Neuroleptic treatment of agitation and psychosis in dementia

The effects of commonly prescribed drugs in patients with Alzheimer's disease on the rate of deterioration

BACKGROUND

Prescribed drugs in patients with Alzheimer's disease may affect the symptomatic progression of their disease, both positively and negatively.

AIM

To examine the effects of drugs on the progression of disease in a representative group of patients with Alzheimer's disease.

METHODS

Patients with the diagnosis of probable Alzheimer's disease were recruited from the community. The prescribed drugs taken by 224 patients (mean age 82.3 years) were recorded at initial assessment and then correlated in logistic regression analysis with progression of the disease, defined as an increase of one point or more in the Global Deterioration Scale over the next 12-month period.

RESULTS

Patients who were taking antipsychotic drugs and sedatives had a significantly higher risk of deterioration than those who were taking none (odds ratios (ORs) 2.74 (95% confidence interval (CI) 1.17 to 6.41) and 2.77 (95% CI 1.14 to 6.73), respectively). Higher risk of deterioration was observed in those who were taking both antipsychotic and sedative drugs together (OR 3.86 (95% CI 1.28 to 11.7). Patients taking drugs licensed for dementia, drugs affecting the renin-angiotensin system and statins had a significantly lower risk of deterioration than those who were not taking any of these drugs (ORs 0.49 (95% CI 0.25 to 0.97), 0.31 (95% CI 0.11 to 0.85) and 0.12 (95% CI 0.03 to 0.52), respectively).

CONCLUSION

Our findings have implications for both clinicians and trialists. Most importantly, clinicians should carefully weigh any potential benefits of antipsychotics and benzodiazepines, especially in combination, against the risk of increased decline. Researchers need to be aware of the potential of not only licensed drugs for dementia but also drugs affecting the renin-angiotensin system and statins in reducing progression in clinical trials.

Impact of second-generation antipsychotics on the use of antiparkinson agents in nursing homes and assisted-living facilities

BACKGROUND

It is not known whether the reduced risk of motor adverse effects with second-generation antipsychotics (SGAPs) translates into less use of antiparkinson drugs (APDs).

OBJECTIVE

This study sought to estimate national rates of concomitant prescribing of APDs and antipsychotic drugs among elderly Medicare beneficiaries without Parkinson's disease (PD) who were residing in institutional settings from 1997 to 2000, a period during which the use of SGAPs increased greatly.

METHODS

This was a retrospective, cross-sectional, descriptive analysis using the Medicare Current Beneficiary Survey database. The population of interest was residents of nursing homes (NHs) and assisted-living facilities (ALFs) who received concomitant antipsychotic drugs and APDs but did not have PD. The primary objective of the study was to estimate the prevalence of concomitant APD and antipsychotic drug use for each study year, by use of first-generation antipsychotics (FGAPs) and SGAPs in each setting. A secondary objective was to compare concomitant use of APDs and individual antipsychotic agents (ie, clozapine, risperidone, olanzapine, quetiapine, ziprasidone, haloperidol, and thioridazine). We computed population-level annual prevalence rates for APD use and tested for statistically significant differences in APD use between FGAPs and SGAPs at the 5% significance level.

RESULTS

In NH residents, concomitant use of APDs and antipsychotics decreased from 20.7% in 1997 to 9.0% in 2000 (P < 0.005). APD use in NH residents declined similarly among users of FGAPs (from 23.2% in 1997 to 13.3% in 2000; P < 0.005) and SGAPs (from 18.4% in 1997 to 8.1% in 2000; P < 0.005). In ALF residents, concomitant use of APDs and antipsychotics decreased from 24.5% in 1997 to 21.1% in 2000 (P < 0.005). ADP use in ALF residents receiving FGAPs decreased from 26.9% in 1997 to 24.2% in 2000 (P < 0.005); there was no significant change in ADP use among ALF residents receiving SGAPs (from 21.0% in 1997 to 21.7% in 2000).

CONCLUSIONS

These results provide the first nationally representative estimate of the concomitant use of APDs and antipsychotic drugs among older individuals in long-term care settings. The decrease in concomitant use of APDs and antipsychotics when SGAPs were used in NHs suggests an association between the use of SGAPs and a reduction in the prescribing cascade, in which one drug is used to treat the adverse effects of another. The results also suggest that some Medicare beneficiaries in ALFs may be continued on APDs despite changes in the prescribing of antipsychotic agents, implying a need for better medication-management practices in these institutions.

Sexually inappropriate behaviour in demented elderly people

AIM

To determine the prevalence, aetiology, and treatment profile of abnormal sexual behaviour in subjects with dementia in psychogeriatric practices.

METHODS

A retrospective cross sectional study was conducted in a long term care psychiatry consultation service, community based geriatric psychiatry service, and an inpatient dementia behavioural unit in Edmonton, Canada.

