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Primary Care 1st Edition Use of Antipsychotics in Behavioural and Psychological Symptoms of Dementia (BPSD) This tool is designed to help providers understand, assess, and manage patients in primary care with behavioural and psychological symptoms of dementia (responsive behaviours), with a focus on antipsychotic medications. 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-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 patient, with consideration given to caregivers and family members.
Identify BPSD Symptom Clusters1, 2 Resistance to care Repetitive actions April 2016. Version 1.
Overview of BPSD Management Treatment for dementia is an ongoing process. Since dementia is a progressive disease, regular fol ow-ups are necessary to ensure that the patient is receiving the best possible treatment for his or her symptoms. The sections in this tool should each be considered at each fol ow-up (even if some of the treatments discussed,
such as drug therapy, will not be necessary for every patient at every stage of treatment).
Section A: Evaluate BPSD
Before beginning any sort of treatment (e.g. drug or non-drug therapy), it is important to evaluate the patient'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 and others• Clinical evaluations that should take place in order to identify any underlying physiological causes of BPSD Section B: 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) Section C: Consider Drug Trial(s)
In some cases, when non-drug therapy approaches alone are not sufficient to manage BPSD, it may be necessary to initiate drug
therapy to manage symptoms.
This section discusses:
• Determining the best drug therapy to treat the patient's symptoms• What symptoms are and are not likely to respond to antipsychotic therapy• General principles for monitoring, documenting, and following-up on patients receiving medications Section D: Additional Information on Antipsychotic Therapy
When BPSD are particularly distressing or disturbing, pose an imminent risk of harm to the patient or others, and are likely to
respond to antipsychotics (see section C), it is sometimes beneficial to initiate antipsychotic therapy.
This section expands on the information about antipsychotics introduced in Section C, and includes:
• The benefits and harms of antipsychotic therapy• A table comparing the efficacy of different antipsychotics for treating BPSD, some common side effects, and the cost of treatment• General guidelines for assessing antipsychotics for possible deprescribing April 2016. Version 1.
Section A: Evaluate 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). 1 Assess & Document Use P.I.E.C.E.S.TM to Identify Causes 9
• Document behaviour or symptom clusters, including frequency, severity,
Use the P.I.E.C.E.S. 3-Question Template TM to ask:
triggers, and consequences 1. What has changed?
• Document any potential reversible causes (e.g. delirium, depression)
2. What are the RISKS and possible causes?
• Designate specific members of the care team or family who wil be responsible 3. What is the action?
for coordinating day-to-day assessment and management • Standardized clinical assessment tools, such as the Antecedent, Behaviour, Consequence (ABC) Chart Form3 and Dementia Observation Scale (DOS)4 can be helpful for monitoring and documenting symptoms • Examples of standardized clinical assessment tools can be found on Page 7
think "the 5 Ds" Disease (cardiovascular, infectious, insomnia,
• Use the P.I.E.C.E.S.TM RISKS mnemonic to assess risks to the patient and
metabolic, nocturia, renal, respiratory, sleep apnea, urinary retention, etc) Roaming: Is risk greater due to patient roaming?
Drugs (e.g. acetycholinesterase inhibitors,
Imminent: Is significant risk imminent?
anticholinergics, anticonvulsants, anti-Parkinson, Suicide: Does the patient display any suicidal tendencies?
benzodiazepines, digoxin, fluoroquinolones, Kin: Is the health or safety of caregivers/family affected?
lithium, opioids, systemic corticosteroid) Self-neglect: Is patient's self-neglect a risk to themself or others?
