Behavioral Disorders in Dementia: Appropriate Nondrug Interventions and Antipsychotic Use

 


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Am Fam Physician. 2016 Aug 15;94(4):276-282.

  Patient information: See related handout on behavior problems in patients with dementia.

Author disclosure: No relevant financial affiliations.

Behavioral and psychological symptoms of dementia pose management challenges for caregivers and clinicians. First-line nonpharmacologic treatments include eliminating physical and emotional stressors, modifying the patient's environment, and establishing daily routines. Family members and caregivers benefit from education about dementia symptoms and reminders that the behaviors are normal and unintentional. Cognitive and emotion-oriented interventions, sensory stimulation interventions, behavior management techniques, and other psychosocial interventions are modestly effective. In refractory cases, physicians may choose to prescribe off-label antipsychotics. Aripiprazole has the most consistent evidence of symptom improvement; however, this improvement is small. Olanzapine, quetiapine, and risperidone have inconsistent evidence of benefit. Physicians should use the smallest effective dose for the shortest possible duration to minimize adverse effects, most notably an increased mortality risk. Other adverse effects include anticholinergic and antidopaminergic effects, extrapyramidal symptoms, neuroleptic malignant syndrome, postural hypotension, metabolic syndrome, cardiac arrhythmia, and sedation. Patients should be monitored for these effects while receiving treatment; however, laboratory monitoring may be limited to patients receiving long-term therapy.

Behavioral and psychological symptoms of dementia pose management challenges for caregivers and clinicians. Although non-drug therapy is effective, Medicare drug claims in 14% of nursing home residents included atypical (second-generation) antipsychotic medication use for treating symptoms of dementia.1 This off-label use of antipsychotics occurs despite a U.S. Food and Drug Administration (FDA) boxed warning noting an increased risk of death when antipsychotics are used in patients with dementia-related psychosis.2 Because the estimated number of U.S. adults with dementia was 3.4 million in 2002 and is projected to double by 2025, primary care physicians should be familiar with nonpharmacologic management of dementia-related symptoms and with the effectiveness and risks of antipsychotic medications before initiating off-label use.35

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BEST PRACTICES IN PSYCHIATRY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not prescribe antipsychotic medications for behavioral and psychological symptoms of dementia in individuals with dementia without an assessment for an underlying cause of the behavior.

American Medical Directors Association

Do not use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.

American Geriatrics Society American Psychiatric Association


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

BEST PRACTICES IN PSYCHIATRY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not prescribe antipsychotic medications for behavioral and psychological symptoms of dementia in individuals with dementia without an assessment for an underlying cause of the behavior.

American Medical Directors Association

Do not use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.

American Geriatrics Society American Psychiatric Association


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationsEvidence ratingReferences

Nonpharmacologic interventions should be used as first-line treatment for behavioral and psychological symptoms of dementia.

C

7, 13

Before initiating antipsychotic therapy in older patients, physicians should have and document a discussion with patients and caregivers about the risks and benefits of these medications.

C

2, 13, 14

The use of atypical antipsychotics for behavioral and psychological symptoms of dementia is associated with increased mortality.

A

23, 24

Antipsychotic medications should be discontinued if there is no evidence of symptom improvement.

A

13, 29, 30


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationsEvidence ratingReferences

Nonpharmacologic interventions should be used as first-line treatment for behavioral and psychological symptoms of dementia.

C

7, 13

Before initiating antipsychotic therapy in older patients, physicians

The Authors

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TYLER R. REESE, MD, CAQHPM, is a faculty physician and palliative care consultant at the Family Medicine Residency Program at Tripler Army Medical Center, Honolulu, Hawaii, and assistant clinical professor of family medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

DERRICK J. THIEL, MD, is a second-year resident in the Family Medicine Residency Program at Tripler Army Medical Center.

KATHERINE E. COCKER, DO, is a faculty physician at the Family Medicine Residency Program at Tripler Army Medical Center and assistant clinical professor of family medicine at the Uniformed Services University of the Health Sciences.

Address correspondence to Tyler R. Reese, MD, Tripler Army Medical Center, MCHK-FM, 1 Jarret White Rd., Honolulu, HI 96859 (e-mail: tyler.r.reese83@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Levinson DR; U.S. Dept. of Health and Human Services; Office of Inspector General. Medicare atypical antipsychotic drug claims for elderly nursing home residents. http://oig.hhs.gov/oei/reports/oei-07-08-00150.pdf. Accessed September 10, 2015....

2. American Society of Consultant Pharmacists. Policy statement: use of antipsychotic medications in nursing facility residents. https://www.ascp.com/sites/default/files/ASCP-antipsychotics-statement.pdf. Accessed September 3, 2015.

3. Plassman BL, Langa KM, Fisher GG, et al. Prevalence of dementia in the United States: the aging, demographics, and memory study. Neuroepidemiology. 2007;29(1–2):125–132.

4. Rayner AV, O'Brien JG, Schoenbachler B. Behavior disorders of dementia: recognition and treatment [published correction appears in Am Fam Physician. 2006; 74(12):2024]. Am Fam Physician. 2006;73(4):647–652.

