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Abstract
PURPOSE OF REVIEW The psychiatric aspects of dementia are increasingly recognized as significant contributors to distress, disability, and care burden, and, thus, are of increasing interest to practicing neurologists. This article examines how psychiatric disorders are entwined with dementia and describes the predictive, diagnostic, and therapeutic implications of the psychiatric symptoms of dementia. RECENT FINDINGS Psychiatric disorders, particularly depression and schizophrenia, are associated with higher risk for late-life dementia. Psychiatric phenomena also define phenotypes such as frontotemporal dementia and dementia with Lewy bodies, cause distress, and amplify dementia-related disabilities. Management requires a multidisciplinary team, a problem-solving stance, programs of care, and pharmacologic management. Recent innovations include model programs that provide structured problem-solving interventions and tailored in-home care. SUMMARY There is new appreciation of the complexity of the relationship between psychiatric disorders and dementia as well as the significance of this relationship for treatment, community services, and research.
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302
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Garay RP, Grossberg GT. AVP-786 for the treatment of agitation in dementia of the Alzheimer's type. Expert Opin Investig Drugs 2016; 26:121-132. [PMID: 27936965 DOI: 10.1080/13543784.2017.1267726] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Agitation is common and distressing in patients with Alzheimer-type dementia, but safe, effective treatments remain elusive. Psychological treatments are first-line options, but they have limited efficacy. Off-label psychotropic medications are frequently used, but they also have limited effectiveness, and their use may have harmful side effects, including death. Areas covered: This review discusses the history leading to the conception of AVP-786 (deuterated (d6)-dextromethorphan/quinidine), its pharmacokinetic and pharmacodynamic profiles and safety issues, together with an overview of recent clinical trials. Data were found in the medical literature, in US and EU clinical trial registries and in information provided by the manufacturer. Expert opinion: AVP-786 is one of six investigational compounds in recent phase III clinical development for agitation in Alzheimer disease (AD). Quinidine and deuteration appear to prolong dextromethorphan's plasma half-life and facilitate brain penetration. The FDA granted fast-track designation to AVP-786 and allowed use of data generated on dextromethorphan-quinidine (AVP-923, Nuedexta®) for regulatory filings. AVP-923 reduced agitation in AD and was well tolerated in a phase II RCT that included more than 200 patients. A phase III clinical development program of AVP-786 for AD agitation was recently initiated. This program is expected to start generating results in July 2018.
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Affiliation(s)
- Ricardo P Garay
- a Geriatric Psychiatry, Department of Psychiatry and Behavioural Neuroscience , Pharmacology and Therapeutics, Craven , Villemoisson-sur-Orge , France
| | - George T Grossberg
- b Department of Psychiatry and Behavioural Neuroscience , St Louis University School of Medicine , St Louis , MO , USA
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303
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Gender differences in clusters of NPS in Dutch nursing homes - a factor analysis. Int Psychogeriatr 2016; 28:1989-1999. [PMID: 27572478 DOI: 10.1017/s1041610216001216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Neuropsychiatric symptoms (NPS) have a high prevalence among patients with dementia, up to 80%. NPS can be grouped by type and stage of dementia. However, NPS have not previously been grouped by gender. Our objective was to investigate whether NPS cluster differently in men or women in the nursing home patients. METHODS Factor analysis to assess the clustering of items in the Cohen-Mansfield Agitation Inventory (CMAI) and Neuropsychiatric Inventory-Nursing home version (NPI-NH) into components, for both scales and for gender. Differences in symptom clustering between male and female patients were assessed using a three-step procedure: (1) identifying a gender specific distinctive item, (2) describe the correlation between the distinctive item with any other item in this cluster, (3) testing whether the correlation between a distinctive item and any other item in the cluster (which is present in both sexes) is different for males and females using a general linear model. RESULTS Our database consisted of 1,609 patients. There were five male and three female clusters for NPI-NH and eight male and seven female clusters for CMAI. There were three distinctive items in the NPI-NH and ten in the CMAI. CONCLUSIONS There are other clusters of NPS in males and females. Our analysis revealed more significant relations in female than male patients. This might have an implication on the clinical course.
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304
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305
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Struble LM, Blazek MC, Kales HC. Managing behavioral disturbances in a patient with dementia. Nurse Pract 2016; 41:50-54. [PMID: 27764068 DOI: 10.1097/01.npr.0000497008.47868.88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
A 92-year-old patient with Parkinson disease and dementia provides an opportunity for the advanced practice registered nurse to shift thinking about behavioral disturbances in dementia, away from controlling behavior with pharmacologic approaches, such as antipsychotics, toward understanding behavior by applying the nonpharmacologic Describe, Investigate, Create, and Evaluate method.
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Affiliation(s)
- Laura M Struble
- Laura M. Struble is a clinical associate professor at University of Michigan, School of Nursing, Ann Arbor, Mich. Mary C. Blazek is an assistant professor in the section of Geriatric Psychiatry, Department of Psychiatry, University of Michigan, Ann Arbor, Mich. Helen C. Kales is a professor in the section of Geriatric Psychiatry, Department of Psychiatry, University of Michigan, Ann Arbor, Mich
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306
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Resnick B, Kolanowski A, Van Haitsma K, Boltz M, Galik E, Bonner A, Vigne E, Holtzman L, Mulhall PM. Pilot Testing of the EIT-4-BPSD Intervention. Am J Alzheimers Dis Other Demen 2016; 31:570-579. [PMID: 27609932 PMCID: PMC10852713 DOI: 10.1177/1533317516662337] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Behavioral and psychological symptoms of dementia are common in nursing home residents, and the Centers for Medicare and Medicaid Services now require that nonpharmacological interventions be used as a first-line treatment. Few staff know how to implement these interventions. The purpose of this study was to pilot test an implementation strategy, Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD), which was developed to help staff integrate behavioral interventions into routine care. The EIT-4-BPSD was implemented in 2 nursing homes, and 21 residents were recruited. A research nurse facilitator worked with facility champions and a stakeholder team to implement the 4 steps of EIT-4-BPSD. There was evidence of reach to all staff; effectiveness with improvement in residents' quality of life and a decrease in agitation; adoption based on the environment, policy, and care plan changes; and implementation and plans for maintenance beyond the 6-month intervention period.
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Affiliation(s)
- Barbara Resnick
- School of Nursing, University of Maryland, Baltimore, MD, USA
| | | | | | - Marie Boltz
- William F. Connell School of Nursing, Boston College, Boston, MA, USA
| | - Elizabeth Galik
- School of Nursing, University of Maryland, Baltimore, MD, USA
| | - Alice Bonner
- School of Nursing, Northeastern University, Boston, MA, USA
| | - Erin Vigne
- School of Nursing, University of Maryland, Baltimore, MD, USA
| | - Lauren Holtzman
- School of Nursing, University of Maryland, Baltimore, MD, USA
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307
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Abstract
The use of psychotropic medication among persons with dementia (PWD) both in nursing home (Wetzels et al., 2011) and community settings (Maust et al., 2016) far exceeds what might be expected based on their limited evidence for benefit (Kales et al., 2015). This relatively high use persists despite years of evidence about the potential harms associated with their use in older adults generally and PWD in particular (e.g. Wang et al., 2001; Schneider et al., 2005). However, the solution to relatively high psychotropic use is not to end all psychotropic use, as there are individual patients for whom use of such medication is appropriate. For example, a policy that defines all antipsychotic use as inappropriate may simply lead to increased use of alternatives with even less evidence of benefit, as suggested by the response to antipsychotics' black box warning in the United States (Kales et al., 2011).
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308
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Peterson K, Hahn H, Lee AJ, Madison CA, Atri A. In the Information Age, do dementia caregivers get the information they need? Semi-structured interviews to determine informal caregivers' education needs, barriers, and preferences. BMC Geriatr 2016; 16:164. [PMID: 27662829 PMCID: PMC5035467 DOI: 10.1186/s12877-016-0338-7] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/15/2016] [Indexed: 12/02/2022] Open
Abstract
Background Most patients with dementia or cognitive impairment receive care from family members, often untrained for this challenging role. Caregivers may not access publicly available caregiving information, and caregiver education programs are not widely implemented clinically. Prior large surveys yielded broad quantitative understanding of caregiver information needs, but do not illuminate the in-depth, rich, and nuanced caregiver perspectives that can be gleaned using qualitative methodology. Methods We aimed to understand perspectives about information sources, barriers and preferences, through semi-structured interviews with 27 caregivers. Content analysis identified important themes. Results We interviewed 19 women, 8 men; mean age 58.5 years; most adult children (15) or spouses (8) of the care recipient. Dementia symptoms often developed insidiously, with delayed disease acknowledgement and caregiver self-identification. While memory loss was common, behavioral symptoms were most troublesome, often initially unrecognized as disease indicators. Emerging themes: 1.) Barriers to seeking information often result from knowledge gaps, rather than reluctance to assume the caregiver role; 2.) Most caregivers currently receive insufficient information. Caregivers are open to many information sources, settings, and technologies, including referrals to other healthcare professionals, print material, and community and internet resources, but expect the primary care provider (PCP) to recommend, endorse, and guide them to specific sources. Conclusions These findings replicated and expanded on results from previous quantitative surveys and, importantly, revealed a previously unrecognized essential factor: despite receiving insufficient information, caregivers place critical value on their relationship with care recipient PCPs to receive recommendations, guidance and endorsement to sources of caregiving information. Implications include: 1.) Greater public education is needed to help caregivers identify and describe diverse cognitive, functional and behavioral symptoms that lead to dementia, and recognize the benefits of early detection in accessing information regarding multi-modality management and care; 2.) Improved methods are needed for PCPs to detect and manage cognitive and behavioral changes, as well as mechanisms that facilitate the busy PCP, either directly or via referral, to provide caregiver information, education, support, and services. The critical relationship between caregivers and PCPs should not be circumvented but should be facilitated to provide more effective guidance regarding dementia caregiver needs. Electronic supplementary material The online version of this article (doi:10.1186/s12877-016-0338-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kendra Peterson
- Ray Dolby Brain Health Center; California Pacific Medical Center, a Sutter Health Affiliate, San Francisco, CA, USA.,California Pacific Medical Center Research Institute, San Francisco, CA, USA
| | - Howard Hahn
- Ray Dolby Brain Health Center; California Pacific Medical Center, a Sutter Health Affiliate, San Francisco, CA, USA
| | - Amber J Lee
- Ray Dolby Brain Health Center; California Pacific Medical Center, a Sutter Health Affiliate, San Francisco, CA, USA.,California Pacific Medical Center Research Institute, San Francisco, CA, USA
| | - Catherine A Madison
- Ray Dolby Brain Health Center; California Pacific Medical Center, a Sutter Health Affiliate, San Francisco, CA, USA.,California Pacific Medical Center Research Institute, San Francisco, CA, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Alireza Atri
- Ray Dolby Brain Health Center; California Pacific Medical Center, a Sutter Health Affiliate, San Francisco, CA, USA. .,California Pacific Medical Center Research Institute, San Francisco, CA, USA. .,Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA. .,, 45 Castro Street, Suite 220, San Francisco, California, 94114, USA.