See Reference List of Drugs with Anticholinergic • Interview family/caregiver independently to ask about family/caregiver strain
and risk of abuse by patient
Discomfort (e.g. pain, constipation, fecal
impaction, urinary retention, hunger, thirst) • Be mindful of any suggestions of patient abuse by family/caregivers
Disability (e.g. sensory loss)
3 Identify BPSD Causes think "the 7 As" • Obtain history from caregivers, family, and friends10
• Consider environmental factors and triggers, including possible role of • Consider using P.I.E.C.E.S.TM to identify causes (see box on right)
Agnosia (recognition of people or things)
Apraxia (purposeful movement)
4 Clinical Evaluation10 Altered Perception (sensory information)
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 ful , rather than targeted, think "the 4 Ds" physical examination is indicated, within the bounds of patient cooperation.
Disorder Adjustment (e.g. related to losses)
Disorders of Mood (e.g. depressive symptoms,
History (include family/caregivers): Physical Examination: Recent changes to environment, Be mindful of sources of:
Delusional (e.g. suspiciousness, psychosis)
routine, sleep pattern, family/social Pain (e.g. dental, skin, joint, feet) Disorders of Personality
Hydration (e.g. dehydration) Medication Review: Adherence,
Sensory loss (hearing, vision) prescription and OTC medications, CNS change (e.g. new stroke) anticholinergic load, drugs Infection (e.g. pneumonia, Capability too low to meet demands of that may increase agitation environment (catastrophic reactions) or not (e.g. cholinesterase inhibitors), Hypo-perfusion (e.g. new atrial utilized enough (boredom) medication induced hypotension or fibril ation, heart failure) Maximize remaining strengths; avoid unnecessary orthostatic hypotension, medication Constipation and urinary retention that may contribute to constipation and urinary retention, drugs and/or Laboratory and Imaging (as guided by physical exam/history): Consider over-/under-stimulation, relocation, Blood: Glucose, calcium, complete blood count (CBC), creatinine, electrolytes,
change in routine, noise, lighting, colours, social TSH, others as appropriate interactions with caregivers/others 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
Consider social network, life story, cultural/spiritual physical exam; CT head if new concerning neurologic findings) April 2016. Version 1.
Section B: Initiate Non-Drug Therapy for BPSD11, 12, 13
Section C: Consider Drug Trial(s)
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 to the next.
• Take advantage of any available system supports, such as the Alzheimer's Society of Canada's First Link program.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/caregiver and severity of symptoms.
Possible Solutions • Ensure the patient's safety and the safety of others • Make sure you are safe (exit near, chair between you and patient) • Distract, engage • Remove ongoing triggers • Individualized music, nature sounds, presence therapy (tapes of family) • Remove potential y dangerous objects • Distract, engage • Educate caregivers in safe approach and indications of need to • Adapt environment to reduce ex- withdraw for safety it-seeking, physical exercise, outdoor • Distract, engage • Adapt environment to reduce exit- Eliminate misleading stimuli
seeking, physical exercise, outdoor • Clutter, TV, radio, noise, people, reflections in mirrors/dark windows, pictures/décor, patterned floors Exit-seeking • Register the individual with MedicAlert
and Alzheimer's Society Safety Home Reduce environmental stress
program (contact information wil be • Extra/new people, holiday decorations, overhead glare, on bracelet or necklace) temperature control, privacy • Hide exits with curtains, or paint a black circle on the floor (the individual • Avoid unsafe furniture and fixtures (sharp edges, hot water pipes, etc.) wil think it is a hole and wil not exit) • Distract, engage • If over-stimulated, reduce noise, activity, confusion • Individualized music, nature sounds, presence therapy (tapes of family) • Increase lighting, to reduce misinterpretation Physical
• Distract, keep calm, remain warm and Adapt the physical setting in order to prioritize patient comfort
