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Transcript
Psychotropic Medications in RCFE Karl Steinberg, MD, CMD, HMDC About Me Harvard, Ohio State, UCSD (Family Medicine) In North County full-time since 1992 Mission ParkSharp Mission ParkScripps Mobile Physicians, Kindred Village Square, Life Care Center of Vista, Hospice by the Sea Post-Acute & Long-Term Care (PA/LTC) Geriatrics Hospice & Palliative Care Medical Ethics Expert Consultation Lots of Boards, Committees, etc. Faculty at CSUSM, Case Western Reserve University Volunteer Faculty at UCSD, Camp Pendleton, others Love My Work! Pets Are Great Therapy! Definition of Dementia Chronic Loss of Cognitive Functioning Usually Progressive Multiple Types and Natural History Common, and Increases with Age 4% at 60 More like 40% at 85 Huge Public Health Issue $100B annually in US estimated, will rise Common Reason for SNF Admission Alzheimer’s Disease By far the most common type of dementia Gradual, Insidious, Progressive, Terminal Generally thought to be at least 60% of all cases But can show sudden decompensation Usual time course 8-10 years (can range 2-20) Starts with Memory Problems, progresses into Behavioral, Language, ADL, Perceptual Problems Diagnosis Made on Clinical Grounds ~85% accurate May Co-Exist with other Dementing Conditions Differential Diagnosis of Alzheimer’s Depression (“pseudodementia”): Apathy, Psychomotor Retardation—antidepressants can be remarkably effective Vascular Dementia (“multi-infarct”): Dementia with Lewy Bodies Behavioral Problems, Visual Hallucinations, Parkinsonian Appearance, Unresponsive Spells. Worsened by traditional antipsychotics. Frontal Lobe Dementias Normal Pressure Hydrocephalus More stutter-step type progression described, but not always Gait Problems, Urinary Incontinence, Dementia Hypothyroidism, B-12 Deficiency, Tertiary Syphilis, HIV Other neurodegenerative conditions (PML, PSP, vCJD, MS) Structural Anomalies: Subdural, Neoplasm Delirium: More of an alteration of attention/sensorium, acute Δ Toxic/Metabolic Syndromes EtOH, anticholinergics, opioids, benzos, NH3, hypoxemia, drug withdrawal, etc. Behavioral & Psychiatric Symptoms of Dementia (BPSD) Commonplace (Close to 100% lifetime prevalence) Exacerbate Physical/Functional Deficits Often Predictable Often Multiple Sx Coexist (e.g., Psychosis & Agitation) Often Persistent (60-80% in 1 Year for Agitation, 40-60% for Psychosis) However, usually resolve in time as dementia becomes advanced/end-stage Tariot & Blazina 1993, Lyketsos et al 2000, Levy et al 1996, Devanand et al 1997, McCarty et al 2000, Haupt et al 1999, Hope et al 1999 Behavioral & Psychiatric Symptoms of Dementia (BPSD) Affective (Depression & Mania) Problems Anxiety/Fear Psychotic (Thought Disorder, Loss of Reality Testing) Symptoms Hallucinations (Auditory, Visual, Tactile, Olfactory) Delusions (Beliefs that are contrary to Reality) Paranoid Delusions Are Common: Poisoning, Held Captive, etc. Delusions of Grandeur Capgras Syndrome (think a relative is an ‘impostor’) Many Other Variations Agitation/Aggression Many Forms: Pacing, Repetitive Vocalizations, Abusive Language, Sexual Aggression, Physical Assault Quiz Question: How many types of medication are approved for treating dementia-related behaviors (BPSD)? FDA-Approved Meds for Behavioral and Psychiatric Symptoms of Dementia: Antipsychotics in dementia: 1 in 100 DIE from adverse effects Overuse of antipsychotic medication can be essentially a CHEMICAL RESTRAINT #14 -18% Pharmacotherapy Basics Assess Specific Target Symptoms & Monitor Them If Initial Rx Ineffective, can either taper/DC and Start New Agent, or Add Second Agent Empiric Trials of Medication—Not Always EvidenceBased Decisions in geriatrics/LTC Medicine Start Low, Go Slow, But Go! Medications Don’t Always Help! Weigh Risks/Benefits/Alternatives & Document Thought Process, Consent Person-Centered!! Pharmacotherapy Basics Omit Unnecessary Drugs Use Non-Pharmacological Measures “Start Low, Go Slow, But Go” Anticholinergics, Benzodiazepines = Bad News 2012 Update of Beers List (AGS) Antipsychotics for Dementia are on it So is Sliding Scale Insulin When Possible, be sure Informed Consent is obtained Treatment of Agitation No Drug is FDA approved for Dementia with Agitation, but it is a common problem! (Nuedexta may get it soon) First consider other causes and non-Rx treatment (pain, noise, constipation, etc.) Determine