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THE EXESSIVE USE OF NEUROLEPTICS IN DEMENTED PATIENTS
Rasa RuseckieneOld age psychiatrist psychotherapistUniversity hospital of VilniusVilnius UniversityLithuania, 2013
What is dementia?
• Deterioration from a previously obtained level of cognition and/or behaviour
• Cognitive deterioration disproportionate to disturbance of arousal
• Duration of at least several months• Deficits that interfere with daily life• The chronic confusional state
Vilnius University, Lithuania
The impact of dementia
• Dementia is one of the most severe and challenging disorders we face
• Worldwide an estimated 36 million people are living with dementia
• A new report predicts that number will increase to more than 115 million by 2025
Vilnius University, Lithuania
The impact of dementia
• The incidence of dementia and the prevalence of dementia rise exponentially with age
• Dementia affects men and women in all social and ethnic groups
• Dementia has negative effects not only on those with disorder, but also on family members who provide the majority of care
Vilnius University, Lithuania
Number of hospitalized patients with dementia
(psychogeriatric units, Lithuania, 2012)
JanuaryFebruary
MarchAprilMayJuneJuly
AugustSeptember
OctoberNovemberDecember
0 5 10 15 20 25
OtherDepresionDementia
Vilnius University, Lithuania
Why are neuroleptics used in dementia?
• Behavioural disturbances and mental symptoms are a frequent source of distress to demented patients at any stage of the illness
• These non-cognitive symptoms are described as neuropsychiatric symptoms or “behavioural and psychological symptoms of dementia” (BPSD)
Vilnius University, Lithuania
Why are neuroleptics used in dementia?
• BPSD are distressing and problematic for carers, they make a large and independent contribution to caregiver strain and are a common precipitating factor for institutionalization
• BPSD are very common and may occur in up to 90% of people with Alzheimer’s and Lewy body dementia
Vilnius University, Lithuania
BPSD rate in dementia (psychogeriatric units, Lithuania, 2012)
7%3%
19%
13%18%
1%
12%
7%
10% 9%
BPSD rate
DelusionsHallucinationsAnxietyDepressionAggressionEuphoriaDisinhibitionIrritabilityApathyAgitation
Vilnius University, Lithuania
Exposure to antipsychotics drugs
• Antipsychotics are widely used as the first line pharmacological approach to treat neuropsychiatric symptoms in dementia
• Up to 60% - 90% of demented patients in hospital may receive neuroleptics, and 13%-70% of elderly people in institutions receive neuroleptics within any 24 hours for at least one year
Vilnius University, Lithuania
Exposure to antipsychotics drugs• Often used antipsychotic drugs include
haloperidol, aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone, tiapridal (Eastern Europe c.), chlorprotixene (Eastern Europe c.)
• Rare used antipsychotics include thioridazine, chlorpromazine, perphenazine, fluphenazine, acetophenazine, promazine, trifluoperazine, triflupromazine, loxapine, pimozide, thiothixene, sulpiridi.
Vilnius University, Lithuania
Exposure medications in demented patients (psychogeriatric units, Lithuania, 2012)
Total patients No
Atypical
Typical
Total patients No
Monotheraphy
Politheraphy
Total patients No
Cognitive enhancers
No cognitive enhancers
0 20 40 60 80 100 120 140 160
Exposure of medications
Vilnius University, Lithuania
Typical and atypical antipsychotics using (psychogeriatic units, Lithuania, 2012)
Olanzapine
Risperidone
Tiapridal
Haloperidol
Quetiapine
Chlorprotixene
Sulpiridi
0 10 20 30 40 50 60 70
Antipsychotics using rate
Vilnius University, Lithuania
Positive effect of antipsychotic drugs in dementia
• Antipsychotic drugs has minimal/modest efficacy for the treatment of BPSD
• There is very limited evidence for the efficacy of typical or atypical neuroleptics for the treatment of symptoms of psychosis in dementia
• No additional falls or fractures using atypical NL for less 12 week (risperidone, olanzapine)
• There is some evidence to support slightly better improvement in aggression for risperidone (licensed for dementia)
• A clinically significant degree of improvement has only been demonstrated for aripiprazole
Vilnius University, Lithuania
Negative effect of antipsychotic drugs in dementia
• All drugs have side effects as well as intended effects
• People with dementia are in high-risk of group for adverse effects on the basis of age, frailty, physical co-morbity and interactions with other drugs
• This means that people with dementia are much more sensitive to the side effects of typical/ atypical antipsychotics such Parkinsonism, disorders of movement and QT prolongation
Vilnius University, Lithuania
Safety of antipsychotic drugs in dementia
• In recent years, was clear that the use of antipsychotics in dementia is a drug safety issue as well
• Food and Drug Administration issued an advisory warning in 2005 that atypical antipsychotics were associated with a 60%-70% increased risk of death among older patients with dementia
• Subsequent studies found risks at least as high among users of conventional antipsychotics , and Food and Drug Administration issued a similar warning for such drugs in 2008
Vilnius University, Lithuania
Safety of antipsychotic drugs in dementia
• All cause mortality• There is a dose – response relation with side effects
for all antipsychotic drugs except quetiapine• Patients, treated with haloperidol, compared with
risperidone, had double the risk of mortality• Risperidone was found to be associated with an
increased risk of stroke compared with olanzapine and quetiapine
• Quetiapine is associated with the lowest risk of mortality
Vilnius University, Lithuania
CAUSE SPECIFIC MORTALITY
Circulatory system
Cerebrovascular system
Respiratory system
Others
Vilnius University, Lithuania
Adverse effects rate (psychogeriatric units, Lithuania, 2012)
31%
16%24%
20% 10%
Most common side effects rate
Circulatory system Circulatory system with suspected strokes Cerebrovascular diseases Respiratory system
Other
Vilnius University, Lithuania
The circulatory system complications risk using neuroleptics
Total Tiapridal Haloperidol Other0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
Chart Title
Circulatory system complications risk
Vilnius University, Lithuania
Good practice recommendations
• A proper assesment using may highlight the problem and appropriate intervention may be provide without the use of antipsychotics
• Non – pharmacological interventions should be recommended as a first line treatment unless BPSD symptoms are severe, persistent or reccurent
• First line treatment may include targeting the cause of the BPSD
Vilnius University, Lithuania
Good practise recommendations
• Carer training• Carer support• Staff training• Respite care
Vilnius University, Lithuania
What to do in a suspected case of BPSD?
