Use of Antipsychotics in Behavioural and Psychological Symptoms of Dementia (BPSD)

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This tool is designed to help providers understand, assess, and manage patients/residents in primary care and LTC homes with behavioural and psychological symptoms of dementia (responsive behaviours), with a focus on antipsychotic medications. It was developed as part of Centre for Effective Practice’s Academic Detailing Service for LTC homes. This tool integrates best-practice evidence with clinical experience, and makes reference to relevant existing tools and services wherever possible.

Important principles include:

  • Being patient/resident-centred,
  • Being mindful of benefits, risks and safety concerns,
  • Using an interprofessional team approach and validated tools,
  • Prescribing conservatively, and,
  • Reassessing regularly for opportunities to deprescribe medications that are no longer needed.

As always, efforts must be made to individualize any treatment decisions for the resident, with consideration given to caregivers, family members, as well as LTC staff.

Identify BPSD Symptom Clusters1, 2

Pyschosis
  • Delusions
  • Hallucinations
  • Misidentification
  • Suspicious

Agression
  • Defensive
  • Resistance to care
  • Verbal
  • Physical

Agitation
  • Dressing/undressing
  • Pacing
  • Repetitive actions
  • Restless/anxious

Depression
  • Anxious
  • Guilty
  • Hopeless
  • Irritable/screaming
  • Sad, tearful
  • Suicidal

Mania
  • Euphoria
  • Irritable
  • Pressured speech

Apathy
  • Amotivation
  • Lacking interest
  • Withdrawn

Treatment for dementia is an ongoing process. Since dementia is a progressive disease, regular follow-ups are necessary to ensure that the patient/resident is receiving the best possible treatment for his or her symptoms. The sections in this tool should each be considered at each follow-up (even if some treatments discussed, such as drug therapy, will not be necessary for every patient/resident at every stage of treatment).

Evaluate BPSD

Before beginning any sort of treatment (e.g. drug or non-drug therapy), it is important to evaluate the patient’s/resident’s symptoms.
This section discusses:

  • Tools for discussing and documenting BPSD
  • How to use the P.I.E.C.E.S.TM tools to assess risks to the patient/resident and others
  • Clinical evaluations that should take place in order to identify any underlying physiological causes of BPSD

Remember: Engage the family/caregiver at every step. Discuss any history that may help the care team understand and manage the behaviour (e.g., preferences, activities, routine).

Assess & Document

  • Document behaviour or symptom clusters, including frequency, severity, triggers, and consequences
  • Document any potential reversible causes (e.g. delirium, depression)
  • Designate specific members of the interprofessional care team who will be responsible for coordinating day-to-day assessment and management
  • Standardized clinical assessment tools, such as the Antecedent, Behaviour, Consequence (ABC) Chart Form3 and Dementia Observation System (DOS)4 can be helpful for monitoring and documenting symptoms
  • Examples of standardized clinical assessment tools can be found in Supporting materials

Identify Risks

  • Use the P.I.E.C.E.S.TM RISKS mnemonic to assess risks to the patient/resident and others:9
    • Roaming: Is risk greater due to patient/resident roaming?
    • Imminent: Is significant risk imminent?
    • Suicide: Does the patient/resident display any suicidal tendencies?
    • Kin: Is the health or safety of patients/residents/caregivers affected?
    • Self-neglect: Is patient/resident’s self-neglect a risk to themself or others?
  • Interview family/caregiver independently to ask about family/caregiver strain and risk of abuse by patient
  • Be mindful of any suggestions of patient abuse by family/caregivers

Identify BPSD Causes

  • Obtain history from caregivers, family, and staff10
  • Consider environmental factors and triggers, including possible role of team members
  • Consider using P.I.E.C.E.S.TM to identify causes (see box on right)
Use P.I.E.C.E.S.TM to identify risks and causes 9
Click to view P.I.E.C.E.S.TM

Clinical Evaluation10

The differential diagnosis of the syndrome of behaviour change in dementia is broad. Careful examination of history, physical examination and appropriate investigations may help identify contributing factors. A full, rather than targeted, physical examination is indicated, within the bounds of patient cooperation.

