Agitation and psychosis in dementia

Characteristics of clinical-pharmacological recommendations in psychiatry in Germany

OBJECTIVE

Psychiatric patients in general, and elderly psychiatric patients in particular, are at risk of adverse drug reactions due to comorbidities and inappropriate polypharmacy. Interdisciplinary and clinical-pharmacologist-led medication reviews may contribute to medication safety in the field of psychiatry. In this study, we reported the frequency and characteristics of clinical-pharmacological recommendations in psychiatry, with a particular focus on geriatric psychiatry.

METHOD

A clinical pharmacologist, in collaboration with the attending psychiatrists and a consulting neurologist, conducted interdisciplinary medication reviews in a general psychiatric ward with a geropsychiatric focus at a university hospital over a 25-week period. All clinical and pharmacological recommendations were recorded and evaluated.

RESULTS

A total of 316 recommendations were made during 374 medication reviews. Indications/contraindications of drugs were the most frequently discussed topics (59/316; 18.7 %), followed by dose reductions (37/316; 11.7 %), and temporary or permanent discontinuation of medications (36/316; 11.4 %). The most frequent recommendations for dose reduction involvedbenzodiazepines (9/37; 24.3 %). An unclear or absent indication was the most common reason for recommending temporary or permanent discontinuation of the medication (6/36; 16.7 %).

CONCLUSION

Interdisciplinary clinical pharmacologist-led medication reviews represented a valuable contribution to medication management in psychiatric patients, particularly the elderly ones.

Pharmacotherapy of Behavioral and Psychological Symptoms of Dementia: State of the Art and Future Progress

The core symptoms of different dementia subtypes are the behavioral and psychological symptoms of dementia (BPSD) and its neuropsychiatric symptoms (NPS). BPSD symptoms may occur at any stage in the case of dementia due to Alzheimer's disease (AD), whereas they tend to occur early on in the case of its behavioral variant frontotemporal dementia or dementia with Lewy bodies and are essential for diagnosis. BPSD treatment consists of non-pharmacological as well as pharmacological interventions, with non-pharmacological interactions being suggested as first-line treatment. Agitation, psychotic features, apathy, depression, and anxiety may not respond to acetylcholinesterase inhibitors or memantine in AD cases; therefore, antipsychotics, antidepressants, sedative drugs or anxiolytics, and antiepileptic drugs are typically prescribed. However, such management of BPSD can be complicated by hypersensitivity to antipsychotic drugs, as observed in DLB, and a lack of effective pro-cognitive treatment in the case of frontotemporal dementia. The present paper reviews current knowledge of the management of BPSD and its limitations and discusses on-going clinical trials and future therapeutic options.

Management of Neuropsychiatric Symptoms in Neurocognitive Disorders

Dementias, renamed neurocognitive disorders (NCDs) in the DSM-5, are defined by acquired decline in cognitive and functional abilities. DSM-5 now also includes mild NCD, which incorporates the previous diagnosis of mild cognitive impairment. DSM-5 recognizes the following etiologies for NCDs: NCD due to Alzheimer's disease, vascular NCD, NCD with Lewy bodies, frontotemporal NCD, substance-/medication-induced NCD, NCD due to traumatic brain injury, NCD due to Huntington's disease, NCD due to HIV infection, NCD due to prion disease, and NCD due to other medical conditions. In this review, the authors discuss a wide variety of interventions that have been studied for the treatment and management of neuropsychiatric symptoms of patients with NCDs. In addition to nonpharmacological interventions, several classes of medications-including antipsychotics, antidepressants, anticonvulsants, and cholinesterase inhibitors-have been studied for this indication.

Galantamine versus risperidone treatment of neuropsychiatric symptoms in patients with probable dementia: an open randomized trial

OBJECTIVE

To examine the effects of galantamine and risperidone on neuropsychiatric symptoms in dementia (NPSD) and global function.

METHODS

Using a randomized, controlled and open-blind, one-center trial at an in- and outpatient clinic at a university hospital, we studied 100 adults with probable dementia and NPSD. Participants received galantamine (N = 50, target dose 24 mg) or risperidone (N = 50, target dose 1.5 mg) for 12 weeks. The primary outcome was effects on NPSD assessed by the Neuropsychiatric Inventory (NPI). Secondary measures included the Mini-Mental State Examination (MMSE), Clinical Dementia Rating, Clinical Global Impression, and Simpson Angus scales. All tests were performed before and after treatment.

RESULTS

Outcome measures were analyzed using analysis of covariance. Ninety-one patients (67% women, mean age 79 ± 7.5 years) with initial NPI score of 51.0 (± 25.8) and MMSE of 20.1 (± 4.6) completed the trial. Both galantamine and risperidone treatments resulted in improved NPSD symptoms and were equally effective in treating several NPI domains. However, risperidone showed a significant treatment advantage in the NPI domains irritation and agitation, F(1, 97) = 5.2, p = 0.02. Galantamine treatment also ameliorated cognitive functions where MMSE scores increased 2.8 points compared with baseline (95% confidence interval: 1.96-3.52). No treatment-related severe side effects occurred.

CONCLUSIONS

These results support that galantamine, with its benign safety profile, can be used as first-line treatment of NPSD symptoms, unless symptoms of irritation and agitation are prominent, where risperidone is more efficient.

Solving the puzzle of Alzheimer disease

Managing patients with dementia and Alzheimer disease can be a challenge. Often, families and caregivers ask clinicians about the latest treatments. This article summarizes the latest evidence-based practice related to pharmacologic and nonpharmacologic management of patients with Alzheimer disease.

