Alprazolam as an alternative to low-dose haloperidol in older, cognitively impaired nursing facility patients

Benzodiazepines for agitation in patients with delirium: selecting the right patient, right time, and right indication

PURPOSE OF REVIEW

To provide an evidence-based synopsis on the role of benzodiazepines in patients with agitated delirium.

RECENT FINDINGS

Existing evidence supports the use of benzodiazepines in two specific delirium settings: persistent agitation in patients with terminal delirium and delirium tremens. In the setting of terminal delirium, the goal of care is to maximize comfort, recognizing that patients are unlikely to recover from their delirium. A recent randomized trial suggests that lorazepam in combination with haloperidol as rescue medication was more effective than haloperidol alone for the management of persistent restlessness/agitation in patients with terminal delirium. In patients with refractory agitation, benzodiazepines may be administered as scheduled doses or continuous infusion for palliative sedation. Benzodiazepines also have an established role in management of delirium secondary to alcohol withdrawal. Outside of these two care settings, the role of benzodiazepine remains investigational and clinicians should exercise great caution because of the risks of precipitating or worsening delirium and over-sedation.

SUMMARY

Benzodiazepines are powerful medications associated with considerable risks and benefits. Clinicians may prescribe benzodiazepines skillfully by selecting the right medication at the right dose for the right indication to the right patient at the right time.

Managing Behavioral and Psychological Symptoms of Dementia

Behavioral and psychological symptoms of dementia (BPSD) are universally experienced by people with dementia throughout the course of the illness and cause a significant negative impact on quality of life for patients and caregivers. Nonpharmacologic treatments have been recommended as first-line treatment of BPSD by multiple professional organizations and should target patients with dementia factors, caregiver factors, and environmental factors. Psychotropic medications are often prescribed off-label without significant evidence to support their use. The Describe, Investigate, Create, Evaluate approach can provide a structured method to investigate and treat BPSD with flexibility to use in multiple treatment settings.

Prescription Benzodiazepine Use Among Older Adults: A Critical Review

OBJECTIVES

Despite evidence for many potential risks, use of benzodiazepines (BZDs) among older adults is common. The authors evaluated the available evidence for BZD effectiveness and tolerability for use in older adults in three psychiatric conditions for which BZDs are commonly prescribed: insomnia, anxiety disorders, and behavioral and psychological symptoms of dementia.

DESIGN

Electronic databases, including PubMed/MEDLINE, were searched to identify articles that (1) included patients ≥50 years of age, (2) focused on patients diagnosed with insomnia, anxiety disorders, or behavioral and psychological symptoms of dementia, and (3) were either a randomized, placebo-controlled trial or a randomized trial comparing a BZD with either another psychotropic medication or psychotherapy.

RESULTS

Thirty-one studies met the inclusion criteria. Of the three clinical indications evaluated, treatment of insomnia had the greatest available evidence for use of BZDs among older adults, with 21 of 25 trials demonstrating improved sleep outcomes with use of BZDs. Only one trial was found to meet eligibility criteria for BZD use in anxiety disorders, demonstrating benefit over placebo. Five studies for use in behavioral disturbances in dementia were included, of which only one demonstrated improvement over placebo.

CONCLUSION

This systematic review suggests that BZD prescribing to older adults is significantly in excess of what the available evidence suggests is appropriate. Future trials should focus on efforts to reduce both acute and chronic BZD use among older adults while improving access to effective non-pharmacologic treatment alternatives.

Patients Aged 80 Years or Older are Encountered More Potentially Inappropriate Medication Use

Background:

Polypharmacy and potentially inappropriate medications (PIMs) are prominent prescribing issues in elderly patients. This study was to investigate the different prevalence of PIM use in elderly inpatients between 65–79 years of age and 80 years or older, who were discharged from Geriatric Department in West China Hospital.

Methods:

A large-scale cohort of 1796 inpatients aged 65 years or over was recruited. Respectively, 618 patients were 65–79 years and 1178 patients were 80 years or older. Updated 2012 Beers Criteria by the American Geriatric Society was applied to assess the use of PIM among the investigated samples.

Results:

A review of the prescribed medications identified 686 patients aged 80 years or older consumed at least one PIM giving a rate of 58.2%. Conversely, 268 (43.4%) patients aged 65–79 years consumed at least one PIM (χ² = 40.18, P < 0.001). Patients aged 80 years or older had higher hospitalization expenses, length of stay, co-morbidities, medical prescription, and mortality than patients aged 65–79 years (all with P < 0.001). Patients aged 80 years or older were prescribed with more benzodiazepines, drugs with strong anticholinergic properties, megestrol, antipsychotics, theophylline, and aspirin. In multiple regression analysis, PIM use was significantly associated with female gender, age, number of diagnostic disease, and number of prescribed medication.

Conclusions:

The finding from this study revealed that inpatients aged 80 years or older encountered more PIM use than those aged 65–79 years. Anticholinergic properties, megestrol, antipsychotics, theophylline, and aspirin are medications that often prescribed to inpatients aged 80 years or older. Doctors should carefully choose drugs for the elderly, especially the elderly aged 80 years or older.

