Options for managing behaviours that challenges and the role we can play

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Antipsychotic Medication

• Options for managing behaviours that challenges
  and the role we can play

Johanna Topps - Medicines Management Pharmacist
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Aim of the session

• Why am I interested in dementia management?
• Drug interventions for behaviour that challenges
• Antipsychotic medication
• What you can do...

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History....

• 2004 Committee Safety Medicines
• Antipsychotics risperidone or olanzapine
• Elderly people with dementia
• 3-fold increase in the risk of stroke compared
  with placebo
• magnitude of risk outweighed any likely benefit
  of treating dementia-related behavioural problems
  with these drugs
• Commonly prescribed to manage challenging
  behaviour
• 2005 Europe-wide review
• Increased risk of stroke possible for all
  antipsychotics

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Banerjee October 2009

• Commissioned by DOH
• Est. 180,000 with dementia treated with an
  antipsychotics, each year in England
• Up to 36,000 (20) may derive benefit
• Estimated two-thirds of antipsychotic prescribing
  could be unnecessary
• Additional 1,620 cerebrovascular events per year
• Studies indicate one additional CVE for every 55
  people treated for 12 weeks
• Additional 1,800 deaths per year
• Studies indicate one additional death in every
  100 people treated for 12 weeks
• Mortality risk increases the longer you take them

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Antipsychotic medicines

• Typical (Older)
• Benperidol
• Chlorpromazine
• Flupentixol
• Haloperidol
• Pericyazine
• Perphenazine

• Atypical (Newer)
• Amisulpiride
• Aripiprazole
• Clozapine
• Olanzapine
• Paliperidone
• Quetiapine
• Risperidone

• Pimozide
• Prochlorperazine
• Promazine
• Sulpiride
• Trifluoperazine
• Zuclopenthixol

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Risperidone

• licensed for the short-term treatment (up to 6
  weeks) of persistent aggression in patients with
  moderate to severe Alzheimer's dementia
  unresponsive to non-pharmacological interventions
  and when there is a risk of harm to self or
  others...
• Use lowest effective dose
• For the shortest period of time

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Document tell someone
Hypothermia Arrhythmias Restlessness Hypotension R
estlessness Diabetes weight gain Reduce bone
mineral density
Dry mouth Blurred vision Constipation Dizziness Dr
owsiness Confusion Urinary retention
Parkinsonian symptoms Dystonia (abnormal face
body movements) Tardive dyskinesia (involuntary
movement of tongue, face jaw)
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BTC What is the cause?

• Dehydrated
• Too hot or too cold
• Hungry
• Sight and Sound
• Hearing aids
• Glasses
• Teeth
• Fear...
• Boredom
• Lonely

• Pain
• Constipation
• Infection
• Depression
• Illness exacerbation
• Medication side-effects

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PAIN - Treating behaviour that challenges

• One of the most common causes of BTC
• Assessment of pain...
• Paracetamol 1g four times a day
• Regular administration
• Liquid preparations ......not soluble....level
  spoons
• Watch and wait and regularly review
• Increase analgesia step wise approach
• Beware of side effects of opiates...

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• Who assesses?
• Pairs?
• End of shift?
• Beginning of day?
• End of day?
• Keep...

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Constipation - Treating behaviour that challenges

• Assessment ....Bristol stool scale, frequency
• Food and fluid intake.....changes
• Laxatives
• Osmotic
• Bulking agents
• Stimulants
• Faecal softening
• Regular administration each day
• Liquid preparations....level spoons
• Watch and wait and regularly review
• Increase or decrease doses in a step wise
  approach

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Infection - Treating behaviour that challenges

• Can cause delirium in older people
• Think about existing conditions....COPD, UTI,
  cellulitis
• Do not delay in getting help
• If antibiotics prescribed ................started
  as soon as possible
• Regular administration, food, empty stomach
• Liquid preparations ......

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Other treatment of BTC

• Depression....slower onset
• Illness exacerbation
• Medication side-effects..........recent changes
  in meds
• ...Do not delay in getting help

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Next step...

• Dehydrated, Hungry, Fear, Lonely, Boredom...
• Pain, Constipation, Infection, illness
  exacerbation....
• NICE Clinical Guideline 42 NICE TAG 217
• Acetylcholinesterase inhibitors (AChE) and
  Memantine
• Antipsychotics

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Slow disease progression...

• Vascular
• Do not use AChE for BTC
• Lewy Bodies
• Consider AChE for symptoms causing significant
  distress or BTC
• Mild to Moderate Alzheimers
• Donepezil (Aricept), galantamine (Reminyl),
  rivastigmine (Exelon)
• Memantine if intolerant of/unable to take AChEs
  above
• Severe Alzheimers
• Memantine (NMDA)
• Review regularly, only continue when worthwhile
  effect on cognitive, global, functional or
  behavioural symptoms seen

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Antipsychotics..

• Do NOT use antipsychotics for mild moderate BTC
• Consider antipsychotics in severe BTC causing
  significant distress only if.
• Changes in cognition are regularly assessed
• Target symptoms have been identified, quantified
  and documented
• Target symptom changes are regularly assessed and
  recorded
• Treatment is time limited reviewed every 3
  months or earlier

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• When to review?
• How to review?

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You can make a difference

• Get to know the individual with dementia
• Think about the basics...hunger, hot, cold, fear
• Think about physical ailments...pain,
  constipation, infection
• Assess and record.....
• .......... Help manage antipsychotic use
• ...........Help stop unnecessary antipsychotic
  prescribing