• If possible, give the person some space • Discrete safety features (hand rails, grab bars, etc.) and try to approach later • Promote an environment that encourages the involvement of family • Understand this is their reality and do and friends (comfortable and close seating, family/caregiver resources) not confront the false belief • Provide familiar and comforting items such as photo albums, favourite • Focus efforts on how the patient feels, not the content; offer distraction, avoid clutter, TV, radio • Calm, soothe, distract Caregiver Approach Considerations • Individualized music, aromatherapy, pet therapy, physical exercise, outdoor • Be calm and compassionate (use/avoid touch as indicated) Resistant to • Identify source of threat (e.g. pain);
• Distract by engaging in individualized activities change routines and approaches • Focus on patient's wishes, interests, concerns • Reassure, address underlying issue, • Approach slowly; look for signs of increased agitation Repetitive
• Approach patient's private space slowly and ask permission prior • Put the answer to the same repetitive question on a piece of paper or card and ask the patient to read the card • Withdraw and re-approach later if patient becomes distressed • Remove items gradual y, re-organize • Keep to the same routine to reduce uncertainty; use cues (e.g. music and clear paths in the case of or song) specific to each of the day's major activities as prompts emergency; be compassionate • Use long-standing history and preferences to guide • Distract, re-direct • Individualize social and leisure activities to reduce boredom • Keep an active and regular schedule to • Try increasing the level of appropriate • Most communication is non-verbal, use positive non-verbal cues physical attention (e.g. disrobing, • Make eye contact unless perceived as aggressive • Provide personal space if possible and come back when the patient is calmer • Use short simple words and phrases (patients with dementia • Allow the individual privacy for have trouble processing multiple words or complex grammar) • Speak clearly and use a positive tone *DOS = Dementia Observation System (Colours used in table are taken from
• Wait for answers (be patient) the DOS system, though you may use different colours in your practice) April 2016. Version 1.
Section C: Consider Drug Trial(s)
1 Ensure Drug Trial is Necessary Selecting an Appropriate Drug Therapy for the Patient's • Treat underlying causes (e.g. pain, constipation, delirium) • Ensure that non-drug therapy options have been attempted, and have been unsuccessful Psychosis,
• Atypical antipsychotics (such as risperidone, Aggression,
aripiprazole, olanzapine, quetiapine as Note: In acute BPSD, if there is a safety risk to patient or others,
discussed in detail on page 6)10, 14
there may not be time to try non-drug approaches before trying
Agitation
• SSRIs such as citalopram or trazodone (severe), unlikely
(however, evidence is lacking for trazodone)15, to respond to
2 Select Appropriate Drug Trial Agitation (severe) • Possible cholinesterase inhibitors
• Select an appropriate drug based on symptoms (see chart at right) in Lewy Body
• Very low dose quetiapine15, 16 • Identify which behaviour(s) you wish to target (e.g. see symptom clusters Dementia or
on cover page and to right) • A short-acting benzodiazepine such as (short term/
lorazepam prior to anxiety provoking events • If you are considering initiating antipsychotic therapy, first ask:
such as bathing17 a. Are symptoms likely to respond to antipsychotics? (see below right) • Antidepressants (such as SSRIs, SNRIs) b. Is there imminent risk of harm to self and/or others? c. Are symptoms particularly disturbing, distressing or dangerous? • Antidepressants such as SSRIs (e.g., d. Have you weighed the potential benefits and harms? (see page 6) citalopram, sertaline), SNRIs (e.g., venlafaxine, duloxetine), other antidepressants • See page 6 for a detailed comparison of antipsychotics Depression