5. Hebert LE, Weuve J, Scherr PA, Evans DA. Alzheimer disease in the United States (2010–2050) estimated using the 2010 census. Neurology. 2013;80(19):1778–1783.

6. Drevets WC, Rubin EH. Psychotic symptoms and the longitudinal course of senile dementia of the Alzheimer type. Biol Psychiatry. 1989;25(1):39–48.

7. Cerejeira J, Lagarto L, Mukaetova-Ladinska EB. Behavioral and psychological symptoms of dementia. Front Neurol. 2012;3:73.

8. Husebo BS, Ballard C, Cohen-Mansfield J, Seifert R, Aarsland D. The response of agitated behavior to pain management in persons with dementia. Am J Geriatr Psychiatry. 2014;22(7):708–717.

9. Woods B, Spector A, Jones C, Orrell M, Davies S. Reminiscence therapy for dementia. Cochrane Database Syst Rev. 2005;(2):CD001120.

10. de Oliveira AM, Radanovic M, de Mello PC, et al. Non-pharmacological interventions to reduce behavioral and psychological symptoms of dementia: a systematic review. Biomed Res Int. 2015;2015:218980.

11. Neal M, Barton Wright P. Validation therapy for dementia. Cochrane Database Syst Rev. 2003;(3):CD001394.

12. Cohen-Mansfield J. Nonpharmacologic interventions for inappropriate behaviors in dementia: a review, summary, and critique. Am J Geriatr Psychiatry. 2001;9(4):361–381.

13. Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173(5):543–546.

14. National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. https://www.nice.org.uk/guidance/cg103. Accessed March 26, 2016.

15. Maher AR, Maglione M, Bagley S, et al. Efficacy and comparative effectiveness of atypical antipsychotic medications for off-label uses in adults: a systematic review and meta-analysis [published correction appears in JAMA. 2012;307(2):147]. JAMA. 2011;306(12):1359–1369.

16. Tan L, Tan L, Wang HF, et al. Efficacy and safety of atypical antipsychotic drug treatment for dementia: a systematic review and meta-analysis. Alzheimers Res Ther. 2015;7(1):20.

17. De Deyn PP, Drenth AF, Kremer BP, Oude Voshaar RC, Van Dam D. Aripiprazole in the treatment of Alzheimer's disease. Expert Opin Pharmacother. 2013;14(4):459–474.

18. Muench J, Hamer AM. Adverse effects of antipsychotic medications. Am Fam Physician. 2010;81(5):617–622.

19. Chew ML, Mulsant BH, Pollock BG, et al. A model of anticholinergic activity of atypical antipsychotic medications. Schizophr Res. 2006;88(1–3):63–72.

20. Kleinberg DL, Davis JM, de Coster R, Van Baelen B, Brecher M. Prolactin levels and adverse events in patients treated with risperidone. J Clin Psychopharmacol. 1999;19(1):57–61.

21. Haddad PM, Sharma SG. Adverse effects of atypical antipsychotics : differential risk and clinical implications. CNS Drugs. 2007;21(11):911–936.

22. Tse L, Barr AM, Scarapicchia V, Vila-Rodriguez F. Neuroleptic malignant syndrome: a review from a clinically oriented perspective. Curr Neuropharmacol. 2015;13(3):395–406.

23. Maust DT, Kim HM, Seyfried LS, et al. Antipsychotics, other psychotropics, and the risk of death in patients with dementia: number needed to harm. JAMA Psychiatry. 2015;72(5):438–445.

24. Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA. 2005;294(15):1934–1943.

25. American Diabetes Association; American Psychiatric Association; American Association of Clinical Endocrinologists; North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care. 2004;27(2):596–601.

26. Marder SR, Essock SM, Miller AL, et al. Physical health monitoring of patients with schizophrenia. Am J Psychiatry. 2004;161(8):1334–1349.

27. Klug G, Hermann G, Fuchs-Nieder B, Stipacek A, Zapotoczky HG. Geriatric psychiatry home treatment (GHT): a pilot study on outcomes following hospital discharge for depressive and delusional patients. Arch Gerontol Geriatr. 2008;47(1):109–120.

28. Rochon PA, Anderson GM. Prescribing optimal drug therapy for older people: sending the right message: comment on “impact of FDA black box advisory on antipsychotic medication use”. Arch Intern Med. 2010;170(1):103–106.

29. Declercq T, Petrovic M, Azermai M, et al. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev. 2013;(3):CD007726.

30. Maglione M, Maher AR, Hu J, et al. Off-label use of atypical antipsychotics: an update. Comparative Effectiveness Review No. 43. Rockville, Md.: Agency for Healthcare Research and Quality; 2011. http://effectivehealthcare.ahrq.gov/ehc/products/150/778/CER43_Off-labelAntipsychotics_20110928.pdf. Accessed March 26, 2016.

31. Devanand DP, Mintzer J, Schultz SK, et al. Relapse risk after discontinuation of risperidone in Alzheimer's disease [published correction appears in N Engl J Med. 2012; 367(25):2458]. N Engl J Med. 2012;367(16):1497–1507.

32. Motsinger CD, Perron GA, Lacy TJ. Use of atypical antipsychotic drugs in patients wth dementia. Am Fam Physician. 2003;67(11):2335–2340.



 

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