History (include family/caregivers):
  • Recent changes to environment, routine, sleep pattern, family/social situation
  • Medication Review:
    • Adherence,prescription and OTC medications, anticholinergic load, drugsthat may increase agitation (e.g. cholinesterase inhibitors), medication induced hypotension or orthostatic hypotension, medication that may contribute to constipation and urinary retention, drugs and/or alcohol
Physical Examination:

Be mindful of sources of:

  • Pain (e.g. dental, skin, joint, feet)
  • Hydration (e.g. dehydration)
  • Sensory loss (hearing, vision)
  • CNS change (e.g. new stroke)
  • Infection (e.g. pneumonia, urosepsis)
  • Hypo-perfusion (e.g. new atrial fibrillation, heart failure)
  • Constipation and urinary retention

 

Laboratory and Imaging (as guided by physical exam/history):
  • Blood: Glucose, calcium, complete blood count (CBC), creatinine, electrolytes,TSH, others as appropriate
  • Urine: Any urinary symptoms? (Note: Caution not to send urine for culture if no urinary symptoms or sudden change in status as “asymptomatic bacteriuria” without lower urinary tract symptoms or symptoms

of urosepsis/bacteremia are rarely the cause of increased
behavioural symptoms)

  • Imaging: If appropriate (e.g. chest x-ray if suspected
    pneumonia based on physical exam; CT head if new
    concerning neurologic findings

Initiate Non-Drug Therapy for BPSD

Non-drug therapy is an important part of managing BPSD, regardless of whether drug therapy is initiated. It is an ongoing process that involves the care team, family, and caregivers.
This section discusses:

  • Safety, environmental, and caregiver approach considerations that are core components of non-drug therapy
  • Possible solutions to behavioural symptoms, including those identified within the Dementia Observation System (DOS)
Tips for successful non-drug therapy
  • As a general principle, individualize your approach as much as possible. Behavioural triggers and effective ways to treat them will vary from one patient/resident to the next.
  • Take advantage of any available system supports, such as Behavioural Supports Ontario (BSO) and Psychogeriatric Resource Consultants (PRCs).14
  • Even if non-drug therapy is successful at managing symptoms (i.e. drug therapy is unnecessary), monitor targeted behaviours for changes and follow-up regularly based on the needs of the patient/resident/caregiver and severity of symptoms.
Safety
  • Ensure the patient’s/resident’s safety and other patients’/residents’ safety by securing the environment
  • Make sure you are safe (exit near, chair between you and patient/resident)
  • Remove potentially dangerous objects
  • Move other individuals away
  • Remove ongoing triggers
Environmental Considerations
  • Eliminate misleading stimuli
    • Clutter, TV, radio, noise, people, reflections in mirrors/dark windows, pictures/décor
  • Reduce environmental stress
    • Caffeine, extra people, holiday decorations, public TV
  • Adjust stimulation
    • If over-stimulated, reduce noise, activity, confusion
    • If under-stimulated, increase activity/involvement
  • Enhance function
    • Increase lighting, to reduce misinterpretation
    • Add signs, cues, or pictures to promote way-finding
  • Adapt the physical setting according to individual preference
    • Secure outdoor areas
    • Home-like features
    • Smaller, segmented recreational and dining areas
    • Spa-like bathing facilities
Caregiver Approach Considerations
  • Personal approach
    • Be calm and compassionate (use/avoid touch as indicated)
    • Distract by engaging in individualized activities
    • Focus on patient/resident’s wishes, interests, concerns
    • Approach slowly; look for signs of increase agitation
    • Approach patient/resident’s private space slowly and ask permission prior to entering
  • Daily routines
    • Keep to the same routine to reduce uncertainty
    • Use long-standing history and preferences to guide
    • Individualize social and leisure activities to reduce boredom
  • Communication style
    • Most communication is non-verbal, use positive non-verbal cues
    • Make eye contact unless perceived as aggressive
    • Use short simple words and phrases (patients/residents with dementia have trouble processing multiple words)
    • Speak clearly and use a positive tone
    • Wait for answers (be patient)

Consider Drug Trial(s) New

Ensure Drug Trial is Necessary

  • Treat underlying causes (e.g. pain, constipation, delirium)
  • Ensure that non-drug therapy options have been attempted, and have been unsuccessful

Note: In acute BPSD, if there is a safety risk to patient or others, there may not be time to try non-drug approaches before trying pharmacological management.

