BPSD “THE AGITATED

ELDERLY”

GP Update August 2011

Dr. Carla Freeman

Senior registrar

Division of Neuropsychiatry

Department of Psychiatry and Mental Health, University of Cape Town

2002: POPULATION >65YRS

BPSD OVERVIEW

Occurs in 70-90% of dementia

Symptoms differ depending on stage of dementia

Aetiology: biological, psychological, environmental and social

Decreased QOL and increased caregiver burden/distress leading

to premature residential placement

Good evidence supporting a number of non-pharmacological and

pharmacological interventions

Behavioural

Screaming

Restlessness

Wandering

Physical aggression

Agitation, apathy

Disinhibition (e.g. sexual,

culturally inappropriate)

Sleep and appetite changes

Hoarding, shadowing etc…

DEFINITION

Psychological

Mood disturbance: depression,

irritability

Anxiety esp. anticipatory

Hallucinations

Delusions

MANAGEMENT K E Y P R I N C I P L E S :

1. Differential diagnosis: Is this dementia?

The 3D‟s

MANAGEMENT K E Y P R I N C I P L E S :

1. Is this dementia?

2. Consider contributing factors or triggers:

Unrecognized or suboptimal management of pain1

Physical health e.g. dehydration, glycemic control

Side effects of medication e.g. constipation (amitriptyline), psychiatric complaints (corticosteroids), confusion(anticonvulsants, lithium,

ciprofloxacin, cimetidine)

Psychosocial and environmental changes

Depression

Relationships with carers, care-workers and family members

Hearing or vision problems

1 BMJ 2011 ;343:d4065 13

MANAGEMENT K E Y P R I N C I P L E S

1. Is this dementia?

2. Consider contributing factors or triggers

3. Identify target problems:

Allows to plan/formulate the best treatment approach

Family: 24hr behaviour chart

Monitoring of behaviour following treatment

Rating scales to assist with management strategy

Clear documentation in notes = essential

MANAGEMENT K E Y P R I N C I P L E S

1. Is this dementia?

2. Consider contributing factors or triggers

3. Identify target problems

4. Formulate the problem

Develop an understanding of the target symptoms, their duration,

possible underlying cause and treatment strategy.

Communicate this to both the caregiver and the patient

MANAGEMENT OF

BPSD

NON - PHAR MACOLOGICAL

INT E RVE NT IONS

Considered first-line

Empowers family

Needs to be monitored and

evaluated

Fine balance between activity

and over-stimulation

NON - PHAR MACOLOGICAL

MANAGE ME NT

Rigorous routine

Environmental strategies

Nursing care interventions

Social contact

Psychological therapies

Avoid punishment!

PHARMACOLOGICAL MX

Principles of prescribing:

• Full discussion with patient and care-giver about possible risks and benefits

• Undertake an individual risk-benefit analysis

• Start low, go slow

• Exclude exacerbating medical illness at each stage of treatment

• Fluctuating nature of BPSD attempt to withdraw meds if possible at appropriate time e.g. sedatives

• Withdraw drugs with poor response before instating a new drug (one at a time!)

• Remember drug interactions

• Record changes in symptoms and cognition regularly

AGITATION

Definition: “mixed-big”

• „mental disturbances or perturbation showing itself usually by

physical excitement‟ (Oxford University Press 2004)

• „excessive motor activity associated with a feeling of inner tension‟

(DSM IV)

• Inappropriate verbal, vocal, or motor activity that is not explained by

needs or confusion per se. It includes behaviours such as aimless

wandering, pacing, cursing, screaming, biting and fighting (Cohen-

Mansfield 1986)

Physically non-aggressive General Restlessness

Repetitive Mannerisms

Pacing

Hiding Objects

Inappropriate Handling

Shadowing

Escaping protected environment

Inappropriate Dressing/Undressing

Verbally non-aggressive:

chanting, constant interruptions and

requests for attention

MANY FOR MS OF AGITAT ION

Physically aggressive

Hitting

Pushing

Scratching

Grabbing

Kicking

Biting

Spitting

Verbally aggressive: screaming, swearing etc.

“RULE NUMBER 3” – S Y N D R O M E S F I R S T, S Y M P T O M S S E C O N D

(courtesy of Dr John Joska)

For Alzheimer’s disease, use anti-dementia drugs

before anti-psychotics

For depression, use anti-depressants before anti-

psychotics

For everything else, use other drugs before

benzodiazepines

C O G N I T I V E E N H A N C E R S

Cholinesterase inhibitors:

• Donepezil (Aricept/Ariknow®) 5-10mg nocte

• Rivastigmine (Exelon®) 3-6mg twice daily

• Galantamine (Reminyl®) 8-12mg twice daily

Equal efficacy, tolerability may differ

Mild to moderate DAT – some use in severe and vascular

dementia

Shown to improve cognition, behaviour, functioning and

delay placement

1/3 improve, 1/3 remain stable and 1/3 deteriorate

COGNIT IVE E NHANCE R S (2 )

NMDA receptor antagonists

• Memantine (Ebixa®) 5-20mg daily in divided doses

• Severe DAT, consider for vascular dementia

• Safe to use with Donepezil

• Monitor adverse effects

• Long term effect is unknown

AGITAT ION T R E AT ME NT CONT.