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309
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Rosenberg PB, Lanctôt KL, Herrmann N, Mintzer JE, Porsteinsson AP, Sun X, Raman R. Changes in Neuropsychiatric Inventory Associated with Semagacestat Treatment of Alzheimer’s Disease. J Alzheimers Dis 2016; 54:373-81. [DOI: 10.3233/jad-151113] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Paul B. Rosenberg
- Department of Psychiatry and Behavioral Sciences, Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Krista L. Lanctôt
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Departments of Psychiatry and Pharmacology/Toxicology, University of Toronto, Toronto, ON, Canada
| | - Nathan Herrmann
- Division of Geriatric Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Psychiatry, Division of Geriatric Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Jacobo E. Mintzer
- Roper St. Francis Clinical Biotechnology Research Institute, Charleston, SC, USA
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
- Medical University of South Carolina, Charleston, SC, USA
- School of Internal Medicine, University of South Carolina, Columbia, SC, USA
| | - Anton P. Porsteinsson
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Xiaoying Sun
- Biostatistics Research Center, University of California, San Diego, La Jolla, CA, USA
| | - Rema Raman
- Alzheimer’s Therapeutic Research Institute (ATRI), Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA
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310
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Björk S, Juthberg C, Lindkvist M, Wimo A, Sandman PO, Winblad B, Edvardsson D. Exploring the prevalence and variance of cognitive impairment, pain, neuropsychiatric symptoms and ADL dependency among persons living in nursing homes; a cross-sectional study. BMC Geriatr 2016; 16:154. [PMID: 27549203 PMCID: PMC4994232 DOI: 10.1186/s12877-016-0328-9] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 08/15/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Earlier studies in nursing homes show a high prevalence of cognitive impairment, dependency in activities of daily living (ADL), pain, and neuropsychiatric symptoms among residents. The aim of this study was to explore the prevalence of the above among residents in a nationally representative sample of Swedish nursing homes, and to investigate whether pain and neuropsychiatric symptoms differ in relation to gender, cognitive function, ADL-capacity, type of nursing-home unit and length of stay. METHODS Cross-sectional data from 188 randomly selected nursing homes were collected. A total of 4831 residents were assessed for cognitive and ADL function, pain and neuropsychiatric symptoms. Data were analysed using descriptive statistics and the chi-square test. RESULTS The results show the following: the prevalence of cognitive impairment was 67 %, 56 % of residents were ADL-dependent, 48 % exhibited pain and 92 % exhibited neuropsychiatric symptoms. The prevalence of pain did not differ significantly between male and female residents, but pain was more prevalent among cognitively impaired and ADL-dependent residents. Pain prevalence was not significantly different between residents in special care units for people with dementia (SCU) and general units, or between shorter-and longer-stay residents. Furthermore, the prevalence of neuropsychiatric symptoms did not differ significantly between male and female residents, between ADL capacities or in relation to length of stay. However, residents with cognitive impairment and residents in SCUs had a significantly higher prevalence of neuropsychiatric symptoms than residents without cognitive impairment and residents in general units. CONCLUSIONS The prevalence rates ascertained in this study could contribute to a greater understanding of the needs of nursing-home residents, and may provide nursing home staff and managers with trustworthy assessment scales and benchmark values for further quality assessment purposes, clinical development work and initiating future nursing assessments.
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Affiliation(s)
- Sabine Björk
- Department of Nursing, Umeå University, Umeå, Sweden.
| | | | - Marie Lindkvist
- Department of Statistics, Umeå School of Business and Economics, Umeå University, Umeå, Sweden.,Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Anders Wimo
- Department of Neurobiology, Care Sciences and Society, Division of Neurogeriatrics, Karolinska Institutet, Stockholm, Sweden
| | - Per-Olof Sandman
- Department of Nursing, Umeå University, Umeå, Sweden.,Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden.,Department of Health Sciences, Luleå University of Technology, Luleå, Sweden
| | - Bengt Winblad
- Department of Neurobiology, Care Sciences and Society, Division of Neurogeriatrics, Karolinska Institutet, Stockholm, Sweden
| | - David Edvardsson
- Department of Nursing, Umeå University, Umeå, Sweden.,School of Nursing and Midwifery, La Trobe University, Melbourne, Australia
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311
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Kazui H, Yoshiyama K, Kanemoto H, Suzuki Y, Sato S, Hashimoto M, Ikeda M, Tanaka H, Hatada Y, Matsushita M, Nishio Y, Mori E, Tanimukai S, Komori K, Yoshida T, Shimizu H, Matsumoto T, Mori T, Kashibayashi T, Yokoyama K, Shimomura T, Kabeshita Y, Adachi H, Tanaka T. Differences of Behavioral and Psychological Symptoms of Dementia in Disease Severity in Four Major Dementias. PLoS One 2016; 11:e0161092. [PMID: 27536962 PMCID: PMC4990196 DOI: 10.1371/journal.pone.0161092] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 07/31/2016] [Indexed: 11/19/2022] Open
Abstract
Background/Aims Behavioral and psychological symptoms of dementia (BPSDs) negatively impact the prognosis of dementia patients and increase caregiver distress. The aims of this study were to clarify the differences of trajectories of 12 kinds of BPSDs by disease severity in four major dementias and to develop charts showing the frequency, severity, and associated caregiver distress (ACD) of BPSDs using the data of a Japan multicenter study (J-BIRD). Methods We gathered Neuropsychiatric Inventory (NPI) data of patients with Alzheimer’s disease (AD; n = 1091), dementia with Lewy bodies (DLB; n = 249), vascular dementia (VaD; n = 156), and frontotemporal lobar degeneration (FTLD; n = 102) collected during a 5-year period up to July 31, 2013 in seven centers for dementia in Japan. The NPI composite scores (frequency × severity) of 12 kinds of items were analyzed using a principal component analysis (PCA) in each dementia. The factor scores of the PCA were compared in each dementia by disease severity, which was determined with Clinical Dementia Rating (CDR). Results Significant increases with higher CDR scores were observed in 1) two of the three factor scores which were loaded for all items except euphoria in AD, 2) two of the four factor scores for apathy, aberrant motor behavior (AMB), sleep disturbances, agitation, irritability, disinhibition, and euphoria in DLB, and 3) one of the four factor scores for apathy, depression, anxiety, and sleep disturbances in VaD. However, no increases were observed in any of the five factor scores in FTLD. Conclusions As dementia progresses, several BPSDs become more severe, including 1) apathy and sleep disturbances in AD, DLB, and VaD, 2) all of the BPSDs except euphoria in AD, 3) AMB, agitation, irritability, disinhibition, and euphoria in DLB, and 4) depression and anxiety in VaD. Trajectories of BPSDs in FTLD were unclear.
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Affiliation(s)
- Hiroaki Kazui
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- * E-mail:
| | - Kenji Yoshiyama
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hideki Kanemoto
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yukiko Suzuki
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Shunsuke Sato
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Mamoru Hashimoto
- Department of Neuropsychiatry, Faculty of Life Sciences, Kumamoto University, Kumamoto, Kumamoto, Japan
| | - Manabu Ikeda
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Department of Neuropsychiatry, Faculty of Life Sciences, Kumamoto University, Kumamoto, Kumamoto, Japan
| | - Hibiki Tanaka
- Department of Neuropsychiatry, Faculty of Life Sciences, Kumamoto University, Kumamoto, Kumamoto, Japan
| | - Yutaka Hatada
- Department of Neuropsychiatry, Faculty of Life Sciences, Kumamoto University, Kumamoto, Kumamoto, Japan
| | - Masateru Matsushita
- Department of Neuropsychiatry, Faculty of Life Sciences, Kumamoto University, Kumamoto, Kumamoto, Japan
| | - Yoshiyuki Nishio
- Department of Behavioral Neurology and Cognitive Neurosciences, Tohoku University School of Medicine, Sendai, Miyagi, Japan
| | - Etsuro Mori
- Department of Behavioral Neurology and Cognitive Neurosciences, Tohoku University School of Medicine, Sendai, Miyagi, Japan
| | - Satoshi Tanimukai
- Department of Neuropsychiatry, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
- Comprehensive community care for elderly, nursing and Health science, Graduate School of Medicine, Ehime University, Toon, Ehime, Japan
| | - Kenjiro Komori
- Department of Neuropsychiatry, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
- Zaidan-Niihama Hospital, Niihama, Ehime, Japan
| | - Taku Yoshida
- Department of Neuropsychiatry, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Hideaki Shimizu
- Department of Neuropsychiatry, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Teruhisa Matsumoto
- Department of Neuropsychiatry, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Takaaki Mori
- Department of Neuropsychiatry, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Tetsuo Kashibayashi
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Departments of Neurology and Cognitive disorders, Hyogo Prefectural Rehabilitation Center at Nishi-harima, Tatsuno, Hyogo, Japan
| | - Kazumasa Yokoyama
- Departments of Neurology and Cognitive disorders, Hyogo Prefectural Rehabilitation Center at Nishi-harima, Tatsuno, Hyogo, Japan
| | - Tatsuo Shimomura
- Department of Dementia Research, Akita Prefectural Center for Rehabilitation and Psychiatric Medicine, Daisen, Akita, Japan
| | - Yasunobu Kabeshita
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- The Sleep Medical Center of Osaka University Hospital, Suita, Osaka, Japan
- Department of Psychiatry, Osaka University Health Care Center, Toyonaka, Osaka, Japan
| | - Hiroyoshi Adachi
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- The Sleep Medical Center of Osaka University Hospital, Suita, Osaka, Japan
- Department of Psychiatry, Osaka University Health Care Center, Toyonaka, Osaka, Japan
| | - Toshihisa Tanaka
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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312
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Antipsychotic use in dementia patients in a general practice setting: a Dutch population-based study. Epidemiol Psychiatr Sci 2016; 25:403-6. [PMID: 26988389 PMCID: PMC7137605 DOI: 10.1017/s2045796016000111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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313
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Gotovac K, Nikolac Perković M, Pivac N, Borovečki F. Biomarkers of aggression in dementia. Prog Neuropsychopharmacol Biol Psychiatry 2016; 69:125-30. [PMID: 26952705 DOI: 10.1016/j.pnpbp.2016.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 02/24/2016] [Accepted: 03/03/2016] [Indexed: 12/17/2022]
Abstract
Dementia is a clinical syndrome defined by progressive global impairment of acquired cognitive abilities. It can be caused by a number of underlying conditions. The most common types of dementia are Alzheimer's disease (AD), frontotemporal dementia (FTD), vascular cognitive impairment (VCI) and dementia with Lewy bodies (DLB). Despite the fact that cognitive impairment is central to the dementia, noncognitive symptoms, most commonly described nowadays as neuropsychiatric symptoms (NPS) exist almost always at certain point of the illness. Aggression as one of the NPS represents danger both for patients and caregivers and the rate of aggression correlates with the loss of independence, cognitive decline and poor outcome. Therefore, biomarkers of aggression in dementia patients would be of a great importance. Studies have shown that different genetic factors, including monoamine signaling and processing, can be associated with various NPS including aggression. There have been significant and multiple neurotransmitter changes identified in the brains of patients with dementia and some of these changes have been involved in the etiology of NPS. Aggression specific changes have also been observed in neuropathological studies. The current consensus is that the best approach for development of such biomarkers may be incorporation of genetics (polymorphisms), neurobiology (neurotransmitters and neuropathology) and neuroimaging techniques.