(bupropion, mirtazapine, moclobemide) • Secondary TCAs (nortriptyline or desipramine) may be suitable if coexisting indication • Obtain and document informed consent (see Psychotropic Medication like neuropathic pain, etc., but caution Consent Discussion Tool)19 regarding anticholinergic load, etc.10, 16, 18 • Start with a low dose, and gradually titrate as necessary/tolerated • Addressing any possible drug causes is of primary importance • Evidence for specific recommendations lacking 3 Maintain and Review • Mood stabilizers are an option, but take caution regarding tolerability and drug • Monitor change in targeted behaviour as wel as side effects (see DOS Tool)4 • Assess over 1-3 weeks, documenting any benefits and harms realized. If • Limited role for drug therapy but sometimes lack of response and/or tolerability, adjust therapy. Increase dose (if not yet cholinesterase inhibitors may be helpful maximized) or taper/discontinue15 • Methylphenidate also sometimes used, but limited by concerns such as stimulant effect • Continue to reassess on an ongoing basis for effectiveness and tolerability on behaviour and risk of diversion15, 18 • Consider dose reduction or discontinuation if the drug: Symptom Likelihood to Respond to Antipsychotic Therapy a. Is not effective, b. Has intolerable side effects, or; c. Behaviours have been manageable and stable for 3-6+ months17 • If considering dose reduction/discontinuation for an antipsychotic, see
• Hallucinations "Reassessing Antipsychotics for Possible Deprescribing" on page 6
Psychosis • Misidentification • Suspicious• Defensive • Resistance to care • Fol ow-up is important for any drug regimen • If antipsychotics used, reassess need at least every 3 months 16
• Restless/anxious • Dressing/undressing• Pacing• Exit seeking17 • Repetitive actions45-47 5 Consider Referral to a Specialist if Drug Trial is Unsuccessful • see below*, ** • see below*, ** • If symptoms persist or worsen, consider referral to a specialist 6 Continue Non-Drug Approaches • Euphoria 46-48• Irritable 46-48 • Continue using non-drug approaches to prevent further BPSD • Pressured speech • Amotivation• Lack of interest Tips for Drug Trials and Deprescribing • In all drug trials, unless clinically indicated, start at a low dose and increase • Hiding or hoarding45 or decrease slowly.
• Wandering without • For more tools and resources, visit effectivepractice.org/dementia.
• Disinhibition (e.g., • For more information about antipsychotic deprescribing, including a deprescribing algorithm, visit deprescribing.org.
* 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.
April 2016. Version 1.
Section D: Additional Information on Antipsychotic Therapy
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.
Antipsychotics: Potential Benefits
Antipsychotics: Potential Harms
Limited benefit: modest improvement seldom observed
Side effects: sedation, fal s, postural hypotension, QT prolongation, confusion,
effect size: 0.12-0.2
EPS (rigidity, stiffness, akinesia), tardive dyskinesia, diabetes, weight gain22, 23 • NNT variable: 5-14
Stroke: increased risk
(i.e. at best, compared to placebo, antipsychotic therapy results in targeted Death: possible increase
behaviour benefit in 1 out of 5 people treated)20, 21 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 KEY: 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 fol owing table is intended only as a general guide. Efficacy or evidence in BPSD therapy • Indicated for severe dementia of the (Risperdal)25, 26, 34 Alzheimer type (Health Canada) • Evidence for efficacy in agitation, aggression & • Off-label use in BPSD (Zyprexa)25, 26, 34 • Evidence for efficacy in agitation & • Off-label use in agitation or aggression18 • Evidence for efficacy in agitation & • Not eligible for dementia or BPSD in the elderly(ODB criteria, Therapeutic Note) • Not for psychosis(same as placebo) • Off-label use in BPSD (Seroquel)25, 26, 34 • Lacks evidence for efficacy in BPSD agitation, aggression & psychosis • Consider in Lewy Body dementia, Parkinson's • Note: although used, not indicated, and lacking evidence for insomnia • Useful short term in acute BPSD or delirium • Consider if other agents have failed and picals (Loxapac, severe, persistent, dangerous behaviour • Severe, acute BPSD• Not to be used long-term due to adverse effects *Aripiprazole, 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
KEY: Terminology
Frequency (%) of Adverse Reactions of Antipsychotics at Therapeutic Doses
EPS: extrapyramidal TD: tardive dyskinesia
‒ : Negligible or absent (<2%)
+++ : Frequent (>30%)
BID: twice daily
TID: three times daily
+ : Infrequent (>2%)
: Increase
BP: blood pressure
lb: pound
QHS: bedtime
++ : Moderate (>10%)
ODB: Ontario Drug Benefit
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 April 2016. Version 1.