Click to view appropriate drug therapy for the patient’s/resident’s symptom(s)

  • SSRIs such as citalopram or trazodone (however, evidence is lacking for trazodone)15, 16, 44
  • Possible cholinesterase inhibitors
  • Very low dose quetiapine15, 16
  • A short-acting benzodiazepine such as lorazepam prior to anxiety provoking events such as bathing17
  • Antidepressants (such as SSRIs, SNRIs)
  • Buspirone10
  • Antidepressants such as SSRIs (e.g., citalopram, sertaline), SNRIs (e.g., venlafaxine, duloxetine), other antidepressants (bupropion, mirtazapine, moclobemide)
  • Secondary TCAs (nortriptyline or desipramine) may be suitable if coexisting indication like neuropathic pain, etc., but caution regarding anticholinergic load, etc.10, 16, 18
  • Addressing any possible drug causes is of primary importance
  • Evidence for specific recommendations lacking
  • Mood stabilizers are an option, but take caution regarding tolerability and drug interactions
  • Limited role for drug therapy but sometimes cholinesterase inhibitors may be helpful
  • Methylphenidate also sometimes used, but limited by concerns such as stimulant effect on behaviour and risk of diversion15, 18
Symptom clusters likelihood to respond to antipsychotic therapy

Click to view symptoms likey to respond to Antipsychotic therapy

Likely

  • Delusions
  • Hallucinations
  • Misidentification
  • Suspicious

Likely

  • Defensive
  • Physical

Unlikely

  • Verbal
  • Resistance to care

Likely

  • Restless/anxious

Unlikely

  • Dressing/undressing
  • Pacing
  • Exit seeking17
  • Repetitive actions45-47

See Additional information on antipsychotic therapy

The role of antipsychotics in those with dementia and depression is beyond the scope of this evidence review.
In cases where depression treatment may be indicated, consider psychiatric consultation to determine appropriate pharmacotherapy options.

Likely

Unlikely

  • Euphoria46-48
  • Irritable46-48
  • Pressured speech

Unlikely

  • Amotivation
  • Lack of interest>
  • Withdrawn

Unlikely

  • Hiding or hoarding45
  • Wandering without aggression17,45
  • Disinhibition (e.g., sexual)45-47

Maintain and Review

  • Monitor change in targeted behaviour as well as side effects (see DOS Tool)4
  • Assess over 1-3 weeks, documenting any benefits and harms realized. If lack of response and/or tolerability, adjust therapy. Increase dose (if not yet maximized) or taper/discontinue15
  • Continue to reassess on an ongoing basis for effectiveness and tolerability
  • Consider dose reduction or discontinuation if the drug:
    1. Is not effective,
    2. Has intolerable side effects, or;
    3. Behaviours have been manageable and stable for 3-6+ months17
  • If considering dose reduction/discontinuation for an antipsychotic, see Reassessing Antipsychotics for Possible Deprescribing

Follow-up

  • Follow-up is important for any drug regimen
  • If antipsychotics used, reassess need at least every 3 months 16

Consider Referral to a Specialist if Drug Trial is Unsuccessful

  • If symptoms persist or worsen, consider referral to a specialist

Continue Non-Drug Approaches

  • Continue using non-drug approaches to prevent further BPSD symptoms
Tips for Drug Trials and Deprescribing
  • In all drug trials, unless clinically indicated, start at a low dose and increase or decrease slowly.
  • For more tools and resources, visit effectivepractice.org/dementia.
  • For more information about antipsychotic deprescribing, including a deprescribing algorithm, visit deprescribing.org.