Efficacy and tolerability of benzodiazepines for the treatment of behavioral and psychological symptoms of dementia: a systematic review of randomized controlled trials

The objective of this review is to summarize the available data on the use of benzodiazepines for the treatment of behavioral and psychological symptoms of dementia (BPSD) from randomized controlled trials (RCTs). A systematic search of 5 major databases, PubMed, MEDLINE, PsychINFO, EMBASE, and Cochrane Collaboration, yielded a total of 5 RCTs. One study compared diazepam to thioridazine, 1 trial compared oxazepam to haloperidol and diphenhydramine, 1 trial compared alprazolam to lorazepam, 1 trial compared lorazepam to haloperidol, and 1 trial compared intramuscular (IM) lorazepam to IM olanzapine and placebo. The data indicates that in 4 of the 5 studies, there was no significant difference in efficacy between the active drugs to treat the symptoms of BPSD. One study indicated that thioridazine may have better efficacy than diazepam for treating symptoms of BPSD. In 1 study, the active drugs had greater efficacy in treating BPSD when compared to placebo. There was no significant difference between the active drugs in terms of tolerability. However, in 2 of the 5 studies, about a third of the patients were noted to have dropped out of the studies. Available data, although limited, do not support the routine use of benzodiazepines for the treatment of BPSD. But these drugs may be used in certain circumstances where other psychotropic medications are unsafe for use in individuals with BPSD or when there are significant medication allergies or tolerability issues with certain classes of psychotropic medications.

Nonpharmacological and pharmacological interventions for symptoms in Alzheimer’s disease

Patients with Alzheimer's disease may suffer from noncognitive symptoms as well as cognitive symptoms, which the condition is better known for. Behavioral and psychiatric symptoms are common in patients with Alzheimer's disease and may cause great distress to them and their carers. Symptoms include agitation, aggression, wandering, shouting, depression, apathy and sleep disturbance. The safe and effective management of behavioral and psychiatric symptoms of Alzheimer's disease is one of the greatest challenges clinicians face. Traditionally, pharmacological interventions have been the mainstay of treatment but there is growing evidence for the effectiveness of a wide range of nonpharmacological measures. In this review, the evidence and appropriateness of both types of intervention for behavioral and psychiatric symptoms in Alzheimer's disease are discussed.

A systematic mapping review of randomized controlled trials (RCTs) in care homes

Background

A thorough understanding of the literature generated from research in care homes is required to support evidence-based commissioning and delivery of healthcare. So far this research has not been compiled or described. We set out to describe the extent of the evidence base derived from randomized controlled trials conducted in care homes.

Methods

A systematic mapping review was conducted of the randomized controlled trials (RCTs) conducted in care homes. Medline was searched for “Nursing Home”, “Residential Facilities” and “Homes for the Aged”; CINAHL for “nursing homes”, “residential facilities” and “skilled nursing facilities”; AMED for “Nursing homes”, “Long term care”, “Residential facilities” and “Randomized controlled trial”; and BNI for “Nursing Homes”, “Residential Care” and “Long-term care”. Articles were classified against a keywording strategy describing: year and country of publication; randomization, stratification and blinding methodology; target of intervention; intervention and control treatments; number of subjects and/or clusters; outcome measures; and results.

Results

3226 abstracts were identified and 291 articles reviewed in full. Most were recent (median age 6 years) and from the United States. A wide range of targets and interventions were identified. Studies were mostly functional (44 behaviour, 20 prescribing and 20 malnutrition studies) rather than disease-based. Over a quarter focussed on mental health.

Conclusions

This study is the first to collate data from all RCTs conducted in care homes and represents an important resource for those providing and commissioning healthcare for this sector. The evidence-base is rapidly developing. Several areas - influenza, falls, mobility, fractures, osteoporosis – are appropriate for systematic review. For other topics, researchers need to focus on outcome measures that can be compared and collated.

Representation of people with intellectual disabilities in randomised controlled trials on antipsychotic treatment for behavioural problems

BACKGROUND

Behavioural problems are common in people with intellectual disability (ID) and are often treated with antipsychotics.

AIM

To establish the frequency and characteristics of people with ID included in randomised controlled trials (RCTs) on antipsychotic treatment for behavioural problems, and to investigate the quality of these RCTs.

METHODS

A literature search in EMBASE, PubMed and Cochrane was performed and reviewed.

RESULTS

People with ID participated in 27 of the 100 included RCTs. The RCTs were of good quality but smaller compared with trials in patients with dementia or schizophrenia (average sample sizes = 55, 124 and 374). In 13/27 trials no clear definition of ID was given. Over 25 different outcome measures were used to assess behavioural problems.

CONCLUSIONS

Studies in which people with ID are included are of a sufficient quality, but of a small size. The heterogeneity in the characteristics of the ID population included as well as in the applied assessment instruments makes performing meta-analyses unfeasible.