RESULTS

Forty one subjects (1.8%) had sexually inappropriate behaviour. Of those cognitively impaired subjects with sexually inappropriate behaviour, 20 (48.8%) were living in nursing homes and the rest, 21 (51.2%) in the community. Of these subjects, 53.7% had vascular dementia, 22% had Alzheimer's, and 9.8% had mild cognitive impairment. History of alcohol misuse and psychosis were reported in 14.6% and 9.8% of subjects respectively. Twenty seven (65.7%) had verbally inappropriate behaviour and 36 (87.8%) had physically inappropriate behaviour. In this study, verbally inappropriate behaviour was more commonly seen in the community sample (81%) than in the nursing home sample (50%) (p = 0.04). Behavioural treatment was also more commonly seen in the community sample (81%) than in the nursing home sample (45%) (p = 0.01).

CONCLUSION

In this study sexually inappropriate behaviour was seen in all stages of dementia, more commonly associated with subjects of vascular aetiology, and is as commonly seen in community dwelling subjects with dementia as in nursing home subjects.

Zotepine for behavioural and psychological symptoms in dementia: an open-label study

OBJECTIVE

To provide initial information on the safety and efficacy of the atypical antipsychotic zotepine in the treatment of behavioural and psychological symptoms of dementia (BPSD).

METHODS

This was an open-label, single-centre field study. Twenty-four patients with BPSD associated with Alzheimer's disease (n=12) or other forms of dementia (n=12) were included. During the 8-week observation period, the patients received zotepine (Nipolept) [12.5-150 mg/day] for the psychotic components of BPSD; no other treatment interventions for BPSD were allowed. At baseline, day 28 and day 56, patients were evaluated using the Clinical Global Impressions (CGI) scale; the Mini-Mental State Examination (MMSE), the Syndrome Brief Test (SKT) and the Age Concentration Test (AKT) to assess cognition; and the Neuropsychiatric Inventory (NPI) and the Cohen-Mansfield Agitation Inventory (CMAI) to assess BPSD. General adverse effects and, more specifically, the emergence of extrapyramidal symptoms were also assessed.

RESULTS

There was no change from baseline to day 56 in the CGI score and the caregiver burden (as indicated by the caregiver-related section of the NPI). There was also no change in cognition (as assessed by the MMSE, SKT and AKT). The neuropsychiatric symptom score according to part 1 of the NPI (especially key psychotic symptoms, aggression and disinhibition) and the CMAI scores improved by 36% and 15%, respectively, between baseline and the end of the study in a highly statistically significant fashion. No significant differences in treatment response or adverse effect profile were noted between the 12 patients with Alzheimer's disease and the 12 patients with other types of dementia. Zotepine was well tolerated, with tiredness and sedation (five and four cases, respectively) being the most frequent complaints. No clinically significant emergence of extrapyramidal symptoms was seen.

CONCLUSIONS

Zotepine appears to be well tolerated and effective in treating BPSD, consistent with the performance of other atypical antipsychotic drugs in this condition. Larger, controlled studies are warranted.

Use of drugs by Old Age Psychiatrists in the treatment of psychotic and behavioural symptoms in patients with dementia

The objective was to elicit the prescribing practises of Old Age Psychiatrists in the UK in the treatment of psychotic and behavioural symptoms in patients with dementia. A structured questionnaire was sent to all Old Age Psychiatrists in the United Kingdom. Respondents were questioned regarding their use of both typical and atypical antipsychotics and the most common dosages prescribed. Information was sought about usage of depot medication and dosages; use of alternative or adjunctive medications to antipsychotics and use of parenteral medication for acute management of agitation. The most commonly used antipsychotic to treat psychotic symptoms was haloperidol, and thioridazine to treat behavioural symptoms. A wide range of dosages was used. Use of depot medication was common, with flupenthixol decanoate being the most frequently used. Most respondents use at least one of the atypical antipsychotics, risperidone being most popular. Use of other psychotropic medication used as alternatives to antipsychotics or adjunctives in the treatment of behavioural symptoms was common, the most popular being trazodone. Of the respondents, 62.7% use parenteral medication for the acute management of agitation, the most popular drug being haloperidol. The typical antipsychotics are still the most commonly used despite the reputed better safety profile of the atypicals. There was wide variation in the dosages prescribed. Use of psychotropics other than phenothiazines was common. More research is needed into the use of psychotropic medication for dementia and there is need for consensus in this area. Forming an expert group may be the best way to create uniformity of prescription.