Additional Information on Antipsychotic Therapy New

Potential Benefits and Harms of Antipsychotic Therapy

Potential benefits tend to be over-appreciated, while harms are underappreciated. Nevertheless, when harmful behaviours are severe and distressing, an antipsychotic trial may be reasonable.

Potential Benefits

Limited benefit: modest improvement seldom observed

  • effect size: 0.12-0.2
  • NNT variable: ~5-14

(ie. at best, compared to placebo, antipsychotic therapy results in targeted behaviour benefit in 1 out of 5 people treated)20, 21


Potential Harms

Side effects: sedation, falls, postural hypotension, QT prolongation, confusion, EPS (rigidity, stiffness, akinesia), tardive dyskinesia, diabetes, weight gain22, 23
Stroke: increased risk
Death: possible increase

Health Canada Advisory noted a 1.6 fold increase in mortality (mostly related to heart failure, sudden death, pneumonia). Some data suggests that there will be 1 extra stroke or death for every ~100 people treated (NNH=100).24, 25, 26

EPS: extrapyramidal symptoms (Parkinson’s-like); NNT: number needed to treat to see one extra benefit; NNH: number needed to treat to see one extra harm

Comparison of Antipsychotics 20, 21, 30, 31, 32, 33, 34

Many effects are dose dependent and direct comparisons are limited. Thus, the following table is intended only as a general guide.

Scroll (left-right) for details
  • Atypicals
    Risperidone* (Risperdal)25, 26, 34

    Efficacy or evidence in BPSD therapy

    • Indicated for severe dementia of the Alzheimer type (Health Canada)
    • Evidence for efficacy in agitation, aggression & psychosis

    BP32

    • Moderate (>10%)

    Ach

    • Moderate (>10%)

    Sedation

    • Moderate (>10%)

    EPS

    • Moderate (>10%)

    TD33

    • Infrequent (>2%)

    Diabetes

    • Moderate (>10%)

    Weight Gain27

    • Increase (0.7lb/month)

    Usual Dose

    • 0.125mg – 2.0mg/d QHS (or divided BID)

    $/Month

    • $10-27
  • Atypicals
    Olanzapine* (Zyprexa)25, 26, 34

    Efficacy or evidence in BPSD therapy

    • Off-label use in BPSD
    • Evidence for efficacy in agitation & aggression

    BP32

    • Infrequent (>2%)

    Ach

    • Frequent (>30%)

    Sedation

    • Frequent (>30%)

    EPS

    • Moderate (>10%)

    TD33

    • Infrequent (>2%)

    Diabetes

    • Frequent (>30%)

    Weight Gain27

    • Increase (1.0lb/month)

    Usual Dose

    • 1.25mg – 7.5mg/d

    $/Month

    • $17-38
  • Atypicals
    Aripiprazole* (Abilify)34

    Efficacy or evidence in BPSD therapy

    • Off-label use in agitation or aggression18
    • Evidence for efficacy in agitation & aggression
    • Not eligible for dementia or BPSD in the elderly (ODB criteria, Therapeutic Note)
    • Not for psychosis (same as placebo)

    BP32

    • Infrequent (>2%)

    Ach

    • Infrequent (>2%)

    Sedation

    • Moderate (>10%)

    EPS

    • Infrequent (>2%)

    TD33

    • Infrequent (>2%)

    Diabetes

    • Negligible or absent

    Weight Gain27

    • Increase

    Usual Dose

    • 2.0mg – 12.5mg QHS

    $/Month

    • $112-260
  • Atypicals
    Quetiapine (Seroquel)25, 26, 34

    Efficacy or evidence in BPSD therapy

    • Off-label use in BPSD
    • Lacks evidence for efficacy in BPSD agitation, aggression & psychosis
    • Consider in Lewy Body dementia, Parkinson’s (low EPS)
    • Note: although used, not indicated, and lacking evidence for insomnia

    BP32

    • Moderate (>10%)

    Ach

    • Frequent (>30%)