Neuropsychiatric symptoms and syndromes in institutionalized elderly people without dementia

BACKGROUND

Neuropsychiatric disorders are mainly studied in people with dementia but estimates are still not available for institutionalized elderly people without dementia. The aim of this work was to investigate neuropsychiatric syndromes in non-demented elderly people living in residential facilities (RFs).

METHODS

Data from the PROGRES-Older people project, including 95 RFs in Italy, were analyzed. From a total of 1215 people, 252 without dementia were recruited. Behavioral syndromes were identified using both factor and cluster analysis of results from the 12-item Neuropsychiatric Inventory. Logistic regression was used to assess factors associated with behavioral syndromes. Global cognitive functioning was assessed with the Mini-mental State Examination (MMSE). Current pharmacological treatments were taken from the residents' records.

RESULTS

Five neuropsychiatric syndromes were identified: (1) Affective (depression, anxiety, night-time behaviors); (2) Hyperactive (agitation, irritability, appetite abnormalities); (3) Psychotic (delusions and hallucinations); (4) Manic (euphoria and disinhibition); (5) Apathetic (apathy and aberrant motor behavior). The risk of having a neuropsychiatric syndrome was higher in people with younger age (OR: 5.1, 1.3-20.0), higher education (OR: 7.3, 2.4-22.1), and low MMSE score (OR: 6.5, 1.9-22.2). Almost half of people with behavioral syndromes were not undergoing psychotropic treatment. Hypnotic and anxiolytic agents were the most frequently used drugs for most of the syndromes.

CONCLUSIONS

Older people without dementia living in RFs exhibit a syndrome pattern of neuropsychiatric behaviors different from those observed in patients with dementia, which are associated with cognitive and sociodemographic characteristics. A large proportion of non-demented older people with neuropsychiatric syndromes are not having adequate treatment for their psychiatric disturbances.

Antipsychotics and risk of cerebrovascular events in treatment of behavioural and psychological symptoms of dementia in Hong Kong: a hospital-based, retrospective, cohort study

OBJECTIVE

The purpose of this study was to investigate the risk of cerebrovascular adverse events (CVAEs) in patients with behavioural and psychological symptoms of dementia (BPSD) treated with typical or atypical antipsychotics in Hong Kong

METHOD

This was a retrospective cohort study. Patients aged 65 or above, diagnosed with Alzheimer's disease, vascular or mixed dementia, and first attended the psychiatric service of our unit between 1st January 2000 to 30th June 2007 were studied. The patients were divided into three groups according to their antipsychotic usage. They were compared on sociodemographic and clinical characteristics. The risk of CVAEs was studied by means of Cox regression analysis.

RESULTS

The studied cohort consisted of 1089 patients. The antipsychotic non-user, typical and atypical users groups consisted of 363, 654 and 72 patients, respectively. Incidence rate of CVAE for the three groups were 44.6/1000, 32.7/1000 and 49.6/1000 person years, respectively. The risk of developing CVAEs did not differ in typical or atypical antipsychotic user groups compared with non-user group. The adjusted hazard ratio of typical and atypical antipsychotic user groups were 0.964 (95% CI = 0.584-1.591) and 1.036 (95% CI = 0.350-3.066), respectively. Subgroup analyses of individual antipsychotic did not show a significant increase in risk of CVAEs.

CONCLUSION

This study showed that there was no statistical difference in risk of cerebrovascular events in treatment of BPSD with typical and atypical antipsychotics compared with non-user group. Nonetheless, given the side effects of antipsychotics, prescription of antipsychotics should be reserved for severe and distressing symptoms with careful consideration.

Prazosin for the treatment of behavioral symptoms in patients with Alzheimer disease with agitation and aggression

OBJECTIVES

Agitation/aggression in Alzheimer disease (AD) is a major cause of patient distress, caregiver burden, and institutionalization. Enhanced behavioral responsiveness to central nervous system norepinephrine (NE) release may contribute to the pathophysiology of agitation/aggression in AD. Prazosin, a nonsedating generic medication used for hypertension and benign prostatic hypertrophy, antagonizes NE effects at brain postsynaptic alpha-1 adrenoreceptors. This pilot study examined the efficacy and tolerability of prazosin for behavioral symptoms in patients with agitation/aggression in AD.

DESIGN

Double-blind, placebo controlled, parallel group study.

SETTING

A university AD center and a nursing home in Seattle, WA.

PARTICIPANTS

Twenty-two nursing home and community-dwelling participants with agitation/aggression and probable or possible AD (mean age: 80.6 +/- 11.2).

INTERVENTION

Randomization to placebo (N = 11) or prazosin (N = 11). Medication was initiated at 1 mg/day and increased up to 6 mg/day using a flexible dosing algorithm.

MEASUREMENTS

The Brief Psychiatric Rating Scale (BPRS) and Neuropsychiatric Inventory (NPI) at Weeks 1, 2, 4, 6, and 8. The Clinical Global Impression of Change (CGIC) at Week 8.

RESULTS

Participants taking prazosin (mean dose: 5.7 +/- 0.9 mg/day) had greater improvements than those taking placebo (mean dose: 5.6 +/- 1.2 mg/day) on the NPI (mean change: -19 +/- 21 versus -2 +/- 15, chi = 6.32, df = 1, p = 0.012) and BPRS (mean change: -9 +/- 9 versus -3 +/- 5, chi = 4.42, df = 1, p = 0.036) based on linear mixed effects models and the CGIC (mean: 2.6 +/- 1.0 versus 4.5 +/- 1.6, z = 2.57, p = 0.011 [Mann-Whitney test]). Adverse effects and blood pressure changes were similar between prazosin and placebo groups.

CONCLUSION

Prazosin was well tolerated and improved behavioral symptoms in patients with agitation/aggression in AD.