Aged Psychiatry in a Residential Care Setting.

1
Aged Psychiatry in a Residential Care Setting.

• Dr Ian Presnell
• Senior Lecturer
• Monash University.

2
The Patient in a Residential Care Facility.

• Usually a new patient.

• New to Residential Care.
• New to this facility.
• New to you.

3
The Patient in a Residential Care Facility.

• Usually a new patient.
• Their Story is important.

• Plot.
• How they came to be there.
• Cast.
• Leads.
• Chorus.
• Lines.
• What motivates the characters.

4
The Patient in a Residential Care Facility.

• Usually a new patient.
• Their Story is important.
• Are they on psychotropic medication?

• Why?
• was it started?
• When?
• How?
• Has the dose changed?
• What?
• Was the effect(/-)?

5
The Patient in a Residential Care Facility.

• Usually a new patient.
• Their Story is important.
• Are they on psychotropic medication?
• No Problems.

• When to change Rx?

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How long do you leave stable patients on
psychotropic Rx?

• Cholinesterase Inhibitors.

• 6 months initial.
• Improvement in 2/12.
• Impression.
• Did any BPSD reduce with Rx?
• Private script.

7
How long do you leave stable patients on
psychotropic Rx?

• Cholinesterase Inhibitors.
• Antidepressants.

• Indefinite.
• Depression at any stage of Dementia.
• Impression.

8
How long do you leave stable patients on
psychotropic Rx?

• Cholinesterase Inhibitors.
• Antidepressants.
• Antipsychotics and Mood Stabilisers.

• IPA recommendations
• 4-6/52 trial at adequate dose.
• IN the event of positive response (except Rx of
  depression) review _at_ 12/52 with a view to trial
  reduction.
• Studies show that ceasing conventional
  antipsychotic stable or improvement.
• Agitation and wandering tend to be most
  persistent.
• (Non affective) BPSD tend to peak at moderate
  levels of impairment.

9
The Patient in a Residential Care Facility.

• Usually a new patient.
• Their Story is important.
• Are they on psychotropic medication?
• No Problems.
• Problems.

• Generally on more than one medication.
• Is drug 1 ineffective?
• Partial continue?
• Complete cease.
• Rationalising
• Reduce side effects.
• Withdrawal syndromes.
• First on First off.

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The Patient in a Residential Care Facility.

• Usually a new patient.
• Their Story is important.
• Are they on psychotropic medication?
• No Problems.
• Problems.
• Principles of managing BPSD.

• See Appendices.

11
The Patient in a Residential Care Facility.

• Usually a new patient.
• Their Story is important.
• Are they on psychotropic medication?
• No Problems.
• Problems.
• Principles of managing BPSD.
• Choice of drug.

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How to choose your drug.

• Match the drug to a symptom / syndrome.
• IPA recommendations.
• Duration of trial.

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How long to try your drug for.

• Antipsychotics.

• APA recommends 2-4 weeks.

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How long to try your drug for.

• Antipsychotics.
• Antidepressants.

• Up to 6-8/52.
• Star-D trial average 6/52 to response and 7/52 to
  remission.

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How long to try your drug for.

• Antipsychotics.
• Antidepressants.
• Mood Stabilisers.

• Trials demonstrating change over 6/52.

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How long to try your drug for.

• Antipsychotics.
• Antidepressants.
• Mood Stabilisers.
• Cholinesterase Inhibitors.

• I usually see change/benefit within 2/12.

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How to choose your drug.

• Match the drug to a symptom / syndrome.
• IPA recommendations.
• Duration of trial.
• How well does it work?

• Bias.
• Tran etal (1997) OgtR
• Conley Mahmood (2001) RgtO
• Ho etal (1999) OR

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How to choose your drug.

• Match the drug to a symptom / syndrome.
• IPA recommendations.
• Duration of trial.
• How well does it work?

• All antipsychotics work BUT
• Modest.
• 25 gt placebo.

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Adults with acute psychosis.McClure etal 2006.

• 319 acute inpatients.
• Using successful D/C as the criterion.
• Haloperidol (16mg, 4-30), Olanzepine (19.1mg,
  5-40mg) Risperidone (5.2mg, 2-9) 90 effective.
• Aripiprazole (21.8mg, 10 45) Quetiepine
  (652.5mg, 50 1200) 65 effective.