    Sedation

    • Frequent (>30%)

    EPS

    • Infrequent (>2%)

    TD33

    • Infrequent (>2%)

    Diabetes

    • Frequent (>30%)

    Weight Gain27

    • Increase (0.4lb/month)

    Usual Dose

    • 12.5mg – 200mg/d (divided QHS-TID)

    $/Month

    • $10-59
  • Typicals
    Haloperidol (Haldol)

    Efficacy or evidence in BPSD therapy

    • Useful short term in acute BPSD or delirium

    BP32

    • Infrequent (>2%)

    Ach

    • Infrequent (>2%)

    Sedation

    • Infrequent (>2%)

    EPS

    • Frequent (>30%)

    TD33

    • Frequent (>30%)

    Diabetes

    • Moderate (>10%)

    Weight Gain27

    • Increase (0.4lb/month)

    Usual Dose

    • 0.25mg – 2.0mg/d

    $/Month

    • $14-25
  • Typicals
    Loxapine (Loxapac, Xylac)2

    Efficacy or evidence in BPSD therapy

    • Consider if other agents have failed and severe, persistent, dangerous behaviour continues
    • Severe, acute BPSD
    • Not to be used long-term due to adverse effects

    BP32

    • Moderate (>10%)

    Ach

    • Moderate (>10%)

    Sedation

    • Frequent (>30%)

    EPS

    • Frequent (>30%)

    TD33

    • Frequent (>30%)

    Diabetes

    • Infrequent (>2%)

    Weight Gain27

    • Negligible or absent

    Usual Dose

    • 5.0mg – 10mg BID

    $/Month

    • $18-27

*Aripriprazole, olanzapine and risperidone were superior to placebo as treatment of behavioural symptoms as measured by total scores on BEHAVE-AD36, Brief Psychiatric Rating Scale (BPRS)37, and Neuropsychiatric Inventory (NPI)20

Terminology

Ach: anticholinergic
BID: twice daily
BP: blood pressure
ODB: Ontario Drug Benefit

EPS: extrapyramidal
symptoms
lb: pound

TD: tardive dyskinesia
TID: three times daily
QHS: bedtime

Tips for Reassessing Antipsychotics for Possible Deprescribing
  • Stopping or tapering antipsychotics may decrease “all cause mortality”27
  • Deprescribing may not be indicated where symptoms are due to psychosis, or where behaviour is especially dangerous or disruptive
  • Evaluate reason for use and any recent changes in targeted behaviour
  • Ensure suitable non-pharmacological measures for BPSD are optimized
  • Due to the nature of responsive behaviours and the usual course of dementia, antipsychotics can often be successfully tapered and/or discontinued.28 As some may worsen, approach cautiously, and monitor behaviour29
  • Taper gradually, often by 25-50% every 2-4+ weeks and look for any resulting behaviour changes. Once on lowest dose, may discontinue in 2-4+ weeks
  • Continue to reassess for emergence of responsive behaviours

Resources New

These supporting materials are an inventory for long-term care providers to help identify useful clinical aids and resident/family material. This list includes direct links (where available) to tools or materials that have been directly referenced in the detailing guide and/or have been reviewed by CEP and identified as important material in supporting the uptake/adoption of the detailing guide. It includes a brief description of the tool, with full references available. The following is a comprehensive but not exhaustive list based on an environmental scan, appraisal by Clinical Leads, and focus groups with long-term care providers. CEP has also compiled a list of additional resources beyond those listed below available at effectivepractice.org/dementia

