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!
QUESTIONS?
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