Neurochemical basis for symptomatic treatment of Alzheimer's disease

Neuron and synapse loss together with neurotransmitter dysfunction have, along with Abeta deposition and neurofibrillary tangles, been recognized as hallmarks of Alzheimer's disease (AD). Furthermore, clinical and preclinical studies point to neuronal loss and associated neurochemical alterations of several transmitter systems as a main factor underlying both cognitive and neuropsychiatric symptoms. Treatment for the cognitive decline in AD, based on early findings of a cholinergic deficit, has been in the clinic for more than a decade but provides only modest benefit in most patients. Therefore there is still considerable scope for new treatments that demonstrate greater efficacy against cognitive dysfunction in spite of the fact that the mainstays of current treatments, the cholinesterase inhibitors Aricept, Exelon and Reminyl (Razadyne) will become generic over the next few years. However, the most important area for drug development is for the treatment of behavioural disturbance in AD since many existing treatments have limited efficacy and have potentially life-threatening side effects. This review examines the neurochemical underpinning of both cognitive and neuropsychiatric symptoms in dementia and provides some basis for rational drug development.

Benzodiazepines for delirium

BACKGROUND

Delirium occurs in 30% of hospitalised patients and is associated with prolonged hospital stay and increased morbidity and mortality. The results of uncontrolled studies have been unclear, with some suggesting that benzodiazepines may be useful in controlling non-alcohol related delirium.

OBJECTIVES

To determine the effectiveness and incidence of adverse effects of benzodiazapines in the treatment of non-alcohol withdrawal related delirium.

SEARCH STRATEGY

The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 26 February 2008 using the search terms: (deliri* or confusion) and (benzo* or lorazepam," or "alprazolam" or "ativan" or diazepam or valium or chlordiazepam).The CDCIG Specialized Register contains records from major health databases (including MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, LILACS) as well as many ongoing trial databases and grey literature sources.

SELECTION CRITERIA

Trials had to be unconfounded, randomized and with concealed allocation of subjects. Additionally, selected trials had to have assessed patients pre- and post-treatment. Where crossover design was present, only data from the first part of the trial were to be examined.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data from included trials. Data were pooled where possible, and were to be analysed using appropriate statistical methods. Odd ratios or average differences were to be calculated. Only "intention to treat" data were to be included.

MAIN RESULTS

Only one trial satisfying the selection criteria could be identified. In this trial, comparing the effect of the benzodiazepine, lorazepam, with dexmedetomidine, a selective alpha-2-adrenergic receptor agonist, on delirium among mechanically ventilated intensive care unit patients, dexmedetomidine treatment was associated with an increased number of delirium- and coma-free days compared with lorazepam treated patients (dexmedetomidine patients, average seven days; lorazepam patients, average three days; P = 0.01). One partially controlled study showed no advantage of a benzodiazepine (alprazolam) compared with neuroleptics in treating agitation associated with delirium, and another partially controlled study showed decreased effectiveness of a benzodiazepine (lorazepam), and increased adverse effects, compared with neuroleptics (haloperidol, chlorpromazine) for the treatment of acute confusion.

AUTHORS' CONCLUSIONS

No adequately controlled trials could be found to support the use of benzodiazepines in the treatment of non-alcohol withdrawal related delirium among hospitalised patients, and at this time benzodiazepines cannot be recommended for the control of this condition. Because of the scarcity of trials with randomization of patients, placebo control, and adequate concealment of allocation of subjects, it is clear that further research is required to determine the role of benzodiazepines in the treatment of non-alcohol withdrawal related delirium.

Benzodiazepines for delirium

BACKGROUND

Delirium occurs in 30% of hospitalised patients and is associated with prolonged hospital stay and increased morbidity and mortality. The results of uncontrolled studies have been unclear, with some suggesting that benzodiazepines may be useful in controlling non-alcohol related delirium.

OBJECTIVES

To determine the effectiveness and incidence of adverse effects of benzodiazapines in the treatment of non-alcohol withdrawal related delirium.

SEARCH STRATEGY

The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 26 February 2008 using the search terms: (deliri* or confusion) and (benzo* or lorazepam," or "alprazolam" or "ativan" or diazepam or valium or chlordiazepam).The CDCIG Specialized Register contains records from major health databases (including MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, LILACS) as well as many ongoing trial databases and grey literature sources.

SELECTION CRITERIA

Trials had to be unconfounded, randomized and with concealed allocation of subjects. Additionally, selected trials had to have assessed patients pre- and post-treatment. Where crossover design was present, only data from the first part of the trial were to be examined.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data from included trials. Data were pooled where possible, and were to be analysed using appropriate statistical methods. Odd ratios or average differences were to be calculated. Only "intention to treat" data were to be included.

MAIN RESULTS

Only one trial satisfying the selection criteria could be identified. In this trial, comparing the effect of the benzodiazepine, lorazepam, with dexmedetomidine, a selective alpha-2-adrenergic receptor agonist, on delirium among mechanically ventilated intensive care unit patients, dexmedetomidine treatment was associated with an increased number of delirium- and coma-free days compared with lorazepam treated patients (dexmedetomidine patients, average seven days; lorazepam patients, average three days; P = 0.01). One partially controlled study showed no advantage of a benzodiazepine (alprazolam) compared with neuroleptics in treating agitation associated with delirium, and another partially controlled study showed decreased effectiveness of a benzodiazepine (lorazepam), and increased adverse effects, compared with neuroleptics (haloperidol, chlorpromazine) for the treatment of acute confusion.

