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Dementia > Management of behavioural and psychological symptoms > Flashcards

Management of behavioural and psychological symptoms Flashcards

1
Q

What is the percentage of dementia patients that experience BPSD symptoms?

A

80-90%

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2
Q

What are some of the behavioural symptoms of dementia?

A

Physical aggression
Screaming
Wandering
Culturally inappropriate
Swearing
Sexual disinhibition

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3
Q

What are some of the psychological symptoms in dementia?

A

Anxiety
Depression
Hallucinations
Delusions

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4
Q

Which of the symptoms are more prevalent in mild dementia?

A

Anxiety
Depression
Greater insight

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5
Q

Which of the symptoms are more prevalent in moderate dementia?

A

Screaming
Physical aggression
Sexual disinhibition
Hallucinations
Wandering
Delusions
Swearing
Paranoia

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6
Q

Which of the symptoms are more prevalent in moderate dementia?

A

Anxiety
Hallucinations
Depression
Delusions

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7
Q

What is it important to recognise about the causes of the dementia symptoms?

A

The causes of symptoms seen in dementia may have non-dementia causes, due to the inability of the patient to communicate with those around them. In some ways the communication barriers are a bit like a baby crying.

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8
Q

What might be some of the underlying causes of screaming and swearing in a dementia patient?

A

Physical discomfort
Pain
Angry
Hungry
Thirsty
Constipation
Infection

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9
Q

What might be some of the underlying causes of wandering in a dementia patient?

A

Hungry
Thirsty
Unfamiliar surroundings
Stress
Anxiety
Pain

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10
Q

What might be some of the reasons behind anxiety and depression in a dementia patient?

A

Stress
Hunger
Thirst
Hypoxia

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11
Q

What might be some of the reasons behind hallucinations and delusions in a dementia patient?

A

Medication induced (morphine)
Infection
Hypoxia
Visual agnosia (impairment in recognising visually presented objects) - although could be due to not having glasses on
Not having hearing aids in

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12
Q

What might be some of the reasons behind aggression in a dementia patient?

A

Pain
Stress
Anxiety
Too much going on
Noise
Incontinence
Hunger
Thirst
Physical discomfort
Medications
Drugs/alcohol
Too hot/too cold
Exhaustion
Inability to communicate
Loss of dignity
Fear
Unfamiliar environment
Embarrassment

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13
Q

What is the first line management strategies for BPSD?

A

Non-pharmacological interventions including:
Modification of the carers behaviour, remaining calm at all times, which can reduce occurrence of BPSD and remove the need to treat it
Avoiding triggers for symptoms
Music and massage strategies - calming techniques

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14
Q

How long do symptoms of BPSD last?

A

They can last throughout the course of dementia however some resolve within 4-6 weeks and therefore pharmacological management may not always be appropriate.

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15
Q

What are the non-drug treatment principles regarding BPSD?

A

Identify symptoms are of most concern
Describe each symptom in detail
ABC approach used to understand behaviours and allow the development of a positive support system
Before, during and afterwards and allows the identification of triggers and how to respond appropriately

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16
Q

What is the importance of pain management in dementia?

A

Due to often their inability to verbally communicate, pain in dementia patients are under-detected and under-dosed.
Use of facial expressions or the Abbey Pain scale ensures correct pain management which may also reduce BPSD symptoms.

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17
Q

What considerations should be made before introducing psychiatric drug treatment?

A

The risk vs benefit of the medication to the individual

Ensuring the symptoms are caused by a modifiable source such as:
Infection, Medication-induced, Environmental

Ensure there is no response to non-drug treatment interventions first
Must also assess capacity to consent

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18
Q

How should psychiatric drugs be dose titrated?

A

Slowly and cautiously using judicious dosing

19
Q

What monitoring should be implemented for psychiatric drugs?

A

For psychotropics monitoring should occur every 3 months
Anti-psychotics specifically should be monitored every 6 weeks

Both should be reviewed for:
Assess whether a need is still required, discontinue whenever possible
Reviewing side effects and reducing drug doses

20
Q

What are the advantages of using combinations of medications?

A

Applies to use of medications in polypharmacy.
Can utilise one medication to address a range of patient symptoms e.g. a sedating anti-depressant can help relieve of agitation, depression and sleep disturbances

21
Q

How frequent is anxiety in dementia patients?

A

Affects 16% of dementia patients and the symptom can be present in whatever stage of dementia, but heightens in moderate

22
Q

What type of anxieties may a dementia patient have?

