5 minute soap box

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5 minute soap box

• Old Age Psychiatry

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Who gets anti-dementia drugs?

• Diagnosis must be AD
• MMSE 10-20
• Or Moderate severity on clinical grounds
• Likely to comply
• 6 monthly review of MMSE, function, behaviour,
  carer views - ? Overall worthwhile effect
• MMSE remains above 10

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Who doesnt get anti-dementia drugs?

• People suffering from other dementias
• Mild AD
• Severe AD
• No memantine

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What does Cochrane say?

• BENEFIT
• Mild to moderate AD
• Parkinsons Disease
• VaD
• Memantine for moderate to severe AD

• NONE PROVEN
• Mild Cognitive Impairment
• FTD
• LBD

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Treatment of Behavioural Disturbance in Dementia
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Risperidone and Olanzapine

• Risk of CVA from 1 to 3 in 12 weeks
• Risk in old old and if CVA risk factors
• No evidence that other atypicals and typicals
  safer

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Treatment of BPSD

• Pharmacological
• Behavioural
• Environmental
• Evidence base for all is poor

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Non-drug strategies

• Day- time activity
• Reminders
• Reassurance
• Regular orientation
• Distraction
• Respite longer or shorter periods
• Help with care tasks
• Is 24-hour care necessary? and if so is it the
  right kind of place?

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NonPharmacological Therapies

• Behavioural analysis and therapy
• Aromatherapy
• Bright light therapy
• Homeopathy
• Pets
• Music therapy
• Staff training

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Some causes of agitation

• Depression
• Anxiety
• Psychotic symptoms
• Physical ill health

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Drug Groups used in BPSD

• Neuroleptics
• Benzodiazepines
• Anti-convulsants
• Anti-depressants
• AcetylCholine-Esterase Inhibitors

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Where BPSD is treatable in people without
dementia treat this

• Eg
• Psychosis (risperidone, others, not olanzapine)
• Depression
• Hypomania
• Anxiety
• Insomnia

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Reasons to use neuroleptics

• Continuing BPSD despite alternatives
• Severe symptoms
• Clear risk to self or others (document)

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The three Ts

• Target symptom (and record it)
• Start low and titrate slowly
• Time limited

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Withdrawal of neuroleptics

• In double-blind r.c.t. no significant difference
  in behavioural symptoms between those continuing
  neuroleptic and switching to placebo
• A small number of people withdrawn show worsening

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The other NICE document of 2006Dementia CG 42

• Use antipsychotics (neuroleptics) only for severe
  BPSD in AD and DLB
• Discuss risks
• Document target symptoms
• Monitor - ? 3 monthly

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The other NICE document of 2006Dementia CG 42

• Donepezil, rivastigmine or galantamine may be
  used for BPSD in LBD
• And in AD if causing significant harm or distress
  and if antipsychotics are ineffective or
  inappropriate

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Summary

• 1) Is the behaviour intolerable?
• 2) Would it be tolerable in a different setting?
• 3) Are there non-drug options?
• 4) Aim to target drug to clinical features, e.g.
  depression, psychotic symptoms.
• 5) Low dose
• 6) Slow increases
• 7) Review and consider withdrawing when stable