AUTHORS' CONCLUSIONS

No adequately controlled trials could be found to support the use of benzodiazepines in the treatment of non-alcohol withdrawal related delirium among hospitalised patients, and at this time benzodiazepines cannot be recommended for the control of this condition. Because of the scarcity of trials with randomization of patients, placebo control, and adequate concealment of allocation of subjects, it is clear that further research is required to determine the role of benzodiazepines in the treatment of non-alcohol withdrawal related delirium.

Alternatives to atypical antipsychotics for the management of dementia-related agitation

Numerous recent studies have challenged the widely held belief that atypical antipsychotics are safe and effective options for the treatment of behavioural problems such as agitation in patients with dementia. Accordingly, there is a need to reconsider the place of atypical antipsychotics in the treatment of patients with dementia. The present article is intended to assist clinicians with the assessment and pharmacological management of agitation in patients with dementia. We review the risk-benefit evidence for the use of atypical antipsychotics in patients with dementia-related agitation (DRA). Emerging evidence indicates that, for patients with dementia, the risks associated with atypical antipsychotics may outweigh the benefits except for patients with severe agitation who require short-term chemical restraint. We then discuss the importance of a careful assessment to rule out potentially reversible factors contributing to DRA. Finally, we summarize the evidence supporting the use of medications other than antipsychotics to treat DRA. There is wide variability in the levels of evidence supporting the use of non-antipsychotic medication for the treatment of DRA. The best evidence currently exists for cholinesterase inhibitors and serotonin-specific reuptake inhibitor antidepressants. Emerging reports suggest that numerous other medications, for example, antiepileptics, lithium, anxiolytics, analgesics, beta-adrenoceptor antagonists, cannabinoid receptor agonists and hormonal agents, may prove to be viable alternatives to antipsychotics for the treatment of severe DRA and more research is urgently needed to help assess the effectiveness of these agents. A comprehensive biopsychosocial assessment and treatment plan is likely the most effective way to manage DRA.

ACNP White Paper: update on use of antipsychotic drugs in elderly persons with dementia

In elderly persons, antipsychotic drugs are clinically prescribed off-label for a number of disorders outside of their Food and Drug Administration (FDA)-approved indications (schizophrenia and bipolar disorder). The largest number of antipsychotic prescriptions in older adults is for behavioral disturbances associated with dementia. In April 2005, the FDA, based on a meta-analysis of 17 double-blind randomized placebo-controlled trials among elderly people with dementia, determined that atypical antipsychotics were associated with a significantly (1.6-1.7 times) greater mortality risk compared with placebo, and asked that drug manufacturers add a 'black box' warning to prescribing information for these drugs. Most deaths were due to either cardiac or infectious causes, the two most common immediate causes of death in dementia in general. Clinicians, patients, and caregivers are left with unclear choices of treatment for dementia patients with psychosis and/or severe agitation. Not only are psychosis and agitation common in persons with dementia but they also frequently cause considerable caregiver distress and hasten institutionalization of patients. At the same time, there is a paucity of evidence-based treatment alternatives to antipsychotics for this population. Thus, there is insufficient evidence to suggest that psychotropics other than antipsychotics represent an overall effective and safe, let alone better, treatment choice for psychosis or agitation in dementia; currently no such treatment has been approved by the FDA for these symptoms. Similarly, the data on the efficacy of specific psychosocial treatments in patients with dementia are limited and inconclusive. The goal of this White Paper is to review relevant issues and make clinical and research recommendations regarding the treatment of elderly dementia patients with psychosis and/or agitation. The role of shared decision making and caution in using pharmacotherapy for these patients is stressed.

Pharmacologic management of neuropsychiatric symptoms of Alzheimer disease

OBJECTIVE

To systematically review published clinical trials of the pharmacotherapy of neuropsychiatric symptoms of Alzheimer disease (AD).

METHOD

We searched MEDLINE and EMBASE for published English-language medical literature. Our review focused on randomized controlled trials (RCTs) and corresponding metaanalyses.

RESULTS

The pharmacotherapy of neuropsychiatric symptoms of AD has been studied with numerous RCTs. The largest number of studies has focused on antipsychotics. Data are of reasonably high quality and indicate that risperidone and olanzapine are more effective than placebo for institutionalized patients with severe agitation, aggression, and psychosis. The efficacy of antipsychotics is counterbalanced by safety concerns that include cerebrovascular adverse events and mortality. Cholinesterase inhibitors and memantine appear to have modest benefits for patients with mildly to moderately severe symptoms. Antidepressants are effective for treating depression in AD, but more data are required to determine the efficacy of trazodone and citalopram for agitation and aggression. Carbamazepine appears to be efficacious, although side effects and concerns about drug-drug interactions limit its use. The data do not support the use of valproate. Benzodiazepines should only be used for short-term, as-needed use. There are insufficient data on other pharmacologic interventions, such as beta blockers, buspirone, and estrogen preparations.