whether there is psychosis Determine whether there are affective (especially manic/hypomanic) features If so, consider an antipsychotic Psychosis without distress does not require Rx If so, consider mood stabilizer (Divalproex) or antidepressant In severe/acute cases, consider antipsychotic, or a benzodiazepine for emergency treatment Treatment of Agitation/Psychosis Antipsychotics (also called Neuroleptics or Major Tranquilizers) Traditional Antipsychotics Haloperidol—Haldol, Chlorpromazine—Thorazine, Fluphenazine—Prolixin, Thiothixene—Navane, Thioridazine— Mellaril, many others. High risk of Tardive Dyskinesia in elderly!! (Do AIMS) May require anticholinergic coverage (e.g. Cogentin, Artane) Adds insult to injury as far as cognition in the elderly Intramuscular Depot forms available For acute delirium, antipsychotics are drug of choice Treatment of Agitation/Psychosis Atypical Antipsychotics Commonly used off-label for agitation of dementia Clozapine (Clozaril), Risperidone (Risperdal), Olanzapine (Zyprexa), *Quetiapine (Seroquel), Ziprasidone (Geodon), *Aripiprazole (Abilify), Paliperidone (Invega), Iloperidone (Fanapt), Asenapine (Saphris), Lurasidone (Latuda) Major Black Box Warning, definitely increase risk of serious cardiovascular/ cerebrovascular events, death Weight Gain, Hyperglycemia, Metabolic Effects even in short run (12 weeks of therapy) Not always a bad thing for the LTC population Many available in oral and immediate-release injectable forms Some available in Depot form (IM) Some available in ODT (Oral Dispersing Tablet) form * Approved for major depressive disorder Drug Treatment of Alzheimer’s 2 General Classes of Approved Drugs Cholinesterase Inhibitors NMDA Antagonist (Mod.-Severe) Donepezil (Aricept) (Mild to Severe) Rivastigmine (Exelon) (Mild to Moderate) Galantamine (Razadyne) (Mild to Moderate) Memantine (Namenda) Acts on glutamatergic neurons Most effective when one from each class used together May show limited utility for BPSD, delirium Drug Treatment of Alzheimer’s Controversy as to Effectiveness They Probably Slow Progression Allow Maintenance of Function for additional 6-12 months Underwhelming Results May be well worth it if it allows patient to remain at home or lower level of care Some Patients actually Improve Cognitive and Behavioral Parameters What antipsychotic use is necessary ?? Antipsychotics are the drug of choice for agitated delirium, although it is off-label Antipsychotics are approved and effective for bipolar disorder (mania) (Some) antipsychotics are approved and effective for refractory major depressive disorder Antipsychotics can be helpful (mostly off-label) for nausea and hiccups Distressing psychotic features (paranoid delusions, disturbing hallucinations, negative ideas of reference, etc.) Care Considerations: Quality of Life What else works? Evidence? No drug approved for BPSD/agitation of dementia Antipsychotics clearly carry significant risks in this population, and limited (but some) benefits Physician availability to explain risks and benefits is of key importance Nonpharmacological interventions can be very helpful, although evidence is limited Systematic Review 2011 done for Veterans Affairs Less than 20 good studies (see next slide) No magic bullet Resident-specific, individualized strategy can work What else works? Evidence? Reminiscence Therapy: No support Simulated Presence Therapy: No support Validation Therapy: Insufficient evidence Acupuncture: No quality evidence of benefit or harm Aromatherapy: Insufficient evidence Light Therapy: Some beneficial effect on agitation and nocturnal restlessness, but poor quality. Insufficient evidence to support its use. (Hand) Massage and Touch: May have beneficial effect Music Therapy: Limited evidence, may be of benefit Snoezelen (Multi-Sensory Stimulation): Insufficient evid. Reminiscence is a Good Thing What else works? Evidence? TENS: Insufficient evidence Animal-assisted therapy: Potential for benefit but no rigorous evidence Exercise: Improvement in sleep and other parameters but no consistent effect on behavior ____________________________________________ Wandering: Exercise, Walking not helpful. Tracking devices, alarms, motion detectors effective. Agitation: some benefit in some studies from hand massage, aromatherapy, thermal bath, calming music From British Columbia (Canada) There is evidence to suggest that