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Affiliation(s)
- Kristina Gotovac
- Department for Functional Genomics, Center for Translational and Clinical Research, University of Zagreb School of Medicine, University Hospital Center Zagreb, Šalata 2, 10 000 Zagreb, Croatia.
| | - Matea Nikolac Perković
- Division of Molecular Medicine, Rudjer Boskovic Institute, Bijenicka, 54, HR 10000, Zagreb, Croatia
| | - Nela Pivac
- Division of Molecular Medicine, Rudjer Boskovic Institute, Bijenicka, 54, HR 10000, Zagreb, Croatia
| | - Fran Borovečki
- Department for Functional Genomics, Center for Translational and Clinical Research, University of Zagreb School of Medicine, University Hospital Center Zagreb, Šalata 2, 10 000 Zagreb, Croatia; Department of Neurology, University Hospital Center Zagreb, Kišpatićeva 12, 10000 Zagreb, Croatia
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314
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Hicken BL, Daniel C, Luptak M, Grant M, Kilian S, Rupper RW. Supporting Caregivers of Rural Veterans Electronically (SCORE). J Rural Health 2016; 33:305-313. [DOI: 10.1111/jrh.12195] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/05/2016] [Accepted: 06/06/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Bret L. Hicken
- Veterans Rural Health Resource Center; Salt Lake City Utah
| | - Candice Daniel
- Salt Lake Department of Veterans Affairs Health Care System; Salt Lake City Utah
| | - Marilyn Luptak
- Department of Social Work; University of Utah; Salt Lake City Utah
| | - Marren Grant
- Veterans Rural Health Resource Center; Salt Lake City Utah
| | - Shirley Kilian
- Loma Linda Department of Veterans Affairs Healthcare System; Loma Linda California
| | - Randall W. Rupper
- VA Geriatric Research, Education, and Clinical Center; Salt Lake City Utah
- Division of Geriatrics; University of Utah; Salt Lake City Utah
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315
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Tampi RR, Tampi DJ, Balachandran S, Srinivasan S. Antipsychotic use in dementia: a systematic review of benefits and risks from meta-analyses. Ther Adv Chronic Dis 2016; 7:229-45. [PMID: 27583123 DOI: 10.1177/2040622316658463] [Citation(s) in RCA: 144] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The purpose of this review is to evaluate the data on the use of antipsychotics in individuals with dementia from meta-analyses. METHODS We performed a literature search of PubMed, MEDLINE, EMBASE, PsycINFO and Cochrane collaboration databases through 30 November, 2015 using the following keywords: 'antipsychotics', 'dementia' and 'meta-analysis'. The search was not restricted by the age of the patients or the language of the study. However, in the final analysis we only included studies involving patients that were published in English language journals or had official English translations. In addition, we reviewed the bibliographic databases of published articles for additional studies. RESULTS This systematic review of the literature identified a total of 16 meta-analyses that evaluated the use of antipsychotics in individuals with dementia. Overall, 12 meta-analyses evaluated the efficacy of antipsychotics among individuals with dementia. Of these, eight also assessed adverse effects. A further two studies evaluated the adverse effects of antipsychotics (i.e. death). A total of two meta-analyses evaluated the discontinuation of antipsychotics in individuals with dementia. Overall, three meta-analyses were conducted in individuals with Alzheimer's disease (AD) whereas one focused on individuals with Lewy Body Dementia (LBD). The rest of the 12 meta-analyses included individuals with dementia. CONCLUSIONS Antipsychotics have demonstrated modest efficacy in treating psychosis, aggression and agitation in individuals with dementia. Their use in individuals with dementia is often limited by their adverse effect profile. The use of antipsychotics should be reserved for severe symptoms that have failed to respond adequately to nonpharmacological management strategies.
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Affiliation(s)
- Rajesh R Tampi
- Case Western Reserve University School of Medicine, Vice Chairman for Education and Faculty Development, Program Director, Psychiatry Residency, Department of Psychiatry, MetroHealth, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Deena J Tampi
- Saint Francis Hospital and Medical Center, Hartford, CT, USA
| | | | - Shilpa Srinivasan
- University of South Carolina School of Medicine, Charleston, SC, USA
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Lichtwarck B, Selbaek G, Kirkevold Ø, Rokstad AMM, Benth JŠ, Myhre J, Nybakken S, Bergh S. TIME - Targeted interdisciplinary model for evaluation and treatment of neuropsychiatric symptoms: protocol for an effectiveness-implementation cluster randomized hybrid trial. BMC Psychiatry 2016; 16:233. [PMID: 27406242 PMCID: PMC4942955 DOI: 10.1186/s12888-016-0944-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 06/15/2016] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Nearly all persons with dementia will experience neuropsychiatric symptoms (NPS) during the course of their disease. Clinicians and researchers emphasize the need for an evidence-informed standardized approach to managing NPS that integrates pharmacological and nonpharmacological treatments for real-world implementation. The Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms (TIME) represents such an approach and is a multicomponent intervention based on the theoretical framework of cognitive behavioural therapy. METHODS/DESIGN The trial is a 3-month cluster randomized trial conducted in 30 nursing homes including 168 participants with dementia and a high level of agitation. Each nursing home defined as a cluster will be randomized to receive either the TIME intervention (the intervention group) or a brief education-only intervention regarding dementia and NPS (the control group). TIME is a manual-based, multicomponent programme that includes a rigorous assessment, one or more case conferences and the treatment and evaluation of NPS. Patient-level measurements are taken at baseline (prior to randomization) and 8 and 12 weeks later. The primary outcome measure is the change in agitation, as defined by the Neuropsychiatric Inventory-Nursing Home Version, at 8 weeks from baseline. Secondary outcome measures include change in agitation at 12 weeks from baseline, and change from baseline at 8 and 12 weeks in other NPS, quality of life, and the use of psychotropic and analgesic medications. Mixed methods will be used to follow, measure and explore the implementation process and the effect of the intervention at the individual staff level and the organization level. Combining measurements of clinical effectiveness and implementation outcomes define this trial as an effectiveness-implementation hybrid trial. DISCUSSION Measuring the implementation and effect of complex interventions aimed at reducing NPS in nursing homes is challenging. In this study protocol, we describe a multicomponent program, TIME, and discuss how an effectiveness-implementation cluster randomized hybrid trial can meet these challenges. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT02655003 . Registered 6 January 2016.
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Affiliation(s)
- Bjørn Lichtwarck
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway. .,Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Geir Selbaek
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway ,Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway ,Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Vestfold, Norway
| | - Øyvind Kirkevold
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway ,Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Vestfold, Norway ,Departement of Health, Care and Nursing, Faculty of medicine NTNU, Norwegian University of Science and Technology, Gjøvik, Norway
| | - Anne Marie Mork Rokstad
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Vestfold, Norway ,Molde University College, Faculty of Health Sciences and Social Care, Molde, Norway
| | - Jūratė Šaltytė Benth
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway ,Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway ,HØKH, Research Centre, Akershus University Hospital, Lørenskog, Norway
| | - Janne Myhre
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway
| | - Solvor Nybakken
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway
| | - Sverre Bergh
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway ,Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Vestfold, Norway
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317
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Sewell DD. 2016 American Association for Geriatric Psychiatry Annual Meeting Presidential Plenary Address Improving the Mental Health Care of Older Americans Four Essential Ingredients: Technology, Advocacy, Education and You (The Members of the AAGP). Am J Geriatr Psychiatry 2016; 24:511-6. [PMID: 27288869 DOI: 10.1016/j.jagp.2016.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 04/26/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Daniel D Sewell
- University of California, San Diego, 200 West Arbor Drive, San Diego, CA 92103-8631, USA.
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318
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Hermabessière S, Lavallart B, Laffon de Mazières C, Vellas B, Rolland Y. [Reinforced accommodation units and the management of patients with dementia]. SOINS. GERONTOLOGIE 2016; 21:38-43. [PMID: 27449309 DOI: 10.1016/j.sger.2016.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Dementia is frequently associated with behavioural disorders that can be difficult to manage. In regards to these symptoms, psychoactive drugs are not very effective and have many potential side effects. In order to take care of patients with such severe disorders, specific units called "reinforced hosting units" ("UHR; Unités d'Hébergement Renforcées" in French) have been developed within long term care units. Specifically trained teams take care of these patients in specially designed settings. A French national inquiry has studied the development, the characteristics and the activity of these units in 2013 and 2012.
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Affiliation(s)
- Sophie Hermabessière
- Gérontopôle, CHU de Toulouse, Hôpital Garonne, 224 avenue de Casselardit, TSA 40031, 31059 Toulouse cedex 9, France.
| | - Benoît Lavallart
- Pilotage du plan Alzheimer, 11 place des cinq martyrs du lycée Buffon, pièce 5024, 75014 Paris, France
| | - Clarisse Laffon de Mazières
- Gérontopôle, CHU de Toulouse, Hôpital Garonne, 224 avenue de Casselardit, TSA 40031, 31059 Toulouse cedex 9, France
| | - Bruno Vellas
- Gérontopôle, CHU de Toulouse, Hôpital Purpan-Casselardit et Garonne, 170 et 224 avenue de Casselardit, TSA 40031, 31059 Toulouse Cedex 9, France
| | - Yves Rolland
- Gérontopôle, CHU de Toulouse, Hôpital Purpan-Casselardit et Garonne, 170 et 224 avenue de Casselardit, TSA 40031, 31059 Toulouse Cedex 9, France
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319
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McConnell ES, Karel MJ. Improving Management of Behavioral and Psychological Symptoms of Dementia in Acute Care: Evidence and Lessons Learned From Across the Care Spectrum. Nurs Adm Q 2016; 40:244-254. [PMID: 27259128 DOI: 10.1097/naq.0000000000000167] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
As the prevalence of Alzheimer disease and related dementias increases, dementia-related behavioral symptoms present growing threats to care quality and safety of older adults across care settings. Behavioral and psychological symptoms of dementia (BPSD) such as agitation, aggression, and resistance to care occur in nearly all individuals over the course of their illness. In inpatient care settings, if not appropriately treated, BPSD can result in care complications, increased length of stay, dissatisfaction with care, and caregiver stress and injury. Although evidence-based, nonpharmacological approaches to treating BPSD exist, their implementation into acute care has been thwarted by limited nursing staff expertise in behavioral health, and a lack of consistent approaches to integrate behavioral health expertise into medically focused inpatient care settings. This article describes the core components of one evidence-based approach to integrating behavioral health expertise into dementia care. This approach, called STAR-VA, was implemented in Veterans' Health Administration community living centers (nursing homes). It has demonstrated effectiveness in reducing the severity and frequency of BPSD, while improving staff knowledge and skills in caring for people with dementia. The potential for adapting this approach in acute care settings is discussed, along with key lessons learned regarding opportunities for nursing leadership to ensure consistent implementation and sustainability.