CONCLUSIONS

Although there have been numerous well-designed studies of the pharmacotherapy of neuropsychiatric symptoms in AD, safer and more effective treatments are urgently needed.

GABAergic function in Alzheimer's disease: evidence for dysfunction and potential as a therapeutic target for the treatment of behavioural and psychological symptoms of dementia

Alzheimer's disease (AD) is characterized by disruptions in multiple major neurotransmitters. While many studies have attempted to establish whether GABA is disrupted in AD patients, findings have varied. We review evidence for disruptions in GABA among patients with AD and suggest that the variable findings reflect subtypes of the disease that are possibly manifested clinically by differing behavioural symptoms. GABA, the major inhibitory neurotransmitter, has long been a target for anxiolytics, hypnotic sedatives, and anticonvulsants. We review the clinical use of GABAergic agents in treating persons with AD symptoms. While newer generation GABAergic medications are now available, they have yet to be evaluated among patients with AD.

Anaesthesia in patients with dementia

PURPOSE OF REVIEW

The next couple of decades will be characterized by an increase in life expectancy, leading to an older population. As the incidence of Alzheimer's dementia and vascular dementia is rising with age, the future anaesthesiologist will be increasingly confronted with perioperative care of patients with impaired cognitive function. This paper tries to highlight some topics specifically related to demented patients.

RECENT FINDINGS

Psychometric testing and behaviour vary according to the type of dementia. Neuroanatomical and biochemical correlates for different types of dementia are more precise and better documented. Evidence exists that cognition may be impaired for weeks after anaesthesia, but the mental capacities of those who have undergone surgery are comparable to those of age controls in the long term. Most research efforts are focused on improving the daily functioning of people with cognitive impairment. Several new anticholinesterases are being evaluated. It is advantageous to keep cognition optimal throughout the perioperative period. Neuroleptics may be badly tolerated and, most importantly, pain pathways may be differentially affected in dementia.

SUMMARY

Anaesthesia in the demented patient may be complicated by a number of potential problems, including the comorbid pathology, the concomitant anticholinesterase activity, the need for normoventilation, monitoring of anaesthesia depth and the evaluation of postoperative pain. Anaesthesia in variant Creutzfeldt-Jakob disease is aimed at preventing the spread of the causing prion. There is a broad consensus that early return to the preoperative level of cognition is to be pursued, with the help of short-acting drugs and loco-regional anaesthesia.

The Pharmacological Approach of Behavioral Disturbances in Dementia

Behavioral and psychological symptoms in dementia (BPSD) are often overlooked due to the main focus of treating or preventing cognitive decline symptoms. Almost two-thirds of patients with dementia will develop some type of noncognitive symptoms that include symptoms such as wandering, agitation, sexually inappropriate behaviors, physical and verbal aggression, uncooperativeness, and “sun-downing.” Psychological symptoms include depression, anxiety, delusions, hallucinations, and suspiciousness/paranoia. Worsening of these symptoms can lead to caregiver burden and is one of the major reasons for patients with dementia to be institutionalized. A major drawback of treating these symptoms pharmacologically is that the response rate is low with the current available therapies such as antipsychotics, anxiolytics, and antidepressants. In addition, all of these therapeutic classes have drawbacks due to side effect profiles. This article provides an overview of the current recommendations for pharmacological approaches for the treatment of behavioral and psychological symptoms of dementia.

Clinical pharmacology, clinical efficacy, and behavioral toxicity of alprazolam: a review of the literature

Alprazolam is a benzodiazepine derivative that is currently used in the treatment of generalized anxiety, panic attacks with or without agoraphobia, and depression. Alprazolam has a fast onset of symptom relief (within the first week); it is unlikely to produce dependency or abuse. No tolerance to its therapeutic effect has been reported. At discontinuation of alprazolam treatment, withdrawal and rebound symptoms are common. Hence, alprazolam discontinuation must be tapered. An exhaustive review of the literature showed that alprazolam is significantly superior to placebo, and is at least equally effective in the relief of symptoms as tricyclic antidepressants (TCAs), such as imipramine. However, although alprazolam and imipramine are significantly more effective than placebo in the treatment of panic attacks, Selective Serotonin Reuptake Inhibitors (SSRIs) appear to be superior to either of the two drugs. Therefore, alprazolam is recommended as a second line treatment option, when SSRIs are not effective or well tolerated. In addition to its therapeutic effects, alprazolam produces adverse effects, such as drowsiness and sedation. Since alprazolam is widely used, many clinical studies investigated its cognitive and psychomotor effects. It is evident from these studies that alprazolam may impair performance in a variety of skills in healthy volunteers as well as in patients. Since the majority of alprazolam users are outpatients, this behavioral impairment limits the safe use of alprazolam in patients routinely engaged in potentially dangerous daily activities, such as driving a car.