Vilnius University, Lithuania
EXPLANATION
TREATMENT
EVALUATION
TREATMENT REVIEW
EVALUATIONPhysical factors
Any acute medical
problems
Recent change in drugs
Recent use of alhocol
Chronic disease relapsed
Pain problem
Vilnius University, Lithuania
EvaluationIntellectual
Any recent screening test of cognitive ability (MMSE)
Any significant change from previuos score
Vilnius University, Lithuania
EvaluationEmotional
symptoms
depression
anxietypsychosis
agression
Vilnius University, Lithuania
Evaluation
Capabilities• Is the patient bored?• Is the patient frustrated
about something?• Is the patient angry about
something?
Environment, social/cultural• Any change of environment?• Does patient feels lost?• Is there exscessive noise?• Is the environment unfreindly
and confusing?• Are there any cultural issues in
meeting patients needs?• How is the interaction with
other residents?• How is the relationship with
family?
Vilnius University, Lithuania
Explanation• Discuss the current situation with the patient and
family members• Explain possible choices of treatment and reasons
for picking one• Risks and benefits have been fully clear• Assess cerebrovascular risk factors and explain
possible increased risk of stroke and mortality• Patients/caregivers should be cautioned to
immediately report signs and symptoms of potential strokes
Vilnius University, Lithuania
Treatment
• If BPSD is severe and complicated, then an atypical antipsychotic should be preferred over a typical one
• Drug treatment should have a specific target symptom
• Starting dose should be initially be low and then titrated upwards
• Drug treatment should be time limited
Vilnius University, Lithuania
Treatment review• Treatment is time limited and regularly reviewed
(every two weeks or one month) and ideally used less than 12 weeks
• Monitor for severe reactions, particularly neuroleptic malignant syndrome sensitivity reactions, development or worsening of extrapyramidal features
• Changes in condition should be regularly assessed and recorded
• Use psychosocial interventions as soon as possible instead of medications
Vilnius University, Lithuania
Conclusions• Although non – pharmacological
interventions are nearly universally recommended as first line treatment, they are commonly insufficient in people with severe and persistent/recurrent BPSD symptoms
• Consequently, most patients will be given a psychotropic drugs at some point in their disease progression despite the clear data confirming their associated risk
• It is very important to asses properly the patients state, when BPSD is suspected and to select marginally harmful method of treatment
Vilnius University, Lithuania
Literature• Knapp M, Prince M, Albanese E, Banerjee S et al. Dementia UK: the Full report. London:
Alzheimer Society,2007.• Black W, Almeida OP. A systematic review of the association between the behavioural and
psychological symptoms of dementia and burden care. International Psychogeriartrics,2004 16(3), 295-315.
• Zimmer JG, Watson N, Treat A. Behavioural problems among patients in skilled nursing homes. Am J Public Health 1984;74:1118.
• Gillerd CJ, Morgan K, Wade BE. Patterns of neuroleptics use among the institutionalised elderly. Acta Psychiatr Scand 1983;68;419-25.
• Huybrechts KF, Gerhard T, Olfson M, Lucas JA. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. 2012 12 (2), 344.
• Scneider LS, Dagerman K Insel. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized trails. American Journal of Geriatric Psychiatry, 2006,14, 191-210.
• Banerjee S. The use of antipsychotic medication for people with dementia: time for action. 2010, 25 (3.3), 1-59.
Vilnius University, Lithuania
Literature• Ballard C, Howard R. Neuroleptic drugs in dementia: benefits and harm. Nat Rev
Neurosi 2006;7:492-500.• FDA Public Health Advisory, Deaths with antipsychotics in elderly patients with
behavioural disturbances. 2010• Wang PS, Schneeweiss S, Avorn J, Fisher MA, Mogun H. Risk of deaths in elderly
users of conventional vs atypical antipsychotics medications. N Engl J Med 2005; 353: 2335-41.
• FDA. Information for Healthcare Professionals – antipsychotics.2011.www.fda.gov/Drugs/drug safety.
• Setoguchi S, Brookhart A, Dormuth C, Wang PS. Risk of the death associated with the use of conventional versus atypical antipsychotics drugs among elderly patients. CMAJ 2007;176:627-32.
• Maher A, Maglione M, Bagley S et al. Efficacy and comparative effectiveness of atypical medications for off-label uses in adults. JAMA 2011, 306:1359-69.
• Cummings J. Behavioural and neuropsychiatric outcomes in AD. CNS Spectr 2005; 10: 22-5.
Vilnius University, Lithuania