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Affiliation(s)
- Eleanor S McConnell
- Geriatric Research, Education and Clinical Center, Department of Veterans Affairs Medical Center, and Duke University School of Nursing, Durham, North Carolina (Dr McConnell) and Mental Health Services, US Department of Veterans Affairs (VA) Central Office, Washington, DC (Dr Karel)
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320
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Garay RP, Citrome L, Grossberg GT, Cavero I, Llorca PM. Investigational drugs for treating agitation in persons with dementia. Expert Opin Investig Drugs 2016; 25:973-83. [PMID: 27232589 DOI: 10.1080/13543784.2016.1193155] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Agitation is common and distressing in persons with dementia, but safe, effective treatments remain elusive. In this review, the authors describe investigational compounds in ongoing or recently completed clinical trials for this indication and provide an opinion on how they may meet current therapeutic needs. AREAS COVERED Phase II and phase III clinical trials for agitation in persons with dementia were searched in US and EU clinical trial registries and in the medical literature for the period January 2013-February 2016 EXPERT OPINION: The authors searches identified 24 recent clinical trials investigating new treatments for agitation in persons with dementia. Candidate drugs in phase III development included the antipsychotic brexpiprazole, the antidepressant citalopram, the novel compound AVP-786 (deuterated-dextromethorphan/quinidine combination) and the cannabinoid nabilone. Of the compounds in phase II clinical trials, ELND005 (scyllo-inositol) is intended to progress into phase III development, based on evidence from a subgroup analysis and biomarker data. After many years without an FDA/EMA (Food and Drug Administration/European Medicines Agency) approved medication to treat agitation in persons with dementia, we may see the arrival of the first approved drug in the near future.
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Affiliation(s)
- Ricardo P Garay
- a Department of Pharmacology and Therapeutics , Craven , Villemoisson-sur-Orge , France
| | - Leslie Citrome
- b Department of Psychiatry and Behavioral Sciences , New York Medical College , Valhalla , NY , USA
| | - George T Grossberg
- c Department of Psychiatry , St Louis University School of Medicine , St Louis , MO , USA
| | - Icilio Cavero
- d Department of Safety Pharmacology , Craven , Villemoisson-sur-Orge , France
| | - Pierre-Michel Llorca
- e Centre Médico-Psychologique B, CHU, Clermont-Ferrand, EA U7280 , Université d'Auvergne , Clermont-Ferrand , France
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321
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Weintraub D, Chiang C, Kim HM, Wilkinson J, Marras C, Stanislawski B, Mamikonyan E, Kales HC. Association of Antipsychotic Use With Mortality Risk in Patients With Parkinson Disease. JAMA Neurol 2016; 73:535-41. [PMID: 26999262 PMCID: PMC5157923 DOI: 10.1001/jamaneurol.2016.0031] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE As many as 60% of patients with Parkinson disease (PD) experience psychosis, 80% develop dementia, and the use of antipsychotics (APs) in the population with PD is common. The use of APs by patients with dementia in the general population is associated with increased mortality, but whether this risk extends to patients with PD remains unknown. OBJECTIVE To determine whether AP use in patients with PD is associated with increased mortality. DESIGN, SETTING, AND PARTICIPANTS This retrospective matched-cohort study used data from a Veterans Health Administration database from fiscal years 1999 to 2010 to examine the risk associated with AP use in a cohort of patients with idiopathic PD and recent stable physical health. The rates of 180-day mortality were compared in 7877 patients initiating AP therapy and 7877 patients who did not initiate AP therapy (matched for age ±2.5 years, sex, race, index year, presence and duration of dementia, PD duration, delirium, hospitalization, Charlson Comorbidity Index, and new nonpsychiatric medications). Data were analyzed from October 19, 2012, to September 21, 2015. MAIN OUTCOMES AND MEASURES Mortality rates at 180 days in those patients who initiated AP therapy compared with matched patients who did not use APs. Cox proportional hazards regression models were used with intent-to-treat (ITT) and exposure-only analyses. RESULTS The study population included 7877 matched pairs of patients with PD (65 women [0.8%] and 7812 men [99.2%] in each cohort; mean [SD] age, 76.3 [7.7] years for those who initiated AP therapy and 76.4 [7.6] years for those who did not). Antipsychotic use was associated with more than twice the hazard ratio (HR) of death compared with nonuse (ITT HR, 2.35; 95% CI, 2.08-2.66; P < .001). The HR was significantly higher for patients who used typical vs atypical APs (ITT HR, 1.54; 95% CI, 1.24-1.91; P < .001). Among the atypical APs used, HRs relative to nonuse of APs in descending order were 2.79 (95% CI, 1.97-3.96) for olanzapine, 2.46 (95% CI, 1.94-3.12) for risperidone, and 2.16 (95% CI, 1.88-2.48) for quetiapine fumarate. CONCLUSIONS AND RELEVANCE Use of APs is associated with a significantly increased mortality risk in patients with PD, after adjusting for measurable confounders. This finding highlights the need for cautious use of APs in patients with PD. Future studies should examine the role of nonpharmacologic strategies in managing psychosis in PD. In addition, new pharmacologic treatments that do not increase mortality in patients with neurodegenerative diseases need to be developed.
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Affiliation(s)
- Daniel Weintraub
- Parkinson's Disease Research, Education and Clinical Center, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania2Mental Illness Research, Education and Clinical Center, Philadelphia Veterans Affairs Medical Center, Philadelphia, Penns
| | - Claire Chiang
- Department of Veterans Affairs, Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Hyungjin Myra Kim
- Department of Veterans Affairs, Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan6Center for Statistical Consultation and Research, University of Michigan, Ann Arbor
| | - Jayne Wilkinson
- Parkinson's Disease Research, Education and Clinical Center, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania3Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia4Department of Neuro
| | - Connie Marras
- Morton and Gloria Shulman Movement Disorder Centre, The Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Barbara Stanislawski
- Department of Veterans Affairs, Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Eugenia Mamikonyan
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia4Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Helen C Kales
- Department of Veterans Affairs, Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan8Geriatric Research, Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan9Dep
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322
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Greenblatt HK, Greenblatt DJ. Use of Antipsychotics for the Treatment of Behavioral Symptoms of Dementia. J Clin Pharmacol 2016; 56:1048-57. [PMID: 26953213 DOI: 10.1002/jcph.731] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 02/29/2016] [Indexed: 01/08/2023]
Abstract
Antipsychotic medications are widely used in the management of behavioral and psychological symptoms of dementia. While nonpharmacological interventions should be the first-line treatment for behavioral symptoms of dementia, these are often unfeasible and/or ineffective. Conventional and atypical antipsychotic agents appear to have modest to moderate clinical efficacy in the treatment of these symptoms, though it is unclear which individual agents are most effective. No conclusive evidence exists that any available alternative medications are safer and more effective than antipsychotics. A number of studies have shown an increased risk of mortality associated with antipsychotics in patients with behavioral symptoms of dementia, though the observed risk increase may be partially confounded by illness severity and/or preexisting health determinants. The mechanisms of increased mortality risk are not fully established, but are likely to involve cardiovascular events. It is probable, though not certain, that conventional antipsychotics are associated with a greater number of poor outcomes than atypical antipsychotics. In certain patients with refractory behavioral symptoms, antipsychotics are a viable treatment option. Key considerations for antipsychotic prescribing for this population are published in regulatory guidelines, and include minimization of dosage and duration of treatment, continuous reevaluation of symptoms, and involvement of caregivers.
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Affiliation(s)
- H Karl Greenblatt
- Program in Pharmacology and Experimental Therapeutics, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
| | - David J Greenblatt
- Program in Pharmacology and Experimental Therapeutics, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
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323
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Yoon SJ, Choi SH, Na HR, Park KW, Kim EJ, Han HJ, Lee JH, Shim YS, Na DL. Effects on agitation with rivastigmine patch monotherapy and combination therapy with memantine in mild to moderate Alzheimer's disease: a multicenter 24-week prospective randomized open-label study (the Korean EXelon Patch and combination with mEmantine Comparative Trial study). Geriatr Gerontol Int 2016; 17:494-499. [PMID: 27111084 DOI: 10.1111/ggi.12754] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 11/25/2015] [Accepted: 12/22/2015] [Indexed: 12/18/2022]
Abstract
AIM Memantine is known to be effective in the treatment of the behavioral symptoms of dementia, especially agitation in moderate to severe Alzheimer's disease (AD). However, memantine and rivastigmine patch combination therapy has not been well studied in determining treatment effectiveness with mild to moderate AD patients. METHODS This was a multicenter, 24-week, prospective, randomized, open-label study design. A total 147 AD patients with Mini-Mental State Examination scores from 10 to 20 were randomly assigned to rivastigmine patch monotherapy and combination therapy with memantine groups. Agitation symptoms, using the Korean Version of the Cohen Mansfield Agitation Inventory were evaluated at baseline and at study end. Suppression and emergence of agitation symptoms were also evaluated. We carried out factor analyses to evaluate the interrelationship of agitation symptoms and to investigate treatment response in these symptoms. RESULTS Factor analyses showed two symptom clusters: factor A - aggressive agitated behaviors - versus factor B - non-aggressive agitated behaviors. The rivastigmine patch monotherapy group showed significantly decreased factor B scores and had a tendency of decreased Korean Version of the Cohen Mansfield Agitation Inventory total scores and factor A scores. Conversely, the combination therapy group showed significantly increased Korean Version of the Cohen Mansfield Agitation Inventory total scores and factor B scores. Neither monotherapy nor combination therapy reduced the emergence of new agitation symptoms. CONCLUSIONS In this trial of mild to moderate AD patients, the rivastigmine patch monotherapy group experienced a reduction of non-aggressive agitated behaviors. However, combination therapy with memantine did not show any benefit on the agitation associated with mild to moderate AD. Geriatr Gerontol Int 2017; 17: 494-499.
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Affiliation(s)
- Soo J Yoon
- Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Korea
| | - Seong H Choi
- Department of Neurology, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Hae R Na
- Department of Neurology, Bobath Memorial Hospital, Seongnam-si, Korea
| | - Kyung-Won Park
- Department of Neurology, Dong-A Medical Center, Dong-A University College of Medicine, Busan, Korea
| | - Eun-Joo Kim
- Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Medical Research Institute, Pusan, Korea
| | - Hyun J Han
- Department of Neurology, Myongji Hospital, Seonam University of College of Medicine, Goyang, Korea
| | - Jae-Hong Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Bucheon, Korea
| | - Young S Shim
- Department of Neurology, Bucheon St. Mary's Hospital, The Catholic University College of Medicine, Bucheon, Korea
| | - Duk L Na
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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324
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Silva R, Cardoso D, Apóstolo J. Effectiveness of multisensory stimulation in managing neuropsychiatric symptoms in older adults with major neurocognitive disorder. ACTA ACUST UNITED AC 2016; 14:85-95. [DOI: 10.11124/jbisrir-2016-2638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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325
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D’Onofrio G, Panza F, Sancarlo D, Paris FF, Cascavilla L, Mangiacotti A, Lauriola M, Paroni GH, Seripa D, Greco A. Delusions in Patients with Alzheimer’s Disease: A Multidimensional Approach. J Alzheimers Dis 2016; 51:427-37. [DOI: 10.3233/jad-150944] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Grazia D’Onofrio
- Geriatric Unit & Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Foggia, Italy
| | - Francesco Panza
- Geriatric Unit & Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Foggia, Italy
- Neurodegenerative Disease Unit, Department of Basic Medicine, Neuroscience, and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Daniele Sancarlo
- Geriatric Unit & Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Foggia, Italy
| | - Francesco F. Paris
- Geriatric Unit & Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Foggia, Italy
| | - Leandro Cascavilla
- Geriatric Unit & Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Foggia, Italy
| | - Antonio Mangiacotti
- Geriatric Unit & Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Foggia, Italy
| | - Michele Lauriola
- Geriatric Unit & Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Foggia, Italy
| | - Giulia H. Paroni
- Geriatric Unit & Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Foggia, Italy
| | - Davide Seripa
- Geriatric Unit & Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Foggia, Italy
| | - Antonio Greco
- Geriatric Unit & Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Foggia, Italy
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326
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Magierski R, Sobow T. Serotonergic drugs for the treatment of neuropsychiatric symptoms in dementia. Expert Rev Neurother 2016; 16:375-87. [PMID: 26886148 DOI: 10.1586/14737175.2016.1155453] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Behavioral and psychological symptoms of dementia (known also as neuropsychiatric symptoms) are essential features of Alzheimer's disease and related dementias. The near universal presence of neuropsychiatric symptoms in dementia (up to 90% of cases) has brought significant attention of clinicians and experts to the field. Non-pharmacological and pharmacological interventions are recommended for various types of neuropsychiatric symptoms. However, most pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia are used off-label in many countries. Cognitive decline and neuropsychiatric symptoms can be linked to alterations in multiple neurotransmitter systems, so modification of abnormalities in specific systems may improve clinical status of patients with neuropsychiatric symptoms. Use of serotonergic compounds (novel particles acting on specific receptors and widely acting drugs) in the treatment of neuropsychiatric symptoms is reviewed.