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Antipsychotic drugs in BPSDSchneider etal 2006

• DAT, MMSE 5-26.
• Mobile, at home/hostel.
• Delusions, hallucinations, agitation, aggression
  daily for 1/52 OR intermittent for 4/52 AND at
  least moderate severity on BPRS or NPI.
• 57 _at_ hostel level, 17 _at_ nursing home BUT 73 at
  home.
• At least 2/52 up to 36/52 trial.

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Antipsychotic drugs in BPSDeffective _at_12/52
Schneider etal 2006
Success still on drug, at least mild
improvement on CGIC
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Antipsychotic drugs in Schizophrenia.
Liebermann et al (2005)

• N 1493 patients 18 65 years.
• Olanzepine (7.5 30mg/d), Perphenazine (8
  32mg/d), Quetiapine (200 800mg/d) or
  Risperidone (1.5 - 6mg/d).
• 74 discontinued within 18/12.
• Olanzepine gt Risperidone/Perphenazine gt
  Quetiapine.
• Olanzepine had the most side effects.

gt remained on medication.
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How to choose your drug.

• Match the drug to a symptom / syndrome.
• IPA recommendations.
• Duration of trial.
• How well does it work?

• Antidepressants.
• Beyond blue guidelines not so much what you do
  but keep doing it.

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IPA Taskforce the Evidence Base for the
Effective use of Antidepressants (Bannerjee 2001)

• Despite impressions no stat. difference b/w
• - TCAs, SSRIs MAOIs
• - Institution vs community
• - Major Depression vs otherdepression

• They all work
• 6/52 trial needed
• little evidence for low dose TCAs
• less effective in med ill (52)
• new tolerated better
• SSRIs prescribed at recommended dose

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Treatment of Mild Depression(Ellis and Smith
2002)

• Problem solving (1) better than SSRIs (2) (NNT
  3.0 vs 10.2) comparing placebo controlled trials.
• Counselling better than drugs (1) (NNT 7.7).
• SSRIs better than TCAs (4) (NNT 10.4).

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STAR-D TrialSequenced treatment alternatives to
relieve depression

• 2876 outpatients (GP specialist), 18 75
  years.
• Stage 1 12-14/52 Citalopram 1/3 remission (av
  7/52), 1/7 response (av 6/52)
• Av 3 medical conditions, 2/3 another psychiatric
  dx, ¾ gt 2 episodes OR current episode gt 2yrs, 1/5
  past suicide attempt.

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STAR-D TrialSequenced treatment alternatives to
relieve depression

• Stage 2 Switch (Sertraline, Buproprion,
  Venlafaxine) OR augment (Buproprion, Buspirone).
  Also include CBT.

• ¼ remission.
• Equal tolerability.

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STAR-D TrialSequenced treatment alternatives to
relieve depression

• Stage 2 Switch (Sertraline, Buproprion,
  Venlafaxine) OR augment (Buproprion, Buspirone).
  Also include CBT.
• Stage 3 Switch OR augment (lithium, T3).

• 1/5 remission.
• T3 better tolerated.

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STAR-D TrialSequenced treatment alternatives to
relieve depression

• Stage 2 Switch (Sertraline, Buproprion,
  Venlafaxine) OR augment (Buproprion, Buspirone).
  Also include CBT.
• Stage 3 Switch OR augment (lithium, T3).
• Stage 4 Switch (Venlafaxine Mirtazepine,
  Tranylcypromine)

• 1/10 remission.
• Combination better tolerated.

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How to choose your drug.

• Match the drug to a symptom / syndrome.
• IPA recommendations.
• Duration of trial.
• How well does it work?
• Side effects.

• McClure etal (2006)
• Haloperidol (16mg, 4-30), Olanzepine (19.1mg,
  5-40mg) Risperidone (5.2mg, 2-9), Aripiprazole
  (21.8mg, 10 45) Quetiepine (652.5mg, 50
  1200).
• Haloperidol worse within 3/52, but no difference
  at discharge. Anticholinergics probably
  underused.

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Risk of Stroke

• In 2003 regulatory agencies reported increased
  risk of stroke CF placebo for patients taking
  Risperidone (2.7 times) and Olanzepine (2
  times).
• Concerns were raised that there was no matching,
  small numbers and that this was a rare event.
• 2.7 and 2 vs. 1 respectively.

32
Hermann et al. (2004)

• Review of 1.4 million patient s from 1997 2002
  revealed 11400 that started an antipsychotic
  during that time.