Antidepressants

Antipsychotics

Anticonvulsants

• Prominent mood features (previous BPMD/affective instability)

• “ictal like” outbursts

• Agitation unresponsive to other treatment

• Valproate 20mg/kg – range 200–1000mg/day divided doses

• High side effect profile (hair loss, weight gain, GIT, plts, osteoporosis?)

• Carbamazepine – fallen out of favour, may be useful if other drugs are contra-indicated)

• Lamotrigine increasing evidenc

Later

DEPRESSION

Common – DAT: 0-20% have full syndrome, up to 50% have

depressive symptoms

Significantly impairs QOL, increases care-giver burden

Increases mortality

Features include: anhedonia, rejection sensitivity, self-pity and

psychomotor disturbances

Symptoms often fluctuate

Commonly recurs

DEPRESSION: TREATMENT

Avoid TCAs

SSRIs are useful – beware agitation

Treatment response = longer

Suggested regimens:

• Citalopram 10-20mg

• Mirtazapine 15-30mg

• Mianserin 30mg

• Venlafaxine 37.5mg (hypertension)

• Agomelatine??

ANXIETY

Common: GAD, Godot syndrome, fear of

being left alone, pacing, wringing hands.

Avoid use of long term benzodiazepines –

dependence, cognitive deficits, falls

Look for co-morbid depression – treat with

antidepressants

Rational use of benzodiazepines if

absolutely necessary

PSYCHOSIS

Definition:

• Criteria for dementia are met + hallucinations or delusions or both

• Present intermittently for longer than one month and interfere with

function. NB chronology

• Not due to another psychiatric illness or part of a delirium syndrome

Bizarre or complex delusions are rare, misidentification syndromes are

common

Exclude epilepsy, intra cerebral pathology.

PSYCHOSIS: TREATMENT

Antipsychotics are indicated for psychosis and

severe agitation

High side effect profile:

• First generation: EPSEs

• Second generation: Metabolic side effects

• Both: Risk of CVA

Risk-benefit assessment and informed consent

Risperidone 0.5mg bd, Quetiapine 25mg at night

Not recommended for longer than 3 months,

reassess regularly!

SLEEP DISTURBANCE

Common: day-night reversal

Non-pharmacological = NB:

• Keep awake during day

• Limit naps

• Sleep requirement decreases with age

• Stimulus control at night

• “White noise”

• Assist carer – relief nights

Pharmacological: Sedating antidepressants, anti-histamines,

non-benzodiazepine hypnotics, melatonin.

ADDIT IONAL PROBLE MAT IC

BE HAVIOUR S

Sexual disinhibition – Cyproterone acetate (Androcur®)

Substance dependence:

• Alcohol

• OTC analgesia

• Benzodiazepines

• Consider detox/withdrawal inpatient/outpatient rehab

WHEN TO REFER:

Valkenberg Geriatric clinic:

• >60 years

• Graduates from adult psychiatry

• Unmanageable BPSD

• Fax: VBH OPD – Att. Dr. Joska (021)-4403157

Memory Clinic:

• Diagnostic dilemmas

• Unusual presentation/symptoms

• Full MDT evaluation

• Fax referral to Sonja Hendrix at IAA – forms on internet

www.instituteofageing.uct.ac.za

REFERENCES

1. Husebo BH, Ballard Clive et al. Efficacy of treating pain to reduce behavioural disturbances in residents of

nursing homes with dementia: cluster randomized control trial. BMJ 2011; 343:d4065

2. Chen Y, Briesacher BA, Field TS et al. Unexplained variation across US nursing homes in antipsychotic

prescribing rates. Arch Intern Med 2010; 170:89-95

3. Devanand DP, Schulz SK. Consequences of antipsychotic medications for the dementia patient. Am J

Psychiatry 2011; 168:767-769

4. Howland RH. A benefit risk assessment of agomelatine in the treatment of major depression. Drug Saf

2011; 34(9):709-731

5. Australian Guidelines for BPSD 2011

6. Alzheimer Europe: Treatment for behavioural and psychological symptoms of dementia 2011

T HANK YOU!

Carla.freeman@uct.ac.za

QUESTIONS?