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Affiliation(s)
- Radoslaw Magierski
- a Department of Old Age Psychiatry and Psychotic Disorders , Medical University of Lodz , Lodz , Poland
| | - Tomasz Sobow
- b Department of Medical Psychology , Medical University of Lodz , Lodz , Poland
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327
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Barton C, Ketelle R, Merrilees J, Miller B. Non-pharmacological Management of Behavioral Symptoms in Frontotemporal and Other Dementias. Curr Neurol Neurosci Rep 2016; 16:14. [PMID: 26750129 PMCID: PMC4790078 DOI: 10.1007/s11910-015-0618-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Worldwide prevalence of dementia is predicted to double every 20 years. The most common cause in individuals over 65 is Alzheimer's disease (AD), but in those under 65, frontotemporal dementia (FTD) is as frequent. The physical and cognitive decline that characterizes these diseases is commonly accompanied by troublesome behavioral symptoms. These behavioral symptoms contribute to significant morbidity and mortality among both patients and caregivers. Medications have been largely ineffective in managing these symptoms and carry significant adverse effects. Non-pharmacological interventions have been recommended to precede the utilization of pharmacological treatments. This article reviews the research about these interventions with special attention to the variations by etiology, especially FTD. The authors offer recommendations for improving utilization of these strategies and future research recommendations.
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Affiliation(s)
- Cynthia Barton
- Department of Neurology, Memory and Aging Center, University of California, 675 Nelson Rising Lane, Suite 190, Box 1207, San Francisco, CA, 94158, USA.
- School of Nursing, University of California, 2 Koret Way, Box 1207, San Francisco, CA, 94143, USA.
| | - Robin Ketelle
- Department of Neurology, Memory and Aging Center, University of California, 675 Nelson Rising Lane, Suite 190, Box 1207, San Francisco, CA, 94158, USA
- School of Nursing, University of California, 2 Koret Way, Box 1207, San Francisco, CA, 94143, USA
| | - Jennifer Merrilees
- Department of Neurology, Memory and Aging Center, University of California, 675 Nelson Rising Lane, Suite 190, Box 1207, San Francisco, CA, 94158, USA
- School of Nursing, University of California, 2 Koret Way, Box 1207, San Francisco, CA, 94143, USA
| | - Bruce Miller
- Department of Neurology, Memory and Aging Center, University of California, 675 Nelson Rising Lane, Suite 190, Box 1207, San Francisco, CA, 94158, USA
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328
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Abstract
Neuropsychiatric symptoms (NPS) of dementia including agitation, depression, and psychosis are common and debilitating facets of the disease process. Despite the significant impact of these symptoms on both individuals with dementia and their caregivers, safe and effective treatment options are lacking. From a pharmacological approach, antipsychotics have historically been the treatment of choice, but these medications are only modestly effective with significant adverse effects. Behavioral and psychosocial interventions have been shown to be effective but are difficult to implement in routine clinical practice. SSRI medications have been investigated as an alternative psychopharmacological approach based on evidence that the serotoninergic system is involved in the etiology of NPS in dementia. The evidence base for using SSRI medications in the treatment of NPS is growing, but the applicability of research findings to the utility of SSRIs in general in routine clinical practice is not entirely clear at this point. Further studies of a variety of SSRI medications in targeting NPS are needed to make a more definitive assessment of the efficacy of these medications in the relief of NPS.
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329
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Helvik AS, Engedal K, Wu B, Benth JŠ, Corazzini K, Røen I, Selbæk G. Severity of Neuropsychiatric Symptoms in Nursing Home Residents. Dement Geriatr Cogn Dis Extra 2016; 6:28-42. [PMID: 26933438 PMCID: PMC4772643 DOI: 10.1159/000442250] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
We aimed at assessing time shift in the severity of neuropsychiatric symptoms (NPS) in nursing home residents between 2004/2005 and 2010/2011 and associations between NPS and socio-demographic variables, physical health status, dementia severity, and the use of psychotropic drugs. The Neuropsychiatric Inventory Nursing Home Version was used in 2004/2005 (n = 1,163) and 2010/2011 (n = 1,858). Linear mixed model analysis was applied. There was no time shift in the severity of apathy, psychosis, and affective symptoms, but agitation did exhibit a time shift. Agitation was less severe in 2010/2011 than in 2004/2005 in residents with a Clinical Dementia Rating (CDR) sum of boxes score ≤4, and more severe in residents with a CDR sum of boxes score >16. Higher CDR sum of boxes scores and use of psychotropic medication were associated with more severe apathy, agitation, psychosis, and affective symptoms. Poor physical health was associated with more severe apathy, psychosis, and affective symptoms. Women had more severe agitation and less severe affective symptoms than men. A longer stay in a nursing home was associated with more severe agitation and less severe affective symptoms. In conclusion, agitation was less severe in 2010/2011 than in 2004/2005 among nursing home residents with a milder degree of dementia, and more severe in residents with severe dementia.
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Affiliation(s)
- Anne-Sofie Helvik
- Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Norway; St. Olav's University Hospital, Trondheim, Norway; Norwegian National Advisory Unit on Aging and Health, Vestfold Health Trust, Tønsberg, Norway
| | - Knut Engedal
- Norwegian National Advisory Unit on Aging and Health, Vestfold Health Trust, Tønsberg, Norway
| | - Bei Wu
- Duke Center for the Study of Aging and Human Development, Duke University School of Nursing, Durham, N.C., USA; Duke Global Health Institute, Durham, N.C., USA
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, Norway; HØKH, Research Centre, Akershus University Hospital, Lørenskog, Norway; Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway
| | - Kirsten Corazzini
- Duke Center for the Study of Aging and Human Development, Duke University School of Nursing, Durham, N.C., USA
| | - Irene Røen
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway
| | - Geir Selbæk
- Norwegian National Advisory Unit on Aging and Health, Vestfold Health Trust, Tønsberg, Norway; Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway; Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway
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330
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Gallagher D, Herrmann N. Agitation and aggression in Alzheimer's disease: an update on pharmacological and psychosocial approaches to care. Neurodegener Dis Manag 2016; 5:75-83. [PMID: 25711456 DOI: 10.2217/nmt.14.46] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Agitation and aggression are prevalent in Alzheimer's disease and have significant consequences for the patient, caregiver and care system more generally. We briefly discuss the epidemiology and etiology of agitation and aggression in Alzheimer's disease and provide an overview of assessment and approaches to care. We then review the evidence for and against a number of pharmacological and psychosocial approaches to care. There has been a growth in the evidence base for psychosocial interventions and nonpharmacological approaches to care should ordinarily be the first option. Antipsychotics remain the pharmacological agents with most evidence to support their use while there is more limited evidence for other agents such as carbamazepine and selective serotonin reuptake inhibitors such as citalopram.
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Affiliation(s)
- Damien Gallagher
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
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331
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Koenig AM, Arnold SE, Streim JE. Agitation and Irritability in Alzheimer's Disease: Evidenced-Based Treatments and the Black-Box Warning. Curr Psychiatry Rep 2016; 18:3. [PMID: 26695173 PMCID: PMC6483820 DOI: 10.1007/s11920-015-0640-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
More than five million Americans suffer from Alzheimer's disease (AD), and this number is expected to triple by 2050. While impairments in cognition, particularly memory, are typically the defining features of the clinical syndrome, behavioral symptoms are extremely common, affecting up to 90% of patients. Behavioral symptoms in AD can be difficult to manage and may require a combination of non-pharmacological and pharmacological approaches. The latter is complicated by FDA "black-box warnings" for the medication classes most often used to target these symptoms, and currently there are initiatives in place to limit their use. In this review, we describe common behavioral symptoms of AD-with a particular focus on the challenging symptoms of "agitation" and "irritability"-and discuss evidence-based approaches to their management. Ultimately, multidimensional approaches must be tailored to the patient and their environment, though evidence-based practices should define the treatment of agitation and irritability in AD.
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Affiliation(s)
- Aaron M Koenig
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Steven E Arnold
- MassGeneral Institute for Neurodegenerative Disease, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Joel E Streim
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
- Behavioral Health Service, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
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332
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Kales HC. Common Sense: Addressed to Geriatric Psychiatrists on the Subject of Behavioral and Psychological Symptoms of Dementia. Am J Geriatr Psychiatry 2015; 23:1209-1213. [PMID: 26705691 DOI: 10.1016/j.jagp.2015.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 10/05/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Helen C Kales
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.
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333
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Rosenberg PB, Drye LT, Porsteinsson AP, Pollock BG, Devanand D, Frangakis C, Ismail Z, Marano C, Meinert CL, Mintzer JE, Munro CA, Pelton G, Rabins PV, Schneider LS, Shade DM, Weintraub D, Newell J, Yesavage J, Lyketsos CG. Change in agitation in Alzheimer's disease in the placebo arm of a nine-week controlled trial. Int Psychogeriatr 2015; 27:2059-67. [PMID: 26305876 PMCID: PMC4669064 DOI: 10.1017/s1041610215001106] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Placebo responses raise significant challenges for the design of clinical trials. We report changes in agitation outcomes in the placebo arm of a recent trial of citalopram for agitation in Alzheimer's disease (CitAD). METHODS In the CitAD study, all participants and caregivers received a psychosocial intervention and 92 were assigned to placebo for nine weeks. Outcomes included Neurobehavioral Rating Scale agitation subscale (NBRS-A), modified AD Cooperative Study-Clinical Global Impression of Change (CGIC), Cohen-Mansfield Agitation Inventory (CMAI), the Neuropsychiatric Inventory (NPI) Agitation/Aggression domain (NPI A/A) and Total (NPI-Total) and ADLs. Continuous outcomes were analyzed with mixed-effects modeling and dichotomous outcomes with logistic regression. RESULTS Agitation outcomes improved over nine weeks: NBRS-A mean (SD) decreased from 7.8 (3.0) at baseline to 5.4 (3.2), CMAI from 28.7 (6.7) to 26.7 (7.4), NPI A/A from 8.0 (2.4) to 4.9 (3.8), and NPI-Total from 37.3 (17.7) to 28.4 (22.1). The proportion of CGI-C agitation responders ranged from 21 to 29% and was significantly different from zero. MMSE improved from 14.4 (6.9) to 15.7 (7.2) and ADLs similarly improved. Most of the improvement was observed by three weeks and was sustained through nine weeks. The major predictor of improvement in each agitation measure was a higher baseline score in that measure. CONCLUSIONS We observed significant placebo response which may be due to regression to the mean, response to a psychosocial intervention, natural course of symptoms, or nonspecific benefits of participation in a trial.
