OtherMedications:
Trazodone(Desyrel®)• Maytreatbothacuteagitationandpreventfurtherepisodes• Maybegoodchoiceforinsomnia• Doserange:25-100mg• Completeresponsemaytake2-4weeks• Sedationiscommon• Priapismisveryrareinolderpatients
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OtherMedications:Prazosin
Thenoradrenergicsystemisthebrain“adrenalin”systemforattentionandarousalDespitethelossofnoradrenergiclocusceruleusneuronsinADthereis
• IncreasedCSFnorepinepherine(NE)• IncreasedagitationresponsetoNE• Increasedalpha-1adrenoreceptorsinlocusceruleus
Asaresult:ExcessivenoradrenergicreactivityproducesanxietyandagitationandmaycontributetoagitationinindividualslivingwithAD
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OtherMedications:Prazosin
• Prazosinisanalpha-1receptorantagonistØ TheonlyonethatcrossesfromthebloodintothebrainØ Non-sedatingØ DoesnotcauseparkinsonismbutmayreduceBPØ Showntohavelong-lastingbenefitsinPTSDØ Anopenlabeltrialandasmallplacebo-controlledtrialhavefoundthatitishelpfulintreatingagitationinNHresidentswithAD
Ø InAD,dosedbetween1-6mg/day
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Dextromethorphane-Quinidine• Dextromethorphanehydrobromideandquinidinesulfate
(Nuedexta®)isapprovedforpseudobulbaraffect(PBA)intheUSandEuropeanUnion
• DextromethorphaneisØ Mostwell-knownasacoughsuppressantØ alowlow-affinity,uncompetitiveNMDAreceptorantagonistØ σ1(sigma1)receptoragonistØ SerotoninandnorepinepherinereuptakeinhibitorØ Neuronalnicotinicα3β4receptorantagonist
• QuinidineØ isaClass1antiarrhythmicØ Whencombinedwithdextromethorphan,quinidineworksbyincreasingthe
amountofdextromethorphaninthebody
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Dextromethorphane-Quinidine• DosinginPBA
– Thecombinationofdextromethorphan(20mg)-quinidine(10mg)comesasacapsuletotakebymouth.
– Itcanbetakenwithorwithoutfood– Startingdoseisonceadayfor7days– After7days,itistakenevery12hours– Morethan2dosesshouldnotbetakenina24-hourperiod– Patientsshouldbesuretoallowabout12hoursbetweeneachdose– Patientsshouldtakedextromethorphan-quinidineataroundthesametime(s)every
day– Importantdrug-druginteractions:desipramine(levelsincrease8-fold),paroxetine
(2-foldincrease),MAOIsandmemantine
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ChampionsforHealth.org/alzheimers
Websitetobeupdatedregularlywithmostcurrentinformation
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