Standardizing Care For Neuropsychiatric Symptoms In Dementia TAREK K. RAJJI, M.D. C A N A D A R E S E A R C H C H A I R • I N N E U R O S T I M U L AT I O N F O R C O G N I T I V E D I S O R D E R S P R O F E S S O R O F P S Y C H I AT R Y, U N I V E R S I T Y O F T O R O N T O C H I E F O F A D U L T N E U R O D E V E L O P M E N T A N D G E R I AT R I C P S Y C H I AT R Y D E P U T Y P H Y S I C I A N - I N - C H I E F F O R R E S E A R C H C E N T R E F O R A D D I C T I O N A N D M E N T A L H E A L T H American University of Beirut, July 1, 2019 1
Disclosure Statement • The presenter has no financial interest/arrangement or affiliation with any organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. • Off-label medication use will be discussed. 2
Objectives 1. Describe the evidence and rationale for an integrated care pathway (ICP) for management of neuropsychiatric symptoms of dementia. 2. Discuss the key components of the ICP and its implementation. 3. Describe the design of a new randomized controlled trial to compare the ICP with usual care (the StaN study). 3
http://www.alz.co.uk/sites/default/files/pdfs/world-alzheimer-report-2015-executive-summary-english.pdf
Auguste Deter “One of the first disease symptoms of a 51-year-old woman was a strong feeling of jealousy towards her husband. Very soon she showed rapidly increasing memory impairments; … thought that people were out to kill her, then she would start to scream loudly .” Dr. A. Alzheimer, 1906. 5
Auguste Deter “From time to time she was completely delirious, dragging her blankets and sheets to and fro, calling for her husband and daughter, and seeming to have auditory hallucinations. Often she would scream for hours and hours in a horrible voice .” Dr. A. Alzheimer, 1906 6
Behavioral and Psychological Symptoms of Dementia “MOTOR HYPERACTIVITY” “AGGRESSION” Increased walking Aggressive resistance Walking aimlessly Physical aggression Moving objects Verbal aggression Trailing “APATHY” “DEPRESSION” “PSYCHOSIS” Withdrawn Sad Hallucinations Lack of interest Tearful Delusions Amotivation Hopeless Misidentifications Low self-esteem Anxiety Guilt McShane, 2000 7
Behavioral and Psychological Symptoms of Dementia • 90% of patients during the course of their illness (Tariot, 1999) • 60-90% of patients with dementia suffer from BPSD (Lyketsos et al., 2002) • Agitation & Aggression (75%) • Wandering (60%) • Depression (50%) • Psychosis (30%) • Screaming and violence (20%) (Jeste DV, Finkel SI, 2000) 8
Behavioral and Psychological Symptoms of Dementia • Agitation/aggression peak during moderate/moderately-severe stages (Reisberg et al., 1987) • Apathy may continue to increase (Mega et al., 1996) • Affective symptoms are more common early in the illness (Rubin et al., 1988) 9
10 Cummings, 2003
Management Guidelines • Position Statement of the American Association for Geriatric Psychiatry Regarding Principles of Care for Patients With Dementia Resulting From Alzheimer Disease, Lyketsos et al., American Journal of Geriatric Psychiatry, (2006). 14: 561-72 • Guidelines: Managing Behaviour Problems in Patients with Dementia ( 2015) NHS Foundation Trust • Guideline watch: Practice guideline for the treatment of patients with Alzheimer’s disease and other dementias. Rabins et al. (2014) • CCCDT4 Guidelines (Dec 2012) 11
Dementia prevention, intervention, and care. Gill Livingston et. al. The Lancet July 2017 12
Vasudev et al. 2015 13
Health Quality Ontario, 2015 14
Algorithmic Treatment • Faster symptom control • Decreased length of stay • Lower rates of polypharmacy • Higher patient and care giver satisfaction • Reduced health care costs Katon et al. 1995, Trivedi et al. 2004, Adli. M et al. 2006, Mulsant et. al. 2001, 2014 15
Treatment Algorithms: Evidence Study year N Intervention TAU Results IMPACT 2002 Int-906 -Depression Algorithm -Primary care Significant: (late-life depression) Cont-895 -Case manager supervision practitioner -available -Decline in depressive sxs, of primary care mental health - Decreased symptom severity services -increased care satisfaction PROSPECT 2004 Int-320 -Depression algorithm -primary care with Significant reduction in: (late life depression) Cont-276 -Case manager supervision education -remission time, of primary care -sx severity, -suicidal ideation TMAP (Texas 2004 Int-175 -Depression algorithm - Outpatient care Significant : improvement in Medication Cont-175 -psychoeducation without algorithm use symptom severity and function at 1 Algorithm Project) -biweekly expert year (depression) consultation GAP 2009 Int-74 -inpatient care with -inpatient mental Significant: (German Algorithm Cont-74 adherence to medication health care decreased time to remission, Project ) algorithm fewer medication changes in (depression) remitters. 16