Assessment and Practice Tools
  • Antecedent, Behaviour, Consequence (ABC) Chart Form3: Chart form to help providers determine and document the events/stimuli that impact behaviour.
  • BEHAVE-AD36: Clinical rating scale to measure behavioural and psychological symptoms of dementia based upon information obtained from caregivers/informants.
  • Brief Psychiatric Rating Scale37: Rating scale of 24 symptom constructs used to assess the positive, negative, and affective symptoms of individuals.
  • Cohen-Mansfield Agitation Inventory (CMAI)5: Inventory questionnaire of grouped agitated behaviours to assess the frequency and severity of these behaviours in elderly persons.
  • Confusion Assessment Method (CAM)7: Diagnostic algorithm/questionnaire for identification of delirium through formal cognitive testing.
  • Cornell Scale for Depression in Dementia38: Scale for assessing signs and symptoms of major depression in people with cognitive impairment.
  • Kingston Standardized Behavioural Assessment (KSBA)6: Behaviour analysis tool designed to indicate the number of behavioural symptoms associated with dementia affecting an individual patient.
  • Neuropsychiatric Inventory – Nursing Home Version (NPI – NH)40: Tool to characterize the neuropsychiatric symptoms and psychopathology of patients with Alzheimer’s disease and other dementias to measure the impact of antidementia and psychotropic drugs.
  • Pain Assessment in Advanced Dementia Scale (PAINAD)8: Pain assessment tool for individuals with advanced dementia including behaviour observation scores.
  • Dementia Observation System (DOS)4: Behaviour assessment tool which captures the frequency and duration of behaviours of concern over 24 hour periods.
  • General Practitioner Assessment of Cognition (GP-COG)50: Screening tools for cognitive impairment for patients and families/caregivers
  • Geriatric Depression Scale – 15 Item51: Self-administered assessment for depression in the elderly
  • Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)52: Short questionnaire for families/friends to determine cognitive decline
  • Instrumental Activities of Daily Living Scale53: Scale to determine functional abilities for tasks, completed by patients and families/caregivers
  • Montreal Cognitive Assessment (MoCA)54: Tool to identify objective evidence of cognitive decline
  • PIECESTM Framework9: Interdisciplinary approach to understanding and enhancing care for individuals with complex physical/cognitive/mental health need and behaviour changes.
  • Psychotropic Medication Consent Discussion Tool19: Aid for initiating antipsychotic medications and key discussion items for informed consent from patients or substitute decision makers.
  • Patient Health Questionnaire (PHQ-9)55: Self-administered multipurpose instrument for depression diagnosis and monitoring
Reference and Support Information
  • Atypical Antipsychotic Drugs and Dementia – Advisories, Warnings and Recalls for Health Professionals24: Advisory concerning atypical antipsychotic treatment of behavioural disorders in elderly patients, which is associated with an increased risk for all-cause mortality. June 2005
  • Behavioural Supports Ontario (BSO)14: Integrated network designed to provide services and supports to individuals with behaviours associated with complex mental health, dementia, and other neurological conditions living in long-term care.
  • Dementia Toolkit for Primary Care56: Primary care toolkit with resources for delirium, caregiver support, high risk situations, and other materials.
  • First Link Program57: Referral program to support newly diagnosed patients with dementia connecting to resources and other people living with Alzheimer’s and other dementias.
  • Meaning and Solutions for Behaviours in Dementia Inventory39: Dementia-related behaviors, including possible causess and solutions for management as a starting point for discussion with caregiver(s).
  • PIECESTM Framework9: Interdisciplinary approach to understanding and enhancing care for individuals with complex physical/cognitive/mental health need and behaviour changes.
  • Psychotropic Medication COnsent Discussion Tool19: Aid for initiating antipsychotic medications and key discussion items for informed consent from patients or substitute decision makers.
  • Reference List of Drugs with Anticholinergic Effects41: Reference list of drugs with low, moderate, and high anticholinergic effects, including side effects and preferred alternatives.
  • Risperidone – Restriction of the Dementia Indication42: Alert for the restriction of risperidone and related antipsychotic use to patients with severe dementia of the Alzheimer type unresponsive to nonpharmacological approaches and when there is a risk of harm to self or others. February, 2015
    Note: Although recent alert is specific for risperidone, other antipsychotics have similar concerns; however, unlike risperidone, others lack an official indication in BPSD.
  • Treating Disruptive Behaviour in People with Dementia (Patient Material)43: Statements on how to treat disruptive behaviours without antipsychotic drug use.

 

References New

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