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Affiliation(s)
- Paul B. Rosenberg
- Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins School of Medicine, Johns Hopkins Bay view Medical Center, 5300 Alpha Commons Dr. #429, Baltimore, MD 21224, Phone: (410) 550 9883, Fax: (410) 550 1407
| | - Lea T. Drye
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 911 S. Ann St, Baltimore, MD 21231
| | - Anton P. Porsteinsson
- University of Rochester School of Medicine and Dentistry, 435 East Henrietta Road, Rochester, N.Y. 14620
| | - Bruce G. Pollock
- Campbell Institute, CAMH, University of Toronto, Toronto, ON, Canada, University of Toronto, Centre for Addiction and Mental Health, 33 Russell Street, Toronto, ON M5S 2S1
| | - D.P. Devanand
- College of Physicians and Surgeons, Columbia University, 1051 Riverside Drive, Unit 126, New York, NY 10032
| | - Constantine Frangakis
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., E3642, Baltimore, MD, 21205-2179
| | - Zahinoor Ismail
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada, University of Toronto, Toronto, ON, Canada, 1403 29 Street NW, Calgary Canada, T2N 2T9
| | - Christopher Marano
- Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, 5300 Alpha Commons Drive, 4th floor, Baltimore, MD 21224
| | - Curtis L. Meinert
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., W5010, Baltimore, MD, 21205-2179
| | - Jacobo E. Mintzer
- Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, Charleston SC, Department of Health Studies, Medical University of South Carolina, Charleston SC, Ralph H. Johnson VA Medical Center, Charleston SC, 316 Calhoun Street, 5th Floor- CBRI, Charleston, SC 29401
| | - Cynthia A. Munro
- Department of Psychiatry and Behavioral Sciences, Department of Neurology, Johns Hopkins Bayview and Johns Hopkins School of Medicine, 600 N. Wolfe St., Meyer 218, Baltimore, MD 21287-7218
| | - Gregory Pelton
- Clinical Psychiatry and Neurology, Division of Geriatric Psychiatry, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 126, New York, New York 10032-2695
| | - Peter V. Rabins
- Johns Hopkins School of Medicine, Johns Hopkins Hospital, Meyer 279, 600 North Wolfe Street, Baltimore, MD 21287
| | - Lon S. Schneider
- Keck School of Medicine, University of Southern California, 1540 Alcazar St, CHP-216, Los Angeles, CA
| | - David M. Shade
- Departments of Medicine (Pulmonary) and Epidemiology (Center for Clinical Trials), Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St Rm 5025-D, Baltimore, MD 21205
| | - Daniel Weintraub
- Psychiatry and Neurology, Perelman School of Medicine at the University of Pennsylvania, Parkinson's Disease Research, Education and Clinical Center (PADRECC), Mental Illness Research, Education and Clinical Center (MIRECC), Philadelphia Veterans Affairs Medical Center, 3615 Chestnut Street, #330, Philadelphia, PA 19104-2676
| | - Jeffery Newell
- Clinical Science, University of Southern California, Culture and Mental Health Lab, 3620 McClintock Ave., Los Angeles, CA 90089-1011
| | - Jerome Yesavage
- Director Mental Illness Research Education and Clinical Center, VA Palo Alto Health Care System, Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Mail Code 151-Y, 3801 Miranda Avenue, Palo Alto, California 94304
| | - Constantine G. Lyketsos
- Johns Hopkins School of Medicine, Department of Psychiatry, Johns Hopkins Bayview Medical Center, 5300 Alpha Commons Dr. #429, Baltimore, MD 21224
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Weintraub D, Drye LT, Porsteinsson AP, Rosenberg PB, Pollock BG, Devanand D, Frangakis C, Ismail Z, Marano C, Meinert CL, Mintzer JE, Munro CA, Pelton G, Rabins PV, Schneider LS, Shade DM, Yesavage J, Lyketsos CG. Time to Response to Citalopram Treatment for Agitation in Alzheimer Disease. Am J Geriatr Psychiatry 2015; 23:1127-33. [PMID: 26238225 PMCID: PMC4653092 DOI: 10.1016/j.jagp.2015.05.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 05/07/2015] [Accepted: 05/12/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Agitation is a common and significant problem in Alzheimer disease (AD). In the recent Citalopram for Agitation in Alzheimer's Disease (CitAD) study, citalopram was efficacious for the treatment of AD agitation. Here we examined the time course and predictors of response to treatment. METHODS Response in CitAD was defined as a modified Alzheimer Disease Cooperative Study Clinical Global Impression of Change (CGIC) score of 1 or 2 or a Neurobehavioral Rating Scale agitation subscale (NBRS-A) score reduction ≥ 50% from baseline. "Stable early response" was defined as meeting the aforementioned criteria at both weeks 3 and 9, "late response" was response at week 9 but not at week 3, and "unstable response" was response at week 3 but not at week 9. RESULTS In the primary analyses, citalopram was superior to placebo on both the CGIC and the NBRS-A response measures. Little between-group differences were found in response rates in the first 3 weeks of the study (21% versus 19% on the CGIC). Citalopram patients were more likely than placebo patients to be a late responder (18% versus 8% on CGIC, Fisher's exact p = 0.09; 31% versus 15% on NBRS-A, Fisher's exact p = 0.02). Approximately half of citalopram responders (45%-56%) at end of study achieved response later in the study compared with 30%-44% of placebo responders. CONCLUSION Treatment with citalopram for agitation in AD needs to be at least 9 weeks in duration to allow sufficient time for full response. Study duration is an important factor to consider in the design of clinical trials for agitation in AD.
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Affiliation(s)
- Daniel Weintraub
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Lea T. Drye
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Paul B. Rosenberg
- Johns Hopkins Bayview and Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Bruce G. Pollock
- Campbell Institute, CAMH, University of Toronto, Toronto, ON, Canada
| | - D.P. Devanand
- Division of Geriatric Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | | | - Zahinoor Ismail
- Departments of Psychiatry and Neurology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Christopher Marano
- Johns Hopkins Bayview and Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Jacobo E. Mintzer
- Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, Charleston, SC, USA
| | - Cynthia A. Munro
- Johns Hopkins Bayview and Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Gregory Pelton
- Division of Geriatric Psychiatry, New York State Psychiatric Institute and College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - Peter V. Rabins
- Johns Hopkins Bayview and Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Lon S. Schneider
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - David M. Shade
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jerome Yesavage
- Stanford University School of Medicine and VA Palo Alto Health Care System, Stanford, CA, USA
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335
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A consensus guideline for antipsychotic drug use for dementia in care homes. Bridging the gap between scientific evidence and clinical practice. Int Psychogeriatr 2015; 27:1849-59. [PMID: 26062126 PMCID: PMC4582430 DOI: 10.1017/s1041610215000745] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND To produce a practice guideline that includes a set of detailed consensus principles regarding the prescription of antipsychotics (APs) amongst people with dementia living in care homes. METHODS We used a modified Delphi consensus procedure with three rounds, where we actively specified and optimized statements throughout the process, utilizing input from four focus groups, carried out in UK, Norway, and the Netherlands. This was done to identify relevant themes and a set of statement that experts agreed upon using the Research and Development/University of California at Los Angeles (RAND/UCLA) methodology. RESULTS A total of 72 scientific and clinical experts and 14 consumer experts reached consensus upon 150 statements covering five themes: (1) General prescription stipulations, (2) assessments prior to prescription, (3) care and treatment plan, (4) discontinuation, and (5) long-term treatment. CONCLUSIONS In this practice guideline, novel information was provided about detailed indication and thresholds of symptoms, risk factors, circumstances at which APs should be stopped or tapered, specific criteria for justifying long-term treatment, involvement of the multidisciplinary team, and family caregiver in the process of prescription. The practice guideline is based on formal consensus of clinicians and consumer experts and provides clinicians relevant practical information that is lacking in current guidelines.
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336
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Särkämö T, Laitinen S, Numminen A, Kurki M, Johnson JK, Rantanen P. Clinical and Demographic Factors Associated with the Cognitive and Emotional Efficacy of Regular Musical Activities in Dementia. J Alzheimers Dis 2015; 49:767-81. [DOI: 10.3233/jad-150453] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Teppo Särkämö
- Cognitive Brain Research Unit, Institute of Behavioural Sciences and Finnish Centre of Interdisciplinary Music Research, University of Helsinki, Finland
| | | | | | - Merja Kurki
- Miina Sillanpää Foundation, Helsinki, Finland
| | - Julene K. Johnson
- Institute for Health and Aging, University of California, San Francisco, USA
| | - Pekka Rantanen
- Finnish Association of People with Physical Disabilities, Validia Rehabilitation Helsinki, Finland
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Panza F, Solfrizzi V, Seripa D, Imbimbo BP, Santamato A, Lozupone M, Prete C, Greco A, Pilotto A, Logroscino G. Progresses in treating agitation: a major clinical challenge in Alzheimer's disease. Expert Opin Pharmacother 2015; 16:2581-8. [PMID: 26389682 DOI: 10.1517/14656566.2015.1092520] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Treatment of neuropsychiatric symptoms (NPS) represents a major clinical challenge in Alzheimer's disease (AD). Agitation and aggression are frequently seen during institutionalization and increase patient morbidity and mortality and caregiver burden. Off-label use of atypical antipsychotics for treating agitation in AD showed only modest clinical benefits, with high side-effect burden and risk of mortality. Non-pharmacological treatment approaches have become the preferred first-line option. When such treatment fails, pharmacological options are often used. Therefore, there is an urgent need to identify effective and safe pharmacological treatments for efficiently treating agitation and aggression in AD and dementia. AREAS COVERED Emerging evidence on the neurobiological substrates of agitation in AD has led to several recent clinical trials of repositioned and novel therapeutics for these NPS in dementia as an alternative to antipsychotics. We operated a comprehensive literature search for published articles evaluating pharmacological interventions for agitation in AD, with a review of recent clinical trials on mibampator, dextromethorphan/quinidine, cannabinoids, and citalopram. EXPERT OPINION Notwithstanding the renewed interest for the pharmacological treatment of agitation in AD, progresses have been limited. A small number and, sometimes methodologically questionable, randomized controlled trials (RCTs) have produced disappointing results. However, recently completed RCTs on novel or repositioned drugs (mibampator, dextromethorphan/quinidine, cannabinoids, and citalopram) showed some promise in treating agitation in AD, but still with safety concerns. Further evidence will come from ongoing Phase II and III trials on promising novel drugs for treating these distressing symptoms in patients with AD and dementia.