Integrated Care Pathway for Agitation in Dementia • Standardized medical work-up • Non-pharmacological interventions, including a clean-up phase • Algorithmic approach for medications • Measurement based decisions 17
Assessments Additional Mid-point Follow up during Exit End of Clean-up (Week 1) End of non- pharmacological Follow up pharmacological phase Baseline interventions (Week 3) (Every two weeks from (End of Week 12) (Week 8) week 4 -12) BPSD symptoms and cognitive assessments Neuropsychiatric Inventory (NPI-C) CGI-Severity CGIC CMAI MOCA and SCIRS (if MOCA score is less than 5) Dementia-FAST Motor Assessments AIMS SAS BAS Pain assessment PAINAD Caregiver/ Quality of Life Assessments ZBI ADRQL 18
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Non-Pharmacological Interventions for Agitation • 33 RCTs were included • Evidence found for • Person Centered Care • Communication Skills training • Dementia Care Mapping • Personalized music • Sensory therapy • Other reviews and met analyses with different results but general consensus about use of personalized, sensory and care giver interventions. Livingstone et al. Br J Psychiatry. 2014 Dec;205(6):436-42 20 Abraha I et al. BMJ Open 2017
Non-Pharmacological Interventions NON-PHARMACOLOGICAL INTERVENTIONS IDENTIFIED Health Professional INITIALLY AS MOST APPROPRIATE Occupational Social Contact: Pet therapy, one-on-one visits Therapist Sensory Enhancement/Relaxation: Hand massage, individualized music, individualized art, sensory modulation, Recreation Snoezelen Therapist Purposeful Activity: Helping tasks/volunteer role, inclusion in group programs, access to outdoors Social Worker Physical Activity: Exercise - group and individual, indoor/outdoor walks Assigned Nurse Neurocognitive Intervention: Paro, tablet computer, gaming 21 console
Medication Algorithm For partial responders: 1. Extend the trial BASELINE ASSESSMENTS & DRUG CLEAN UP 2. Increase the dose 3. Augment with another agent that showed RISPERIDONE also partial response QUETIAPINE PRNs: 1. Trazodone 2. Lorazepam ARIPIPRAZOLE CARBAMAZEPINE CITALOPRAM GABAPENTIN PRAZOSIN COMBINATION or E.C.T. 22 Davies et. al. J Psychopharmacol. 2018
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Overall Results Based on literature (Vasudev et. al, 2015*) , 50% of similar patients were treated with 2 or more medications in LTCFs in 2013, an increase from 42% in 2004. Enrolled (N= 62) Our results show that 4% needed to be 2 or more medications. Premature Exit (N = 5) Successfully Active - 3 Medical discharge Completed 85% : Step 2 or before - 1 Lewy Body (N = 3) (N = 54) - 1 Deceased No medications Step 1 Step 2 Step 3 ECT Polypharmacy (N = 2, 4%) (N = 9, 16%) (N = 23, 43%) (N =14, 26%) (N = 5, 9%) (N = 1, 2%) *http://www.ncbi.nlm.nih.gov/pubmed/26525997 24
Assessing the outcomes and comparison to usual care Dementia NON ICP Group Dementia ICP Group ( Usual Care) Non Dementia Group 1 Non Dementia Group 2 (Control group 1) (Control Group 2) ICP 2010 2016 2013
Group Characteristics Dementia NON Dementia ICP Control Group Control Group ICP Group Group 1 2 (2010-2013) (2013-2016) (2010-2013) (2013-2016) Number 33 (14) 37 (23) 22 (9) 36 (21) (Females) Age, Mean 76.7 (9.2) 77.1 (9.8) 68.3 (4.5) 69.1 (8.6) (SD) Number of 1.7 (1.3) 1.1 (1.1) 1.8 (1.3) 1.9 (1.1) Psychotropic Medications at Admission Mean (SD)
Active Length of Stay Dementia NON ICP group = 99.3 (107.0) days Dementia ICP group = 57.3 (36.3) days Control Group 1 = 34.7 (34.9) days Control Group 2 = 41.4 ( 38.7) days Univariate Multifactor ANOVA Group*Time Interaction F 1, 126 = 4. 46, p = 0.037
Psychotropic Medications at Discharge Mean (SD) Number of Psychotropics: Dementia NON ICP Group = 1.7 (1.1) Dementia ICP Group = 1.1 (0.5) Control Group 1 = 1.9 (1.2) Control Group 2 = 2.2 (1.0) Univariate Multifactor ANOVA Group*Time Interaction F 1, 127 = 8.29, p = 0.003
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