A risk-benefit assessment of risperidone for the treatment of behavioural and psychological symptoms in dementia

The importance of behavioural and psychological symptoms in dementia (BPSD) is increasingly being recognised. Symptoms such as verbal and physical aggression, agitation, sleep disturbances and wandering are common, cause great distress to caregivers and are likely to lead to institutionalisation of patients. At present, these symptoms are also more amenable to treatment compared with the progressive intellectual decline caused by dementing illnesses. The care of individuals with BPSD involves a broad range of psychosocial treatments for the patient and his or her family. If pharmacotherapy is deemed necessary to manage BPSD, a careful balance must be struck between the benefits of symptom control and the inherent risks associated with most psychotropic agents in the elderly. Elderly patients in general, and patients with dementia in particular, are more sensitive to medication adverse effects, including anticholinergic effects, orthostatic hypotension, sedation, parkinsonism, tardive dyskinesia and cognitive impairment than younger patients with dementia or individuals without dementia. To date, treatment of symptoms of aggression and psychosis has relied on the empirical use of antidepressants, anxiolytics, typical antipsychotics (neuroleptics) and other agents. Treatment-limiting adverse effects are frequently reported with all of these agents. However, it is the typical antipsychotics and the atypical antipsychotic clozapine that are associated with the greatest risk of adverse effects in the elderly. The present review highlights the issues that limit the use of older psychotropic agents in the elderly, and presents an assessment of the available evidence concerning the efficacy, safety and tolerability of the atypical antipsychotic risperidone, in the treatment of BPSD in elderly patients with dementia. The extensive clinical development programme for risperidone has shown the drug to be effective and well tolerated in many fragile patients. As a result of its efficacy and safety profile, risperidone can be used for the treatment of behavioural and psychological symptoms in patients with dementia. Risperidone therefore represents a significant addition to the armamentarium for BPSD. While efforts continue in the development of treatment for the cognitive decline associated with dementia, treatment is now available for the noncognitive symptoms. By treating the latter, risperidone has the potential to be of substantial benefit to patients with dementia, their carers and the costs of healthcare.

Novel Antipsychotics in the Treatment of Behavioral Disturbances and Psychoses Associated With Neurodegenerative Disorders

Behavioral disturbances and psychosis are common features of neurodegenerative disorders and may be drug induced, intrinsic to the underlying pathology, or both. These disturbances, including psychotic and mood symptoms, apathy, aggression and other behavioral symptoms, and superimposed delirium, cause a great amount of disability to the patient and stress on the caregiver. Conventional neuroleptics have been shown to be effective in the treatment of these symptoms, but unacceptable side effects may occur. However, the novel antipsychotics, with their lower risk of inducing extrapyramidal symptoms, have shown promise in the treatment of behavioral disturbances and psychosis associated with neurodegenerative disorders.

Palliative care for advanced dementia

Dementia is a common, devastating, and ultimately fatal illness. Although no cure exists for most causes of dementia, palliative interventions for the predictable complications of the illness can effectively reduce the suffering of patients and families. Care of patients with end-stage dementia is clinically and conceptually consistent with hospice and palliative care, and this approach to care for patients with terminal dementia is preferred. Although the 6-month risk for mortality can be predicted (to satisfy current American hospice eligibility requirements), palliative care interventions are appropriate much earlier in the course of deterioration from dementia.

Longitudinal predictors of non-aggressive agitated behaviors in the elderly

Longitudinal predictors of physically and verbally non-aggressive inappropriate behaviors were examined in 200 community-dwelling elderly persons attending senior day care centers. Models based on ratings obtained from staff members and family caregivers were compared. Multiple factors contributed simultaneously to the prediction of non-aggressive behaviors. Similar to previous cross-sectional results, physically non-aggressive behaviors were predicted mainly by good health and cognitive impairment. In addition, depression emerged consistently as a predictor of physically non-aggressive behaviors in all models. Verbally non-aggressive behaviors were predicted by depressed affect and pain, confirming previous suggestions that these behaviors are related to discomfort. The relationship of these behaviors with cognitive functioning was relatively weak. Understanding the etiologies of non-aggressive problem behaviors can aid in developing appropriate care for this population.

Reliability and validity of the Overt Agitation Severity Scale in adult psychiatric inpatients

An instrument, that validly and reliably identifies and measures agitation is required to evaluate environmental modifications, interpersonal strategies, psychopharmacological interventions, directed toward managing these commonly occurring and highly-disabling emotions and behavior. The conceptualization of agitation on a continuum from anxiety to aggression provides a practical framework for guiding clinical practice toward the early identification and intervention of agitation. The results of this study established the reliability and validity of the Overt Agitation Severity Scale (OASS) in measuring agitation severity in young adult psychiatric inpatients based on objectifiable vocalizations and motoric upper and lower body behaviors. The OASS differs from other agitation scales in its ability to capture both the intensity and frequency of observable behavioral manifestations of agitation, as opposed to subjective interpretations and a diffuse range of symptoms and problem behaviors.