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Affiliation(s)
- Francesco Panza
- a 1 University of Bari Aldo Moro, Neurodegenerative Disease Unit, Department of Basic Medicine, Neuroscience, and Sense Organs , Bari, Italy , .,b 2 University of Bari Aldo Moro, Department of Clinical Research in Neurology, "Pia Fondazione Cardinale G. Panico" , Tricase, Lecce, Italy.,c 3 Geriatric Unit & Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS "Casa Sollievo della Sofferenza" , San Giovanni Rotondo, Foggia, Italy
| | - Vincenzo Solfrizzi
- d 4 University of Bari Aldo Moro, Geriatric Medicine-Memory Unit and Rare Disease Centre , Bari, Italy
| | - Davide Seripa
- c 3 Geriatric Unit & Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS "Casa Sollievo della Sofferenza" , San Giovanni Rotondo, Foggia, Italy
| | - Bruno P Imbimbo
- e 5 Research & Development Department, Chiesi Farmaceutici , Parma, Italy
| | - Andrea Santamato
- f 6 University of Foggia, Physical Medicine and Rehabilitation Section, "OORR" Hospital , Foggia, Italy
| | - Madia Lozupone
- a 1 University of Bari Aldo Moro, Neurodegenerative Disease Unit, Department of Basic Medicine, Neuroscience, and Sense Organs , Bari, Italy ,
| | - Camilla Prete
- g 7 Geriatrics Unit, Department of OrthoGeriatrics, Rehabilitation and Stabilization, Frailty Area, Galliera Hospital NR-HS , Genova, Italy
| | - Antonio Greco
- c 3 Geriatric Unit & Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS "Casa Sollievo della Sofferenza" , San Giovanni Rotondo, Foggia, Italy
| | - Alberto Pilotto
- g 7 Geriatrics Unit, Department of OrthoGeriatrics, Rehabilitation and Stabilization, Frailty Area, Galliera Hospital NR-HS , Genova, Italy
| | - Giancarlo Logroscino
- a 1 University of Bari Aldo Moro, Neurodegenerative Disease Unit, Department of Basic Medicine, Neuroscience, and Sense Organs , Bari, Italy , .,b 2 University of Bari Aldo Moro, Department of Clinical Research in Neurology, "Pia Fondazione Cardinale G. Panico" , Tricase, Lecce, Italy
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Interventions for Neuropsychiatric Symptoms in Neurocognitive Impairment Due to Alzheimer's Disease: A Review of the Literature. Harv Rev Psychiatry 2015; 23:377-93. [PMID: 26332220 DOI: 10.1097/hrp.0000000000000097] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Neurocognitive impairment due to Alzheimer's disease (previously termed Alzheimer's dementia) (AD) is the most common form of cognitive impairment worldwide. Given the anticipated increase in the population aged 65 and over, the prevalence of persons with AD is expected to increase exponentially during the next 30 years. Noncognitive neuropsychiatric symptoms (NPS) commonly occur in AD and are associated with adverse outcomes for patients and their caregivers. This review summarizes randomized, controlled trials (RCTs) published between 2004 and 2014 with a primary outcome measure of change in symptom severity for NPS in AD. Of the 388 articles initially identified through a literature search, 33 trials met inclusion criteria. Fifteen of these studies had agitation/aggression as a targeted symptom. Twenty-eight evaluated pharmacologic treatments, including psychotropics, cognitive enhancers, stimulants, and nutraceuticals. Nonpharmacologic interventions included bright light, music, exercise, and cognitive-stimulation therapies. Among the pharmacologic interventions, modest efficacy was reported with aripiprazole, citalopram, trazodone, methylphenidate, and scheduled analgesics. Significant reduction in symptom severity was reported with nearly all the nonpharmacologic interventions. Variations in methodology such as inclusion criteria, study setting, and outcome measures limit the generalizability of these results. Barriers to the implementation of nonpharmacologic interventions in clinical settings include resource and training limitations. Electroconvulsive therapy and dronabinol are promising as emerging treatment strategies. Randomized clinical trials are needed in order to validate the utility of electroconvulsive therapy and dronabinol, including where and with whom these interventions will prove most valuable.
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339
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Huang TY, Wei YJ, Moyo P, Harris I, Lucas JA, Simoni-Wastila L. Treated Behavioral Symptoms and Mortality in Medicare Beneficiaries in Nursing Homes with Alzheimer's Disease and Related Dementias. J Am Geriatr Soc 2015; 63:1757-65. [DOI: 10.1111/jgs.13606] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Ting-Ying Huang
- Department of Pharmaceutical Health Services Research; School of Pharmacy; University of Maryland; Baltimore Maryland
| | - Yu-Jung Wei
- Department of Pharmaceutical Health Services Research; School of Pharmacy; University of Maryland; Baltimore Maryland
| | - Patience Moyo
- Department of Pharmaceutical Health Services Research; School of Pharmacy; University of Maryland; Baltimore Maryland
| | | | - Judith A. Lucas
- Department of Behavioral and Community Health; College of Nursing; Seton Hall University; South Orange New Jersey
| | - Linda Simoni-Wastila
- Department of Pharmaceutical Health Services Research; School of Pharmacy; University of Maryland; Baltimore Maryland
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340
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Peisah C, Strukovski JA, Wijeratne C, Mulholland R, Luscombe G, Brodaty H. The development and testing of the quality use of medications in dementia (QUM-D): a tool for quality prescribing for behavioral and psychological symptoms of dementia (BPSD). Int Psychogeriatr 2015; 27:1313-22. [PMID: 25642751 PMCID: PMC4501300 DOI: 10.1017/s1041610214002816] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 12/03/2014] [Accepted: 12/10/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Behavioral and psychological symptoms of dementia (BPSD) are virtually ubiquitous in dementia. Excessive recourse to use of psychotropics which have high risk to benefit ratio remains a global problem. We aimed to identify components of quality prescribing in BPSD to develop a tool for quality prescribing and to test this tool. METHODS We used Delphi methodology to identify elements of quality prescribing in BPSD. The tool was tested by a range of medical and nursing professionals on 48 patients, in inpatient and ambulatory settings in Northern Sydney Local Health District, Australia. RESULTS Consensual opinion using Delphi method was that quality prescribing in dementia comprised ten factors including failure to use first line non-pharmacological strategies, indication, choice of drug, consent, dosage, mode of administration, titration, polypharmacy, toxicity, and review. These elements formed the quality use of medications in dementia (QUM-D) tool, lower scores of which reflected quality prescribing, with a possible range of scores from 0 to 30. When inter-rater reliability was tested on a subgroup of raters, QUM-D showed high inter-rater reliability. A significant reduction in QUM-D scores was demonstrated from baseline to follow-up, mean difference being 5.3 (SD = 3.8; 95% confidence interval 4.1-6.4; t = 9.5; df = 47; p < 0.001). There was also a significant reduction in score from baseline to follow-up when rated by clinical nurse consultants from a specialized behavior assessment management service (BAMS) (N = 12). CONCLUSION The QUM-D is a tool which may help to improve quality prescribing practices in the context of BPSD. In this setting, we consider quality prescribing, and accordingly the obligations of prescribers, to be an inclusive concept rather than just adding to the mantra of "not prescribing."
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Affiliation(s)
- Carmelle Peisah
- Specialist Mental Health Services for Older People, Mental Health Drug and Alcohol, Northern Sydney Local Health District, Sydney, Australia
- University of Sydney, Sydney, Australia
- University of NSW, Sydney, Australia
| | - Julie-Anne Strukovski
- Specialist Mental Health Services for Older People, Mental Health Drug and Alcohol, Northern Sydney Local Health District, Sydney, Australia
| | | | - Rosalind Mulholland
- Specialist Mental Health Services for Older People, Mental Health Drug and Alcohol, Northern Sydney Local Health District, Sydney, Australia
| | | | - Henry Brodaty
- Dementia Collaborative Research Centre, University of New South Wales, Sydney, Australia
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Karel MJ, Teri L, McConnell E, Visnic S, Karlin BE. Effectiveness of Expanded Implementation of STAR-VA for Managing Dementia-Related Behaviors Among Veterans. THE GERONTOLOGIST 2015; 56:126-34. [DOI: 10.1093/geront/gnv068] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 05/06/2015] [Indexed: 11/14/2022] Open
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Antonsdottir IM, Smith J, Keltz M, Porsteinsson AP. Advancements in the treatment of agitation in Alzheimer’s disease. Expert Opin Pharmacother 2015; 16:1649-56. [DOI: 10.1517/14656566.2015.1059422] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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343
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Porsteinsson AP, Keltz MA, Smith JS. Role of citalopram in the treatment of agitation in Alzheimer's disease. Neurodegener Dis Manag 2015; 4:345-9. [PMID: 25405648 DOI: 10.2217/nmt.14.35] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Neuropsychiatric symptoms (NPS) are common among individuals with Alzheimer's disease (AD), associated with excess morbidity and mortality, greater healthcare use, earlier institutionalization, and caregiver burden. Agitation presents as emotional distress, excessive psychomotor activity, aggressive behaviors, disruptive irritability and dishibition. There is an unmet need to find pharmacologic treatment for agitation in patients with AD that can be safely and effectively used as a concurrent treatment alongside psychosocial interventions. A recent, multicenter, randomized, placebo-controlled trial explored the efficacy of a 30-mg daily dose of citalopram for agitation in patients with AD and showed a significant decrease in agitation for citalopram compared with placebo. Both QTc prolongation and cognitive worsening, as measured by the Mini Mental State Examination, were observed in the citalopram group and present a concern to clinicians. Citalopram at a 20-mg daily dose should be considered as a possible first-line treatment in addition to psychosocial intervention.
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Affiliation(s)
- Anton P Porsteinsson
- University of Rochester School of Medicine & Dentistry Alzheimer's Disease Care, Research & Education Program (AD-CARE), 435 East Henrietta Road, Rochester, NY 14620, USA
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344
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Molano JRV, Bratt R, Shatz R. Treatment and Management of Dementia Due to Alzheimer’s Disease. Curr Treat Options Neurol 2015; 17:363. [DOI: 10.1007/s11940-015-0363-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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345
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Rothenberg KG, Wiechers IR. Antipsychotics for Neuropsychiatric Symptoms of Dementia—Safety and Efficacy in the Context of Informed Consent. Psychiatr Ann 2015. [DOI: 10.3928/00485713-20150626-06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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346
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van den Elsen GAH, Ahmed AIA, Verkes RJ, Kramers C, Feuth T, Rosenberg PB, van der Marck MA, Olde Rikkert MGM. Tetrahydrocannabinol for neuropsychiatric symptoms in dementia: A randomized controlled trial. Neurology 2015; 84:2338-46. [PMID: 25972490 DOI: 10.1212/wnl.0000000000001675] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 03/03/2015] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To study the efficacy and safety of low-dose oral tetrahydrocannabinol (THC) in the treatment of dementia-related neuropsychiatric symptoms (NPS). METHODS This is a randomized, double-blind, placebo-controlled study. Patients with dementia and clinically relevant NPS were randomly assigned to receive THC 1.5 mg or matched placebo (1:1) 3 times daily for 3 weeks. Primary outcome was change in Neuropsychiatric Inventory (NPI), assessed at baseline and after 14 and 21 days. Analyses were based on intention-to-treat. RESULTS Twenty-four patients received THC and 26 received placebo. NPS were reduced during both treatment conditions. The difference in reduction from baseline between THC and placebo was not significant (mean difference NPItotal: 3.2, 95% confidence interval [CI] -3.6 to 10.0), nor were changes in scores for agitation (Cohen-Mansfield Agitation Inventory 4.6, 95% CI -3.0 to 12.2), quality of life (Quality of Life-Alzheimer's Disease -0.5, 95% CI -2.6 to 1.6), or activities of daily living (Barthel Index 0.6, 95% CI -0.8 to 1.9). The number of patients experiencing mild or moderate adverse events was similar (THC, n = 16; placebo, n = 14, p = 0.36). No effects on vital signs, weight, or episodic memory were observed. CONCLUSIONS Oral THC of 4.5 mg daily showed no benefit in NPS, but was well-tolerated, which adds valuable knowledge to the scarce evidence on THC in dementia. The benign adverse event profile of this dosage allows study of whether higher doses are efficacious and equally well-tolerated. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that for patients with dementia-related NPS, low-dose THC does not significantly reduce NPS at 21 days, though it is well-tolerated.