A

They may have new anxieties that they have never expressed previously and original coping symptoms now do no longer work.
These can include, but are not exclusive to:
Being alone
Crowded spaces
ADLs
Travel
Darkness

23
Q

What percentage of dementia patients experience depression?

A

50%

24
Q

How may depression present in dementia patients?

A

Weight loss
Sleep disturbances
Agitation
Apathy (lack of interest or concern)

25
Q

What are some of the pharmacological management for depression/associated symptoms?

A

First line are anti-depressants

In addition AChE inhibitors are shown a 50% improvement in apathy (unlicensed use of this medication)

26
Q

What are some of the non antipsychotics used in BPSD?

A

Although they have limited evidence they may be worth a try, these include:
AChE inhibitors and Memantine (NMDA antagonist)

27
Q

When may it be appropriate to initiate psychiatric drugs?

A

In cases of:
Persistent aggression
Moderate to severe Alzheimer’s
Unresponsive to non-drug therapies
Risk of harm to self/others

28
Q

What percentage of dementia patients experience hallucinations?

A

50% and intensifies in the moderate stages of dementia, less so in severe stages

29
Q

What is important to clarify regarding hallucinations?

A

Visual agnosia and misinterpretation of objects are not hallucinations.
It is important to examine both the auditory and visual function of the patient.

30
Q

What are the 5 typical types of delusions?

A

Someone is stealing
Spouse are imposters
Abandonment
Spouse is being unfaithful
Misidentification

31
Q

Explain what is meant by misidentification delusions.

A

Also known as misperceptions these occur when an associated belief that is held with delusional intensity.
Examples include delusions regarding
Presence of persons in the patients own home (also known as phantom boarder syndrome)
Cannot identify own self in the mirror
Cannot identify others
Television/photos are seen as real

32
Q

What percentage of dementia patients are prescribed anti-psychotics?

A

25%

33
Q

What are some of the statistics associated with anti-psychotics?

A

They double of the risk of death in dementia
Out of the 180,000 dementia patients that are prescribed anti-psychotics in the UK; 1800 strokes will occur and there will be 1600 deaths

34
Q

What are some of the major adverse outcomes associated with anti-psychotics?

A

Oversedation and dehydration which in turn increase the risk of infection and strokes (there are a three times risk of strokes, associated with all anti-psychotics)
Antipsychotics also increase the risk of falls and fractures by x2 fold

35
Q

What are some of the other adverse effects associated with anti-psychotics?

A

Parkinsonism
Gait disturbances
Falls
Chest infection
Confusions
Movement problems
Agitation
Restlessness
Akathisias
Anticholinergic side effects

36
Q

When is Risperidone licensed for the treatment of BPSD?

A

Short duration, up to 6 week course, in the treatment of persistent aggression in patients with moderate to severe Alzheimer’s disease, unresponsive to non-pharmacological management and where there is a risk to self or others.

37
Q

Is Risperidone licensed for all dementia types?

A

No only Alzheimer’s dementia

38
Q

How does the effects of Risperidone and Quetiapine compare to that of the placebo in Alzheimer’s disease?

A

Risperidone was found to be superior to the placebo for aggression and psychosis in dementia whereas other anti-psychotics were found to be harmful/ineffective

A greater cognitive decline occurred with Quetiapine when compared to the placebo possibly due to its anticholinergic side effect

39
Q

What is the dosing regimen for Risperidone?

A

Initially 250 micrograms twice daily, then increased in steps of 250 micrograms twice a day on alternate days, adjusted according to response; usual dose 500 micrograms twice daily (max. per dose 1 mg twice daily)

Evaluate use frequently and regularly
Maximum six week dose only

40
Q

How should discontinuation of anti-psychotic occur?

A

A physician/GP/dementia nurse or prescribing pharmacist
May continue antipsychotic after determining it would still be appropriate or if the patient relapses

41
Q

What is an important consideration regarding discontinuation of Schizophrenia?

A

Always check the indication of the medication, anti-psychotics used in Schizophrenia should never be stopped.
Usually for Risperidone the dose is 2mg rather than 0.5mg BD but always check.

42
Q

Can benzodiazepines be used in the treatment of Schizophrenia?

A

No benzodiazepines should not be used in the management of BPSD because they have an 8x increased risk of falls

43
Q

In recap which is the only anti-psychotics licensed for the management of BPSD?

A

Risperidone
Not Haloperidol, Quetiapine or Benzodiazepines as they have not shown any improvement in symptoms and if anything pose a greater risk.

Dementia (3 decks)

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