Agitation/Psychosis In Dementia Flashcards
Mild NPS
Depression, anxiety, irritability, apathy
Severe NPS
agitation, aggression, vocalizing, hallucinations, delusions, disinhibiton
Medical causes of agitation in dementia
Meds, infection, CVA, trauma, pain
Assessments and diagnostic tests for NPS
PE with cognitive testing, labs, drug levels
General approach to behavior management
Define target symptoms
Establish or revisit medical diagnoses
Establish or revisit neuropsychiatric diagnoses
Assess and reverse aggravating factors
Adapt to specific cognitive deficits
Identify relevant psychosocial factors
Educate caregivers
Employ behavior management principles
Use psychotropics for specific psychiatric symptoms
Principles for APS use
Start low, go slow
Avoid toxicity
Use lowest effective dose
Withdraw after appropriate period, observe for relapse
Serial trials sometimes needed
BBW for antipsychotics
Increased mortality in elderly patients with dementia-related psychosis
Which APS had a higher rate of death: FGAs or SGAs?
FGAs (haloperidol had an increased risk of mortality vs. quetiapine and olanzapine which had the same risk)
D/C’ing an APS
Older patients with Alzheimer’s dementia and NPS can be withdrawn from chronic APS meds without detrimental effects on their behavior
Nonpharm treatment: caregivers
Scheduled toileting and prompted toileting
Offer graded assistance (as little help as possible to perform ADLs), role modeling, cueing, positive reinforcement to increase independence
Avoid adversarial debates; redirect the conversation
Maintain a calm demeanor
Caregiver support groups
Nonpharm treatment: problem behaviors
Music during meals, bathing
Walking/light exercise
Simulate family presence with video or audio
Pet therapy
Speak at patient’s comprehension level
Bright light, “white” noise (low-level background noise)
Nonpharm treatment: general environmental interventions
Education for families and caregivers
Structuring the physical and psychosocial environment (having a set routine)
Behavioral interventions
Nonpharm treatment: mild environmental interventions
environment and interventions
Nonpharm treatment: severe environmental interventions
constant supervision
Nonpharm treatment: agitation or aggression
Exclude underlying physical discomfort
Identify antecedents of the behavior and avoiding triggers is often most useful
Behavioral modification using positive reinforcement of desirable behavior
Avoid physical restraint if possible
Treatment options: psychotic symptoms
Olanzapine, quetiapine, risperidone, aripiprazole, paliperidone, ziprasidone: SGAs
Thioridazine (low potency FGA), haloperidol (FGA for quick onset)
Treatment options: depression
SSRIs are first line and preferred for more favorable ADE profiles
citalopram, escitalopram, fluoxetine, sertraline
SNRIs: desvenlafaxine, duloxetine, venlafaxine
Avoid what ADs?
Paroxetine, TCAs –> anticholinergic!
AD that’s helpful for insomnia and weight loss
Mirtazapine
AD that’s helpful for sedation
Trazodone
AD for severe depression and anxiety
Venlafaxine
Apathy treatment
Methylphenidate, dextroamphetamine, modafinil
Treatment options: manic-like behavioral symptoms
CBZ, LTG, Li, Divalproex sodium
Ideally, use divalproex because it’s better tolerated in older adults
Treatment options: agitation in context of psychosis
Aripiprazole, olanzapine, quetiapine, risperidone
Treatment options: agitation in context of depression
SSRI, citalopram
Treatment options: anxiety with mild-moderate irritability
Buspirone, trazodone
Treatment options: agitation or aggression unresponsive to first-line treatment
CBZ, divaloproex, IM olanzapine
Treatment options: sexual aggression, impulse-control symptoms in men
SGA or divalproex
Sundowning treatment: nonpharm
Nightlights, check-ins
Sundowning treatment: acute
trazodone, CHAPs, SGAs
Sundowning treatment: chronic
trazodone, melatonin, SGAs, CHAPs
Insomnia treatment: nonpharm
Limiting caffeine before bedtime, fluid intake, light, activity, time in bed
Insomnia treatment: acute
Trazodone, melatonin, short-acting BZDs for short-term use, mirtazapine
Insomnia treatment: chronic
Trazodone, melatonin