NB Total CVAs 92.
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Conclusions regarding risk of Stroke.

• Adjusting for age, gender and other risk factors
  (including H/O HPT, Stroke and AF but NOT smoking
  or obesity) relative risk for olanzepine 1.1 and
  risperidone 1.4. (NS because wide confidence
  intervals.
• Risk ratio of 1.4 relates to 2 additional strokes
  per 1000 persons treated per year.

34
Antipsychotic Side Effects in the Elderly
(Schneider etal 2006)
Increased blood glucose.
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CONCLUSION

• Story is important.
• Choice relatively unimportant.
• Side effects not important _at_ popn level.
• What you do subsequently important.
• BUT Individuals are receiving treatment.

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Appendices

• Aetiological Modals.
• IPA General Principles of drug treatment for
  BPSD.
• Predictable and potential side effects of the
  drugs commonly used to control BPSD.
• Evidence for drugs working.

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Aetiological Models(Cohen-Mansfield)

• Direct.
• Behavioural.
• Environmental Vulnerability.
• Unmet needs.
• NOTE these models assume that behaviour arises
  from the interaction of the patient with their
  environment.

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Direct Modal

• Neurobiological Impairment
• Disinhibition.
• Decreased attention.
• Decreased STM.

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Behavioural

• Antecedent
• Behaviour Reinforcement
• Consequence

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Environmental vulnerability

• Dementia Decreased Reduced
• Threshold / Coping For Stress
  Strategies
• Behaviour
• Environmental Stimulus

41
Unmet Needs

• Lifelong habits
  fulfil
• Environmental Needs Attempt to
• limitations meet
  needs
• Current (medical) communicate
• condition

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Needs

• Basic needs food, sleep, shelter.
• More complex needs.

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Description (Cohen-Mansfield)
Verbal
Not agitated
Agitated
Non verbal
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Description
Verbal
INCREASES WITH fear, pain, loneliness, depression
Not agitated
Agitated
Non verbal
45
Description
Verbal
INREASES WITH restraint, lack of activities,
decreased staff , cold, being alone.
Not agitated
Agitated
Non verbal
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Place of Drug Treatment

• Medical causes.
• Delirium.
• Psychological/ environmental
  strategies.

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General Principles(IPA BPSD Education Pack)

• Does it warrant treatment and why?
• Will it respond to drugs?
• Which drug category is most suitable for it?
• What are predictable and potential side effects?
• How long do you continue treatment?

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General Principles(IPA BPSD Education Pack)

• Does it warrant treatment and why?
• Will it respond to drugs?
• Which drug category is most suitable for it?
• What are predictable and potential side effects?
• How long do you continue treatment?

• Consequences.
• Distress.
• Compromised care.
• Other resident morbidity.
• Staff morbidity.

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General Principles(IPA BPSD Education Pack)

• Does it warrant treatment and why?
• Will it respond to drugs?
• Which drug category is most suitable for it?
• What are predictable and potential side effects?
• How long do you continue treatment?

• Aggression (hostility).
• Psychosis.
• Agitation.
• Anxiety.
• Tension.
• Irritability.
• Insomnia.
• Apathy.
• Depression.
• Hallucinations.

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BPSD NOT on the R list.
Not an exhaustive list.

• Calling out.
• Wandering.
• Absconding.
• Intrusive behaviour.
• Incontinence.
• Inappropriate elimination.
• Destructive behaviour.

Some behaviours on this list MAY be secondary to
BPSD that MAY respond to drugs.
E.G. DEPRESSION
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General Principles(IPA BPSD Education Pack)

• Does it warrant treatment and why?
• Will it respond to drugs?
• Which drug category is most suitable for it?
• What are predictable and potential side effects?
• How long do you continue treatment?

• Aggression (hostility).
• Psychosis.
• Agitation.
• Anxiety.
• Tension.
• Irritability.
• Insomnia.
• Apathy.
• Depression.
• Hallucinations.

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Which drug category is most suitable for it?
CHOLINESTERASE INHIBITORS Apathy. Hallucinations.
Delusions. Anxiety. Depression. (Emergent
symptoms)
ANTIPSYCHOTICS Aggression/hostility.
ANTICONVULSANTS Agitation. Aggression/hostility.
ANXIOLYTICS Irritability.
IPA guidelines (2003)
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General Principles(IPA BPSD Education Pack)

• Does it warrant treatment and why?
• Will it respond to drugs?
• Which drug category is most suitable for it?
• What are predictable and potential side effects?
• How long do you continue treatment?