risperidone and olanzapine are useful in reducing aggression, and risperidone is more effective in reducing psychosis. (In Canada,) Risperidone is the only atypical antipsychotic medication approved for the short-term treatment of aggression or psychosis in patients with severe dementia. Despite the modest efficacy, the significant increase in adverse events suggests that neither risperidone nor olanzapine should be used routinely to treat residents with aggression or psychosis unless there is marked risk or severe distress. Best Practice Guideline for Accommodating and Managing Behavioural and Psychological Symptoms of Dementia in Residential Care (Province of British Columbia, 2012) From British Columbia (Canada) Carefully weigh the potential benefits of pharmacological intervention versus the potential for harm. Recognize that the evidence base for drug therapy is modest. (Number needed to treat that ranges from 5-14) Engage the resident/family/substitute decision-maker in the health care planning and decision-making process. Obtain consent for health care treatment from the appropriate decision-maker before administering antipsychotic medication. Regularly review the need (or not) for ongoing antipsychotic therapy for BPSD and trial withdrawal. Continue non-pharmacological interventions. Best Practice Guideline for Accommodating and Managing Behavioural and Psychological Symptoms of Dementia in Residential Care (Province of British Columbia, 2012) From British Columbia (Canada) Table 2- Examples of BPSD Usually not Amenable to Antipsychotic Treatment wandering vocally disruptive behaviour inappropriate voiding hiding and hoarding inappropriate dressing /undressing eating inedible objects repetitive activity tugging at seatbelts pushing wheelchair bound residents Best Practice Guideline for Accommodating and Managing Behavioural and Psychological Symptoms of Dementia in Residential Care (Province of British Columbia, 2012) Everything Ages~! Some Things (and People) Age Better Than Others Other Useful Medications Antidepressants can be helpful—some evidence that citalopram (Celexa) can reduce agitation symptoms when given regularly Trazodone, an old, sedating antidepressant, can be helpful for sleep and acute agitation at doses well below antidepressant dose (25-50 mg) Female hormones, SSRIs sometimes used successfully for hypersexual behavior SNRIs (e.g. duloxetine [Cymbalta]) can help for pain and depression Nuedexta (dextromethorphan/quinidine) can help for PBA “emotional incontinence” Take-Home Messages No drug is approved for treating dementia with agitation, because nothing has ever been demonstrated to be consistently effective—individualize care decisions! Much of what we do in LTC is trial-and-error, not necessarily evidence-based Off-label use does not mean inappropriate use. Some offlabel use is absolutely appropriate. Treat people like you would want your own family members to be treated—but be mindful that not everyone will agree on specific treatment plans, etc. Take-Home Messages Psychotropic medications can be extremely valuable and improve the quality of life of our residents Non-pharmacological measures should be tried first whenever possible In general, dose reduction is a good idea, but not for everyone Especially longstanding psychotic disorders (For depression with 2 more more lifetime episodes, definitely a bad idea!) The less medications, the better! Always! Antipsychotic drugs are dangerous Antipsychotic drugs are very useful for psychotic disorders Summary Antipsychotics are not always poison Nonpharmacologic measures are always better, if they work! Individualize these, be creative. Your caregivers may have the best ideas Consider other kinds of medication Risperidone, olanzapine probably best for BPSD Especially Pain Meds Insist on prescriber involvement and active engagement, and document in chart notes—these drugs are under a lot of scrutiny, AL included Take-Home Messages We all agree that reducing the unnecessary use of these drugs is a good idea! Documentation of risks, benefits, alternatives and informed consent is important to obtain—especially for antipsychotics. Doc Needs to Participate! Good idea document informed consent forms and have a process to ensure physician participation You need an engaged medical consultant and/or psychiatrist Thank you for working in long-term care! I Wish You Smooth Sailing