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Treatment for Behavioral and Psychological Symptoms of Alzheimers Disease

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... and Psychological Symptoms of Alzheimer's Disease. Mindy Wasson ... Alzheimer's ... J, Cherry D. Guidelines for managing Alzheimer's disease: part II treatment. ... – PowerPoint PPT presentation

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Title: Treatment for Behavioral and Psychological Symptoms of Alzheimers Disease


1
Treatment for Behavioral and Psychological
Symptoms of Alzheimers Disease
  • Mindy Wasson
  • April 12, 2007
  • Mr. Powdrill

2
Alzheimers Disease (AD)
  • Definition a progressive neurodegenerative
    disease characterized by a loss of function and
    death of nerve cells in several areas of the
    brain.

3
Statistics in the U.S.
  • Prevalence
  • affects 4.5 million people
  • accounts for 90 of all cases of
    neurodegenerative diseases.
  • Expected to affect as many as 16 million by 2050
  • Mortality
  • over 100,000 die each year
  • 4th leading cause of death in adults

4
Symptoms of AD
  • Cognitive
  • memory loss, language disturbances
  • Functional
  • difficulty dressing, difficulty eating,
    incontinence
  • Behavioral/Psychological
  • agitation, aggression, delusions, hallucinations

5
Behavioral and Psychological Symptoms of AD (BPSD)
6
BPSD are very common
  • Cumulative prevalence
  • since onset of illness
  • Point prevalence
  • over the last month
  • Community sample of 362 people with dementia
  • ___________________
  • 80
  • 62

7
Why are BPSD important?
  • Excess disability
  • Increased hospitalization
  • Premature institutionalization
  • Suffering for patient and caregiver
  • Substantial increase in financial costs
  • Increased risk for abuse

8
Overview of Treatment Strategy
  • Address underlying medical/medication-related
    factors
  • Caregiver education/training
  • Non-pharmacological interventions
  • Always 1st choice
  • Pharmacological interventions
  • ONLY if non-pharmacological behavioral
    interventions fail

9
Medical and Medication-related factors
  • Medical factors
  • Vision/hearing loss
  • Acute/chronic pain
  • Malnutrition
  • Dehydration
  • Urinary retention
  • Urinary incontinence
  • Constipation
  • Infection
  • Medications
  • Anticholinergics
  • Opiates
  • Sedative-hypnotics
  • Antidepressants
  • Beta-blockers
  • Antipsychotics
  • Benadryl
  • Quinolones

10
Caregiver Education and Support
  • 3 Rs
  • Repeat
  • Reassure
  • Redirect
  • Used to stress the importance of patience and
    coolness during interactions and redirection
  • Also to remind the difficulty of patients
    situation and the need to be supportive and not
    demanding
  • ABCs
  • Antecedent
  • Must assess multitude of potential causes of BPSD
  • Behavior
  • Assess reactions of patient to causes found and
    develop a theme and appropriate plan of action
  • Consequences
  • Assess the severity of behavior
    positive/negative reinforcement

11
Non-pharmacological Interventions
  • Careful evaluation of environment may be a clue
    to underlying cause of BPSD
  • Consistent and pleasant environment
  • Speak slowly, keep commands simple, use gestures
  • Gentle touch, soft lighting, music, calm colors,
    orientation clues, plants
  • Consistent schedule
  • Stable routine change must be gradual
  • Promote sleep increase daytime activity with
    supervised walks spend time outside gardening
    molding clay

12
Pharmacological Interventions
  • In general, modest benefits with significant
    potential for side effects
  • Categories
  • Atypical antipsychotics- best evidence
  • Antidepressants- some evidence
  • Cognitive Enhancers- some evidence
  • Anticonvulsants- mixed results
  • Typical antipsychotics- not used
  • Sedative-hypnotics- serious side effects
  • All choices are off-label usages

13
Efficacy of Atypical Antipsychotics
  • Primary off-label treatment choice
  • Up to 45 people with dementia are taking
    antipsychotics
  • small effect on behavioral symptoms
  • NNT6 patients must be treated for 1 to respond
  • Response usually in first 2-4 weeks
  • Effects can be variable high rates of
    discontinuation

14
Atypical Antipsychotics SAFETY
  • Extrapyramidal symptoms
  • Diabetes and dyslipidemia
  • Cerebrovascular adverse events (CVAEs)
  • Mortality
  • Cognitive Impairment
  • Fails
  • Sedation
  • QT prolongation

15
FDA Warnings Atypical Antipsychotics
  • CVAEs (Apr. 2003, Jan. 2004)
  • Risperidone
  • Meta-analysis of elderly patients with AD
    (n1779)
  • significantly higher incidence of CVAEs with
    risperidone versus placebo
  • Overall odds ratio was 3.32
  • 45 of events were considered serious/life-threate
    ning

16
FDA Warnings Atypical Antipsychotics
  • Mortality (April 2005)
  • Meta-analysis of 17 placebo-controlled clinical
    trials (n5106) among elderly patients with
    dementia
  • assessed incidence of mortality for aripiprazole,
    olanzapine, risperidone, quetiapine
  • Pooled 4.5 incidence of mortality for atypical
    antipsychotics compared to 2.6 for placebo

17
FDA Warnings
  • FDA concluded that atypical antipsychotics should
    no longer be used among elderly patients with
    dementia

18
So what should be used?
  • Very few well designed clinical trials mostly
    retrospective and contradictory
  • Antidepressants modest benefits, but safer
  • Anticonvulsants questions about efficacy,
    tolerability, and drug-drug interactions
  • Cognitive enhancers modest benefits, patient
    should probably already be on these anyway
  • Sedative-hypnotics risks generally outweigh
    benefits

19
Conclusions
  • AD is prevalent, deadly, and on the rise
  • BPSD has been seen up in to 80 patients with AD
  • Major negative impact on patients, families, and
    caregivers
  • Non-pharmacological Evidence-based
    interventions can be very effective even in
    extreme situations of distress
  • ALWAYS 1st choice requires persistence and
    training to be fully effective
  • Continue interventions even when pharmacological
    treatment is indicated

20
Conclusions
  • Pharmacological
  • Antipsychotics have been primary treatment choice
    for over a decade
  • Are unsafe and only modestly effective
  • Should only be used when immediate harm to
    patient or others exists NEVER as 1st line
  • Best treatment option is now unclear
  • Need well-designed clinical trials assessing
    effectiveness and safety of non-antipsychotic
    choices

21
References
  • Alzheimers Association homepaga on the
    internet. Chicago The Association. 1980-2006
    cited 2006 Nov 1. Available from
    http//www.alz.org.
  • Anti-Aging Research Laboratories. The assessment
    and diagnosis of Alzheimers disease. 2007 cited
    2007 Jan 5. Available from http//www.antiagingre
    search.com
  • Ballard C, Waite J, Birks J. Atypical
    antipsychotics for aggression and psychosis in
    Alzheimers disease (Review). Cochrane Database
    of Systematic Reviews. 20061003476.
  • Brodaty H, Ames D, Snowdon J. A randomized
    placebo-controlled trial of risperidone for the
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22
References
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23
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