Assessment and treatment of nursing home residents with depression or behavioral symptoms associated with dementia: a review of the literature

Depression and the behavioral symptoms associated with dementia remain two of the most significant mental health issues for nursing home residents. The extensive literature on these conditions in nursing homes was reviewed to provide an expert panel with an evidence base for making recommendations on the assessment and treatment of these problems. Numerous assessment instruments have been validated for depression and for behavioral symptoms. The Minimum Data Set, as routinely collected, appears to be of limited utility as a screening instrument for depression but is useful for assessing some behavioral symptoms. Laboratory evaluations are often recommended, but no systematic study of the outcomes of these evaluations could be found. Studies of nonpharmacological interventions out-number those of pharmacological interventions, and randomized, controlled trials document the efficacy of many interventions. Antidepressants are effective for major depression, but data for minor depressive syndromes are limited. Recreational activities are effective for major and minor depression categories. Neither pharmacological nor nonpharmacological interventions totally eliminate behavioral symptoms, but both types of interventions decrease the severity of symptoms. In the absence of comparison studies, it is unclear whether one approach is more effective than another. Despite federal regulations limiting their use, antipsychotics are effective and remain the most studied medications for treating behavioral symptoms, whereas benzodiazepines and antidepressants have less support. Structured activities are effective, but training interventions for behavioral symptoms had limited results. There are sufficient data to formulate an evidenced-based approach to treatment of depression and behavioral symptoms, but more research is needed to prioritize treatments.

Correlates of behavioral disturbances and pattern of psychotropic medication use in five skilled nursing facilities

There are several treatment options for behavioral disturbances (BDs) in dementia. However, the choice of a specific psychotropic agent is directed by personal preferences and local community practice patterns. We examined the relationship between common clusters of BDs and the use of different classes of psychotropic agents in our community. A cross-sectional study of 430 long-term care residents from 5 nursing homes was undertaken. The Behavior Measurement Scale (BMS) was used to measure the frequency of BDs grouped in 4 categories. Residents with > 4 BD episodes in at least one category during a 2-week observation period were the behavior group and were considered to have clinically significant BDs. A sample of patients who had < 4 BDs in all BMS categories during the same observation period defined the nonbehavior group. A BD cluster was defined as > 4 BDs occurring in one or more BMS categories during the 2-week observation. Data on functional status, comorbidity, use of benzodiazepines, antidepressants, and neuroleptic agents were collected with chart review. The chi-square test was used to examine the correlation between variables. Clinically significant BDs were identified in 27.2% (117/430) of the residents in the sample. Five of 15 behavior clusters accounted for 73% of all clinically significant BDs. The 5 clusters were verbally nonaggressive behaviors (cluster 1, 20.5%), behaviors from all 4 categories (cluster 2, 17.9%), verbally and physically nonaggressive behaviors (cluster 3, 14.5%), physically nonaggressive behaviors (cluster 4, 12.8%), and verbally aggressive and nonaggressive behaviors (cluster 5, 7.7%). Cluster 5 had a negative correlation with functional impairment (P = .009). There was a significant correlation between cluster 2 and benzodiazepine use (P = .014). No other significant correlation was found between any of the 5 clusters and demographic variables, comorbidity status, and use of antidepressant or neuroleptic medications. Residents in the behavior group had higher impairment in self-feeding (P = .036) and bathing (P < .001) and were more likely to be treated with benzodiazepines (P = .004) and neuroleptic agents (P = .009) than residents in the nonbehavior group (n = 116). The higher use of neuroleptics and benzodiazepines in the behavior group compared with the nonbehavior group indicates that BDs are being identified for treatment, but the medications used may not be efficacious. The lack of association between specific classes of psychotropic medications and distinct behavior clusters indicates that clinicians are not using a standardized approach to target the neurochemical abnormalities that may underlie certain behavior clusters. Some behavior clusters correlate with impairment in specific activities of daily living categories such as bathing and feeding, making room for nonpharmacologic interventions.

Pharmacological treatment of psychosis and agitation in elderly patients with dementia: four decades of experience

A number of studies, using different research designs and assessment instruments, have been conducted to elucidate the differential effects of drug treatments for psychosis, agitation and aggression in elderly patients with dementia. We have reviewed literature published from 1960 to 2000 on this topic; 48 studies that met our selection criteria were identified from Medline and Science Citation Index. Antipsychotic medication was generally effective for the treatment of psychosis and agitation in elderly patients with dementia. In double-blind, placebo-controlled trials in this population, mean improvement rates were 61% with antipsychotics and 35% with placebo. Atypical antipsychotics appeared promising, but the number of well-designed studies has been small so far. Methodological limitations of the studies reviewed are discussed; future trials should ensure adequate sample size and duration and involve direct comparisons of individual medications. In conclusion, conventional antipsychotics are modestly effective for treatment of psychosis and agitation in elderly individuals with dementia, whereas newer treatments such as atypical antipsychotics appear to be at least as effective while having fewer adverse effects. Nonetheless, there is no currently available ideal pharmacotherapy, and psychosocial management is a necessary part of overall treatment. Additional large-scale, well-controlled studies are needed before conclusive statements regarding the value of treatment of psychosis and agitation with atypical antipsychotics and non-antipsychotic agents can be made.

