Cyproterone to treat aggressivity in dementia: a clinical case and systematic review

Prevention and management of behavioural and psychological symptoms in patients with dementia in acute care: a best practice implementation project

INTRODUCTION

Behavioural and psychological symptoms of dementia are very common in acute care. Agitation and aggressive behaviours are the most common symptoms and are challenging to manage. Early detection and a nonpharmacological approach are recommended.

OBJECTIVES

To implement evidence-based recommendations for the prevention and management of aggression/agitation in patients with dementia in an acute geriatric care unit.

METHODS

The project used the JBI Practical Application of Clinical Evidence System and Getting Research into Practice audit and feedback tool. A baseline audit was conducted with seven audit criteria based on evidence summaries. It was followed by the implementation of an action plan and a follow-up audit.

RESULTS

Results showed moderate improvements in compliance with best practice recommendations. The second audit indicated an improvement up to 46% with the identification of factors/triggers that precipitate aggression/agitation and completion of a risk assessment. The highest improvement was the training of the nursing team (79%). Compliance with the involvement of patients and their families in the care planning improved slightly (14%). The lowest improvement was for the development and implementation of individualized care plans (10%).

CONCLUSION

The project implementation achieved some positive changes. A formalized process for preventing aggression/agitation is in place. The interprofessional collaboration, the support given to the nursing team and the basket of nonpharmacological interventions were strengthened. The electronic documentation and a limited collaboration of the nursing team were challenging. As further strategies were implemented, further audit would be required to assess achievement in change and/or demonstration of improved care provided for this vulnerable population.

Double-Blind, Placebo-Controlled Trial of Cyproterone Acetate to Prevent Flare-Up Effect on Dogs Implanted With Deslorelin

Deslorelin slow-released implants are registered in Europe for the reversible suppression of fertility in male dogs. After administration, a time-limited increase in sex hormones concentration and related behavioral problems may be observed. The aim of this work was to assess whether cyproterone acetate, a synthetic progestogen, can prevent this flare-up effect. Eighteen privately-owned entire male dogs were enrolled in this double-blind, placebo-controlled, randomized clinical trial. All subjects received a 4.7 mg deslorelin implant by SC route and 1-3 capsules containing either cyproterone acetate 2 mg/kg (N = 9) or a placebo (N = 9), by oral route BID for 14 days, depending on the dog's weight. The dogs were followed for 28 days. An increase in the blood testosterone concentration was observed in respectively 9/9 and 7/9 dogs of the control and cyproterone groups (p = 0.47). However, a worsening of the sex hormone related problems (i.e., urinary marking, mounting, aggressiveness toward other dogs and/or escape) was only observed in the placebo group, in 56 or 66% of the dogs as measured by respectively the veterinarian and the owners. Our study suggests that cyproterone acetate is effective and safe to supress the deslorelin induced behavioral flare-up effect, but not the rise in testosterone.

Interpreting molecular similarity between patients as a determinant of disease comorbidity relationships

Comorbidity is a medical condition attracting increasing attention in healthcare and biomedical research. Little is known about the involvement of potential molecular factors leading to the emergence of a specific disease in patients affected by other conditions. We present here a disease interaction network inferred from similarities between patients’ molecular profiles, which significantly recapitulates epidemiologically documented comorbidities. Furthermore, we identify disease patient-subgroups that present different molecular similarities with other diseases, some of them opposing the general tendencies observed at the disease level. Analyzing the generated patient-subgroup network, we identify genes involved in such relations, together with drugs whose effects are potentially associated with the observed comorbidities. All the obtained associations are available at the disease PERCEPTION portal (http://disease-perception.bsc.es).

Disease comorbidity is attracting increasing attention, but the involvement of molecular factors in forecasting risk of a disease in the presence of other diseases is poorly understood. Here the authors build a disease interaction network based on gene expression profile and discover new comorbidity relationships in patient subgroups.

Sequential drug treatment algorithm for agitation and aggression in Alzheimer's and mixed dementia

INTRODUCTION

Behavioural and psychological symptoms of dementia (BPSD) include agitation and aggression in people with dementia. BPSD is common on inpatient psychogeriatric units and may prevent individuals from living at home or in residential/nursing home settings. Several drugs and non-pharmacological treatments have been shown to be effective in reducing behavioural and psychological symptoms of dementia. Algorithmic treatment may address the challenge of synthesizing this evidence-based knowledge.

METHODS

A multidisciplinary team created evidence-based algorithms for the treatment of behavioural and psychological symptoms of dementia. We present drug treatment algorithms for agitation and aggression associated with Alzheimer's and mixed Alzheimer's/vascular dementia. Drugs were appraised by psychiatrists based on strength of evidence of efficacy, time to onset of clinical effect, tolerability, ease of use, and efficacy for indications other than behavioural and psychological symptoms of dementia.

RESULTS

After baseline assessment and discontinuation of potentially exacerbating medications, sequential trials are recommended with risperidone, aripiprazole or quetiapine, carbamazepine, citalopram, gabapentin, and prazosin. Titration schedules are proposed, with adjustments for frailty. Additional guidance is given on use of electroconvulsive therapy, optimization of existing cholinesterase inhibitors/memantine, and use of pro re nata medications.

CONCLUSION

This algorithm-based approach for drug treatment of agitation/aggression in Alzheimer's/mixed dementia has been implemented in several Canadian Hospital Inpatient Units. Impact should be assessed in future research.