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Affiliation(s)
- Geke A H van den Elsen
- From the Departments of Geriatric Medicine/Radboudumc Alzheimer Centre (G.A.H.v.d.E., A.I.A.A., M.A.v.d.M., M.G.M.O.R.), Pharmacology and Toxicology (A.I.A.A., C.K.), Psychiatry (R.-J.V.), Internal Medicine (C.K.), and Health Evidence (T.F.), Radboud university medical center, Nijmegen; the Department of Elderly (A.I.A.A.), Vincent van Gogh Institute, Venray; the Department of Clinical Pharmacy (C.K.), Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands; and the Department of Psychiatry and Behavioral Sciences (P.B.R.), John Hopkins University School of Medicine, Baltimore, MD.
| | - Amir I A Ahmed
- From the Departments of Geriatric Medicine/Radboudumc Alzheimer Centre (G.A.H.v.d.E., A.I.A.A., M.A.v.d.M., M.G.M.O.R.), Pharmacology and Toxicology (A.I.A.A., C.K.), Psychiatry (R.-J.V.), Internal Medicine (C.K.), and Health Evidence (T.F.), Radboud university medical center, Nijmegen; the Department of Elderly (A.I.A.A.), Vincent van Gogh Institute, Venray; the Department of Clinical Pharmacy (C.K.), Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands; and the Department of Psychiatry and Behavioral Sciences (P.B.R.), John Hopkins University School of Medicine, Baltimore, MD
| | - Robbert-Jan Verkes
- From the Departments of Geriatric Medicine/Radboudumc Alzheimer Centre (G.A.H.v.d.E., A.I.A.A., M.A.v.d.M., M.G.M.O.R.), Pharmacology and Toxicology (A.I.A.A., C.K.), Psychiatry (R.-J.V.), Internal Medicine (C.K.), and Health Evidence (T.F.), Radboud university medical center, Nijmegen; the Department of Elderly (A.I.A.A.), Vincent van Gogh Institute, Venray; the Department of Clinical Pharmacy (C.K.), Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands; and the Department of Psychiatry and Behavioral Sciences (P.B.R.), John Hopkins University School of Medicine, Baltimore, MD
| | - Cees Kramers
- From the Departments of Geriatric Medicine/Radboudumc Alzheimer Centre (G.A.H.v.d.E., A.I.A.A., M.A.v.d.M., M.G.M.O.R.), Pharmacology and Toxicology (A.I.A.A., C.K.), Psychiatry (R.-J.V.), Internal Medicine (C.K.), and Health Evidence (T.F.), Radboud university medical center, Nijmegen; the Department of Elderly (A.I.A.A.), Vincent van Gogh Institute, Venray; the Department of Clinical Pharmacy (C.K.), Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands; and the Department of Psychiatry and Behavioral Sciences (P.B.R.), John Hopkins University School of Medicine, Baltimore, MD
| | - Ton Feuth
- From the Departments of Geriatric Medicine/Radboudumc Alzheimer Centre (G.A.H.v.d.E., A.I.A.A., M.A.v.d.M., M.G.M.O.R.), Pharmacology and Toxicology (A.I.A.A., C.K.), Psychiatry (R.-J.V.), Internal Medicine (C.K.), and Health Evidence (T.F.), Radboud university medical center, Nijmegen; the Department of Elderly (A.I.A.A.), Vincent van Gogh Institute, Venray; the Department of Clinical Pharmacy (C.K.), Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands; and the Department of Psychiatry and Behavioral Sciences (P.B.R.), John Hopkins University School of Medicine, Baltimore, MD
| | - Paul B Rosenberg
- From the Departments of Geriatric Medicine/Radboudumc Alzheimer Centre (G.A.H.v.d.E., A.I.A.A., M.A.v.d.M., M.G.M.O.R.), Pharmacology and Toxicology (A.I.A.A., C.K.), Psychiatry (R.-J.V.), Internal Medicine (C.K.), and Health Evidence (T.F.), Radboud university medical center, Nijmegen; the Department of Elderly (A.I.A.A.), Vincent van Gogh Institute, Venray; the Department of Clinical Pharmacy (C.K.), Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands; and the Department of Psychiatry and Behavioral Sciences (P.B.R.), John Hopkins University School of Medicine, Baltimore, MD
| | - Marjolein A van der Marck
- From the Departments of Geriatric Medicine/Radboudumc Alzheimer Centre (G.A.H.v.d.E., A.I.A.A., M.A.v.d.M., M.G.M.O.R.), Pharmacology and Toxicology (A.I.A.A., C.K.), Psychiatry (R.-J.V.), Internal Medicine (C.K.), and Health Evidence (T.F.), Radboud university medical center, Nijmegen; the Department of Elderly (A.I.A.A.), Vincent van Gogh Institute, Venray; the Department of Clinical Pharmacy (C.K.), Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands; and the Department of Psychiatry and Behavioral Sciences (P.B.R.), John Hopkins University School of Medicine, Baltimore, MD
| | - Marcel G M Olde Rikkert
- From the Departments of Geriatric Medicine/Radboudumc Alzheimer Centre (G.A.H.v.d.E., A.I.A.A., M.A.v.d.M., M.G.M.O.R.), Pharmacology and Toxicology (A.I.A.A., C.K.), Psychiatry (R.-J.V.), Internal Medicine (C.K.), and Health Evidence (T.F.), Radboud university medical center, Nijmegen; the Department of Elderly (A.I.A.A.), Vincent van Gogh Institute, Venray; the Department of Clinical Pharmacy (C.K.), Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands; and the Department of Psychiatry and Behavioral Sciences (P.B.R.), John Hopkins University School of Medicine, Baltimore, MD
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347
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Porsteinsson AP, Smith JS, Keltz MA, Antonsdottir IM. Can antidepressant medication relieve agitation in Alzheimer's disease? Expert Rev Neurother 2015; 14:969-71. [PMID: 25148535 DOI: 10.1586/14737175.2014.947964] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Neuropsychiatric symptoms (NPS) are a major concern in the treatment of Alzheimer's disease. Historically, NPS are difficult to treat effectively due to a high side-effect burden associated with commonly used medications, such as atypical antipsychotics. Non-pharmacological treatment approaches have become the first line option. However, when such treatment fails, pharmacological options are often used. Thus, a push toward finding safer alternative pharmacological treatments has occurred. Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs) have shown promise in clinical trials for alleviating the burden of NPS. Lower overall agitation and caregiver stress has been reported to correlate to treatment with the SSRI citalopram. However, certain side effects of citalopram, such as QTc interval prolongation and increased cognitive decline, carry clinical concern and should be weighed when prescribing their use.
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Affiliation(s)
- Anton P Porsteinsson
- University of Rochester School of Medicine and Dentistry, 435 East Henrietta Road, Rochester, NY14620, USA
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348
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Abstract
Behavioral and psychological symptoms of dementia include agitation, depression, apathy, repetitive questioning, psychosis, aggression, sleep problems, wandering, and a variety of inappropriate behaviors. One or more of these symptoms will affect nearly all people with dementia over the course of their illness. These symptoms are among the most complex, stressful, and costly aspects of care, and they lead to a myriad of poor patient health outcomes, healthcare problems, and income loss for family care givers. The causes include neurobiologically related disease factors; unmet needs; care giver factors; environmental triggers; and interactions of individual, care giver, and environmental factors. The complexity of these symptoms means that there is no "one size fits all solution," and approaches tailored to the patient and the care giver are needed. Non-pharmacologic approaches should be used first line, although several exceptions are discussed. Non-pharmacologic approaches with the strongest evidence base involve family care giver interventions. Regarding pharmacologic treatments, antipsychotics have the strongest evidence base, although the risk to benefit ratio is a concern. An approach to integrating non-pharmacologic and pharmacologic treatments is described. Finally, the paradigm shift needed to fully institute tailored treatments for people and families dealing with these symptoms in the community is discussed.
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Affiliation(s)
- Helen C Kales
- Section of Geriatric Psychiatry, Department of Psychiatry, University of Michigan, Ann Arbor, MI 48109, USA Department of Veterans Affairs, Center for Clinical Management Research, Ann Arbor, MI, USA Geriatric Research Education and Clinical Center, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Laura N Gitlin
- Department of Community Public Health, School of Nursing, Johns Hopkins University, Baltimore, MD, USA Division of Geriatrics and Gerontology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA Center for Innovative Care in Aging, Johns Hopkins University, Baltimore, MD, USA
| | - Constantine G Lyketsos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview and Johns Hopkins University, Baltimore, MD, USA
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349
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Gitlin LN, Marx K, Stanley IH, Hodgson N. Translating Evidence-Based Dementia Caregiving Interventions into Practice: State-of-the-Science and Next Steps. THE GERONTOLOGIST 2015; 55:210-26. [PMID: 26035597 DOI: 10.1093/geront/gnu123] [Citation(s) in RCA: 210] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 11/03/2014] [Indexed: 11/12/2022] Open
Abstract
Over the past 3 decades, more than 200 dementia caregiver interventions have been tested in randomized clinical trials and found to be efficacious. Few programs have been translated for delivery in various service contexts, and they remain inaccessible to the 15+ million dementia family caregivers in the United States. This article examines translational efforts and offers a vision for more rapid advancement in this area. We summarize the evidence for caregiver interventions, review published translational efforts, and recommend future directions to bridge the research-practice fissure in this area. We suggest that as caregiver interventions are tested external to service contexts, a translational phase is required. Yet, this is hampered by evidentiary gaps, lack of theory to understand implementation challenges, insufficient funding and unsupportive payment structures for sustaining programs. We propose ways to advance translational activities and future research with practical applications.
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Affiliation(s)
- Laura N Gitlin
- Center for Innovative Care in Aging, School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Katherine Marx
- Center for Innovative Care in Aging, Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Ian H Stanley
- Center for Innovative Care in Aging, School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Nancy Hodgson
- Center for Innovative Care in Aging, Johns Hopkins University School of Nursing, Baltimore, Maryland
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350
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Passmore MJ. Management of dementia-related agitation: between the devil and the deep blue sea. EVIDENCE-BASED MENTAL HEALTH 2015; 18:29. [PMID: 25216654 PMCID: PMC11235040 DOI: 10.1136/eb-2014-101931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Michael J Passmore
- Department of Psychiatry, University of British Columbia, Mount St. Joseph Hospital, Ward 1 South, 3080 Prince Edward St, Vancouver, British Columbia, Canada V5T 3N4;
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