Supporting Materials These supporting materials are an inventory for primary care providers to help identify useful clinical aids and patient/family material. This list includes direct links (where available) to tools or materials, based on an environmental scan, appraisal by Clinical Leads, and focus groups with primary care providers. The materials below can be accessed at: ementia.
Antecedent, Behaviour, Consequence (ABC) Chart Form3 Pain Assessment in Advanced Dementia Scale (PAINAD)8 Chart form to help providers determine and document the events/stimuli Pain assessment tool for individuals with advanced dementia including that impact behaviour. behaviour observation scores.
Patient Health Questionnaire (PHQ-9)55 Clinical rating scale to measure behavioural and psychological symptoms of Self-administered multipurpose instrument for depression diagnosis and dementia based upon information obtained from caregivers/informants.
Reference and Support Information
Brief Psychiatric Rating Scale37 Rating scale of 24 symptom constructs used to assess the positive, negative, and affective symptoms of individuals.
Advisory concerning atypical antipsychotic treatment of behavioural disorders in elderly patients, June 2005 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 Primary care toolkit with resources for delirium, caregiver support, high risk Diagnostic algorithm/questionnaire for identification of delirium through situations, and other materials.
formal cognitive testing.
Cornell Scale for Depression in Dementia38 Scale for assessing signs and symptoms of major depression in people with Referral program to support newly diagnosed patients with dementia connecting to resources and other people living with Alzheimer's and other Behaviour assessment tool which captures the frequency and duration of behaviours of concern over 24 hour periods.
URL:
Interdisciplinary approach to understanding and enhancing care for individuals with complex physical/cognitive/mental health needs and Screening tool for cognitive impairment for patients and families/ behaviour changes.
Psychotropic Medication Consent Discussion Tool19 Geriatric Depression Scale - 15 Item 51 Aid for initiating antipsychotic medications and key discussion items for Self-administered assessment for depression in the elderly.
informed consent from patients or substitute decision makers.
Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)52 Short questionnaire for families/friends to determine cognitive decline.
Reference list of drugs with low, moderate, and high anticholinergic effects, including side effects and preferred alternatives.
Instrumental Activities of Daily Living Scale53 Scale to determine functional abilities for tasks, completed by patients and 42Alert for the restriction of risperidone and related antipsychotic use for patients with severe dementia of the Alzheimer type unresponsive to non- Behaviour analysis tool designed to indicate the number of behavioural pharmacological approaches and when there is a risk of harm to self or symptoms associated with dementia affecting an individual patient.
others, February 2015 Note: Although recent alert is specific for risperidone, other antipsychotics
have similar concerns; however, unlike risperidone, others lack an official Montreal Cognitive Assessment (MoCA)54 indication in BPSD. Tool to identify objective evidence of cognitive decline.
Tool to characterize the neuropsychiatric symptoms and psychopathology Statements on how to treat disruptive behaviours without antipsychotic of patients with Alzheimer's disease and other dementias to measure the impact of antidementia and psychotropic drugs. April 2016. Version 1.



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[57] Alzheimer Society Canada. First link program. 2016. Available from: http://www.alzheimer.ca/en/We-can- [29] Pan YJ, Wu CS, Gau SS, Chan HY, Banerjee S. Antipsychotic discontinuation in patients with dementia: a This Tool was developed by Centre for Effective Practice (CEP) with input and review from our Academic Detailing Service Team for our long-term care version. This Tool has been adapted for primary care as part of the Knowledge Translation in Primary Care Initiative which is led by CEP with collaboration from OCFP and NPAO. Clinical leadership for the development of this tool was provided by Dr. Sid Feldman MD CCFP and was subject to external review by primary care providers and other relevant stakeholders. This Tool was funded by the Government of Ontario as part of the Knowledge Translation in Primary Care Initiative.
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