54
Risperidone
Boumann Pinner 2002

• orthostatic hypotension, prolactin elevation,
  weight gain.
• sedation.
• /- EPS, seizures, anticholinergic.

0 absent, mild, moderate, severe.
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Olanzepine
Boumann Pinner 2002

• / weight gain
• sedation.
• anticholinergic, orthostatic hypotension.
• /- seizures.
• 0 to /- EPS, prolactin elevation.

0 absent, mild, moderate,
severe.
56
Quetiapine
Boumann Pinner 2002

• weight gain
• to sedation, orthostatic hypotension.
• /- anticholinergic, seizures.
• 0 to /- EPS, prolactin elevation.

0 absent, mild, moderate,
severe.
NB. In Liebermann et al minimum rate of
anticholinergic side effects for ANY atypical was
20.
57
Tardive Dyskinesia(Jeste et al 1995)
58
Accelerated Cognitive Decline

• Treatment with haloperidol over 6-8 weeks
  associated with decline on MMSE (Devenand et al
  1999).
• Note that histaminergic, anticholinergic and
  dopaminergic activity can produce cognitive
  decline.

59
Mood Stabilizers.

• Carbamazepine
• Sedation, skin rash, headache, leucopoenia, mild
  abnormal LFTs.
• Sodium Valproate
• (fewer drug interactions and side effects)
• Sedation, diarrhoea, tremor, nausea, weight gain,
  hair loss, abnormal LFTs.

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General Principles(IPA BPSD Education Pack)

• Does it warrant treatment and why?
• Will it respond to drugs?
• Which drug category is most suitable for it?
• What are predictable and potential side effects?
• How long do you continue treatment?

• IPA recommendations
• 4-6/52 trial at adequate dose.
• IN the event of positive response (except Rx of
  depression) review _at_ 12/52 with a view to trial
  reduction.
• Studies show that ceasing conventional
  antipsychotic stable or improvement.
• Agitation and wandering tend to be most
  persistent.
• (Non affective) BPSD tend to peak at moderate
  levels of impairment.

61
Conventional Antipsychotics(from Lanctot 1995)

• Meta-analysis trials
• 1 antipsychotic.
• Random.
• Double blind.
• Controlled.
• Dementia.
• Behaviour outcome scale.
• At least 4 weeks.
• How many b/w 1966 1995?
• 16

62
Conventional Antipsychotics(from Lanctot 1995)

• Overall efficacy 61.
• BUT Only 26 better than placebo.
• No differences b/w high and low potency drugs.
• No differences in drop outs b/w high and low
  potency drugs,

63
Atypical Antipsychotics(from Boumann Pinner)

• Risperidone
• Katz et al (1999) n625 N.H. residents. 50
  reduction in BEHAVE-AD _at_ 12/52 for 1 and 2 mg
  doses.
• DeDeyn et al (1999) n344 institutional. 30
  reduction BEHAVE-AD _at_ 12/52 and fewer EPS than
  Haloperidol.

64
Atypical Antipsychotics(from Boumann Pinner
2002)

• Olanzepine
• Satterlee et al (1995) n238 SF and AD. N.S. CF
  placebo but 2/3 lt 5mg.
• Street et al (2000) n206 NH with AD. 5-10 mg/d
  65 57 (placebo 36).

65
Atypical Antipsychotics(from Boumann Pinner
2002)

• Quetiapine (NB open trials)
• McManus et al (1999) n151 f(x) organic (mean
  100mg/d). Improved BPRS _at_ 12/52.
• Schneider et al (1999) hostility. Improved
  hostility across 52/52 gt and ?independent of
  effects on positive symptoms.

66
REDUCTION IN BPRS SCORE WITH CBZ TARIOT ETAL
(1994)
BPRS SCORE
PLACEBO
CBZ
67
Carbam REDUCTION IN BPRS SCORE WITH CBZ
TARIOT ETAL (1998) azepine
60
50
BPRS SCORE
40
30
20
10
PLACEBO
CBZ
68
Effect of Donepezil on BPSD in 80 Memory Clinic
patients after 3/12.
A Apathy. B Hallucinations. C Delusions. D
Anxiety. E Depression. F Irritability. G
Aggression.
Matthews et al 2000