Haloperidol for agitation in dementia

BACKGROUND

Agitation occurs in up to 70% of demented patients. Haloperidol has been used for decades to control agitation in dementia, but its effectiveness remains unclear. Previous meta-analyses examined only English language publications or compared haloperidol with other drugs rather than with placebo. To study the effectiveness of haloperidol a more widely based review was performed.

OBJECTIVES

To determine whether evidence supported the use of haloperidol in agitated dementia.

SEARCH STRATEGY

The CDCIG Specialized Register which contains references from medical databases (MEDLINE, EMBASE, PsycInfo and CINAHL) as well as from many trials databases was searched on 26 July 2000 to identify reports of randomised controlled trials on haloperidol treatment of agitation in dementia.

SELECTION CRITERIA

Randomized, placebo-controlled trials, with concealed allocation, where subjects' dementia and agitation were assessed.

DATA COLLECTION AND ANALYSIS

1. Two reviewers extracted data from included trials 2. Data were pooled where possible, and analysed using appropriate statistical methods 3. Odds ratios of average differences were calculated 4. Only 'intention to treat' data were included 5. Analysis included haloperidol treated patients, compared with placebo

MAIN RESULTS

The five included trials led to the following results: 1. There was no significant improvement in agitation among haloperidol treated patients, compared with controls. 2. Aggression decreased among patients with agitated dementia treated with haloperidol; other aspects of agitation were not affected significantly in treated patients, compared with controls. 3. Although two studies showed increased dropouts due to adverse effects among haloperidol patients, there was no significant difference in dropout rates, comparing all haloperidol treated patients with controls. 4. The data were insufficient to examine response to treatment in relation to length of treatment, degree of dementia, age or sex of patients, and cause of dementia.

REVIEWER'S CONCLUSIONS

1. Evidence suggests that haloperidol was useful in the control of aggression, but was associated with increased side effects; there was no evidence to support the routine use of this drug for other manifestations of agitated dementia. 3. Similar dropout rates among haloperidol and placebo treated patients suggested that poorly controlled symptoms, or other factors, may be important in causing treatment discontinuation. 4. Variations in degree of dementia, dosage and length of haloperidol treatment, and in ways of assessing response to treatment suggested caution in the interpretation of reported effects of haloperidol in the management of agitated dementia. 4. The present study confirmed that haloperidol should not be used routinely to treat patients with agitated dementia. Treatment of agitated dementia with haloperidol should be individualized and patients should be monitored for side effects of therapy.

Recognition and Management of Behavioral Disturbances in Dementia

Behavioral disturbances are seen in most patients with dementia at some point in their course. They cause immense patient suffering and are responsible for caregiver stress, institutionalization, and hospitalization. Identification of predisposing and precipitating factors is very important. The approach to the management of behavioral disturbances in dementia patients should be structured and thorough. Ensuring the safety of the patient and others should be paramount. Addressing the causes of behavioral disturbances such as comorbid medical illnesses, polypharmacy, pain, personal need, environmental factors, etc. is critical to a successful outcome. Many behavioral disturbances such as wandering and hoarding are not amenable to pharmacotherapy. Nonpharmacologic interventions are the mainstay of managing behavioral disturbances. Success of pharmacologic interventions will depend on accurate identification of specific syndromes, e.g., depression-anxiety and psychosis and severity of symptoms. Response to pharmacologic interventions is usually modest and may be associated with significant symptom resolution. Many behavioral disturbances can be prevented by avoiding inappropriate medications and educating patient, family, caregivers, and health care providers. Hospitalization can be avoided and institutionalization delayed by early recognition and treatment of behavioral disturbances. Leadership from physicians to implement preventive measures is recommended. Research to clarify the biological underpinnings of behavioral disturbances and to address cost-effectiveness of currently identified interventions is needed.

Pharmacologic therapy for behavioral symptoms of alzheimer's disease

Behavioral signs and symptoms in dementia are common, morbid, classifiable, and treatable. The current state-of-the-art approach is to evaluate carefully for social or environmental causes, intercurrent medical conditions, or other triggers of the behavior and attempt to deal with those directly. When these conservative steps fail, there may be a role for medication. A rational approach typically hinges on matching the most dominant behavioral target symptoms to the most relevant medication class, the key information of which is summarized.

Defining patterns of benzodiazepine use in older adults

Benzodiazepines are disproportionately prescribed to older adults. Elderly adults with comorbid medical and psychiatric conditions, elderly adults taking multiple medications, and elderly women are the most likely adults to continuously use benzodiazepines. These are also the groups of elderly who are likely to experience adverse effects, including falls, accidents, and motor vehicle crashes. Despite recommendations for short-term treatment and the potential risks of long-term use, some patients continue to receive benefit for extended time periods, occasionally years. Future research needs to be directed at improved identification of which patients will benefit from intermittent versus continuous treatment while minimizing risk for adverse side effects. In order to advance the study of the risks and benefits of benzodiazepine use, we have proposed a set of definitions for classification of use. These definitions can be used to develop clinical guidelines based on empirically derived clinical research models.

