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5 minute soap box

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5 minute soap box Old Age Psychiatry Who gets anti-dementia drugs? Diagnosis must be AD MMSE 10-20 Or Moderate severity on clinical grounds Likely to comply 6 monthly ... – PowerPoint PPT presentation

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Title: 5 minute soap box


1
5 minute soap box
  • Old Age Psychiatry

2
Who gets anti-dementia drugs?
  • Diagnosis must be AD
  • MMSE 10-20
  • Or Moderate severity on clinical grounds
  • Likely to comply
  • 6 monthly review of MMSE, function, behaviour,
    carer views - ? Overall worthwhile effect
  • MMSE remains above 10

3
Who doesnt get anti-dementia drugs?
  • People suffering from other dementias
  • Mild AD
  • Severe AD
  • No memantine

4
What does Cochrane say?
  • BENEFIT
  • Mild to moderate AD
  • Parkinsons Disease
  • VaD
  • Memantine for moderate to severe AD
  • NONE PROVEN
  • Mild Cognitive Impairment
  • FTD
  • LBD

5
Treatment of Behavioural Disturbance in Dementia
6
Risperidone and Olanzapine
  • Risk of CVA from 1 to 3 in 12 weeks
  • Risk in old old and if CVA risk factors
  • No evidence that other atypicals and typicals
    safer

7
Treatment of BPSD
  • Pharmacological
  • Behavioural
  • Environmental
  • Evidence base for all is poor

8
Non-drug strategies
  • Day- time activity
  • Reminders
  • Reassurance
  • Regular orientation
  • Distraction
  • Respite longer or shorter periods
  • Help with care tasks
  • Is 24-hour care necessary? and if so is it the
    right kind of place?

9
NonPharmacological Therapies
  • Behavioural analysis and therapy
  • Aromatherapy
  • Bright light therapy
  • Homeopathy
  • Pets
  • Music therapy
  • Staff training

10
Some causes of agitation
  • Depression
  • Anxiety
  • Psychotic symptoms
  • Physical ill health

11
Drug Groups used in BPSD
  • Neuroleptics
  • Benzodiazepines
  • Anti-convulsants
  • Anti-depressants
  • AcetylCholine-Esterase Inhibitors

12
Where BPSD is treatable in people without
dementia treat this
  • Eg
  • Psychosis (risperidone, others, not olanzapine)
  • Depression
  • Hypomania
  • Anxiety
  • Insomnia

13
Reasons to use neuroleptics
  • Continuing BPSD despite alternatives
  • Severe symptoms
  • Clear risk to self or others (document)

14
The three Ts
  • Target symptom (and record it)
  • Start low and titrate slowly
  • Time limited

15
Withdrawal of neuroleptics
  • In double-blind r.c.t. no significant difference
    in behavioural symptoms between those continuing
    neuroleptic and switching to placebo
  • A small number of people withdrawn show worsening

16
The other NICE document of 2006Dementia CG 42
  • Use antipsychotics (neuroleptics) only for severe
    BPSD in AD and DLB
  • Discuss risks
  • Document target symptoms
  • Monitor - ? 3 monthly

17
The other NICE document of 2006Dementia CG 42
  • Donepezil, rivastigmine or galantamine may be
    used for BPSD in LBD
  • And in AD if causing significant harm or distress
    and if antipsychotics are ineffective or
    inappropriate

18
Summary
  • 1) Is the behaviour intolerable?
  • 2) Would it be tolerable in a different setting?
  • 3) Are there non-drug options?
  • 4) Aim to target drug to clinical features, e.g.
    depression, psychotic symptoms.
  • 5) Low dose
  • 6) Slow increases
  • 7) Review and consider withdrawing when stable
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