Managing delirium and agitation in elderly hospitalized orthopaedic patients: Part 2--Interventions

Delirium, a disorder of consciousness that may afflict over one-half of elderly surgical orthopaedic patients is a common sequela of surgery in the elderly. Agitation, either as an element of the delirium or dimension of a preexisting dementia, is another common behavioral problem that can confront the orthopaedic nurse in acute care. It is time now to tear down the barriers to intelligent and compassionate care of patients with agitation and delirium, including late or missed recognition and diagnosis, biases about what is "normal" and acceptable behavior in the elderly, and lack of familiarity with pharmacologic strategies. In Part 1 (Jan/Feb issue), current thinking about the phenomena was presented, including hypotheses about causation and pathophysiology. That foundation is intended to serve as the basis for the current discussion. The triad of interventions available to manage disorganized behavior in elderly orthopaedic patients is presented in Part 2. They include an extensive selection of pharmacologic options, a discussion of therapeutic use of self and environmental-organizational issues to address and consider on a case-by-case basis. Though it may be impossible to prevent behavioral decompensation during an acute orthopaedic admission, it is certainly possible to improve our performance to date, using a compassionate, intelligent, and inclusive approach with every patient.

Managing delirium and agitation in elderly hospitalized orthopaedic patients: Part I--Theoretical aspects

Managing behavioral disorders such as delirium and agitation while simultaneously attending to the acute needs of elderly patients is a challenge that confronts orthopaedic nurses on a daily basis. This will only increase in frequency and complexity as the new century dawns. Delirium and agitation affect morbidity, mortality, length of stay, and costs--in short, outcomes. To manage and care for these patients, orthopaedic nurses must first update their knowledge of acute disorders that can disrupt mental status and behavior, and the effects of systemic events on brain function. With the knowledge of the pathophysiology of delirium and agitation, nurses then need to refine their assessment and intervention skills. This article describes the phenomena of agitation and delirium in the elderly acute orthopaedic patient, outlines current perceptions regarding pathophysiology, and offers guidelines for prevention and intervention. An algorithm has been developed that can assist with the identification of at-risk individuals, causes of delirium, and early assessments in the acute care setting.

Pharmacotherapy of behavioral and psychological symptoms of dementia: time for a different paradigm?

Behavioral and psychological symptoms of dementia can occur in 60-80% of patients with Alzheimer's disease or other dementing illnesses, and are important in that they are a source of significant caregiver stress and often precipitate nursing home placement. These symptoms, namely, aggression, delusions, hallucinations, apathy, anxiety, and depression, are clinically managed with a variety of psychotropic drugs such as antipsychotics, antidepressants, antiepileptic drugs, and benzodiazepines. Various advances in the neuropathophysiology and pharmacotherapy must be considered in the optimal design of regimens for patients with these symptoms.

Comparative effects of pharmacotherapy on the maintenance of cognitive function

The quality of human cognitive performance appears today as one of the main components of quality of life, whatever the age. Ageing by itself and most of the diseases affecting the central nervous system alter higher brain functions such as memory, vigilance and attention. Dementia is the most acute example, with a cascade of behavioral and psychological consequences (BPSD), which are the main cause of the caregiver's burden and need specific pharmacotherapy. In this respect, the problem will be the choice of the best drug in situations such as wandering, agitation, violence, and screaming. The psychotropics, however, should not deteriorate the already disturbed cognition of the patients. This is the reason why we propose to establish for each drug, and notably for the antipsychotics, a precise and exact "cognitive mapping"; in other words, to measure the effects of drugs on the different components of cognition. The results of such studies will be predictive of the future phase III clinical trials and therapeutic responses. As an illustration of this approach we shall relate two studies, TIATEM (phase I) and TIAGE (phase III/IV), leading to the determination of a good cognitive safety profile of an atypical neuroleptic drug, tiapride.

Palliative care in inflammatory bowel disease: an evidence-based approach

The management of the patient with inflammatory bowel disease (IBD) is challenging for both the physician and the patient. IBD imposes both a physical and emotional burden on patients' lives. Palliative care is important for IBD patients because it focuses on improving quality of life. While palliative care does not change the natural history of the disease, it provides relief from pain and other distressing symptoms. This article focuses on various aspects of care for IBD patients including pain control, management of oral and skin ulcerations, stomal problems in IBD patients, control of nausea and vomiting, management of chronic diarrhea and pruritus ani, evaluation of anemia, treatment of steroid-related bone disease, and treatment of psychological problems associated with IBD. Each of these areas is reviewed using an evidence-based approach. Evidence in category A refers to evidence from clinical trials that are randomized and well controlled. Category B Evidence refers to evidence from cohort or case-controlled studies. Category C is evidence from case reports or flawed clinical trials. Evidence from category D is limited to the clinical experience of the authors. Evidence labelled as category E refers to situations where there is insufficient evidence available to form an opinion. Algorithms for management of pain and nausea in IBD patients are presented.