Psychosis&agitation In The Elderly

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Contents

Introduction

  • Inclusive of:
  • late onset
  • early onset in now older patient
  • other behavioral disturbances

Etiology

  • pain or physical discomfort
  • adjustment to change; misinterpretation of environmental cues
  • intrusion into the patient's personal space
  • poor communication
  • feelings of poor self-esteem due to increasing dependence
  • feelings of insecurity
  • changes in routine, environment, or personnel

Epidemiology

  • 40% of nursing home residents exhibit behavioral disturbances [5]

Pathology

  • relevant factors

Clinical-manifestations

  • relevant factors
  • diagnosis
  • personal & family history
  • see pathology

Laboratory

Radiology

Complications

Management

  • specific therapies for specific etiologies
  • behavioral & general measures are 1st line (also see OBRA)
  • ensure safety
  • minimize distress
  • minimize disruption to other patients
  • identify target symptoms & desired outcome
  • behavioral interventions
  • repetition
  • redirection
  • reassurance
  • environmental modification
  • education
  • reasoning will not change the patient's behavior
  • the caregiver or the environment must change
  • pharmaceutical agents
  • superior to placebo, but efficacy modest
  • no clear difference in efficacy among agents
  • some patients don't improve; some worsen
  • treatment principles
  • use high-potency agents
  • dose conservative, yet sufficient
  • monitor, adjust, consider discontinuation
  • OBRA regulations require documentation of symptoms & attempts to gradually reduce dose
  • increased risk of stroke in patients receiving any antipsychotic [20]
  • use of antipsychotics (all types) associated with increased mortality in the elderly [5,13,15,21]*

More General Terms

Additional Terms

References

  1. Sultzer, D. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  2. Prescriber's Letter 8(7):40 2001 Doody RS et al, Practice Parameter: management of dementia (an evidence-based review). Report of the quality standards subcommitte of the American Academy of Neurology, Neurology 56:1154-1156, 2001 (Guideline withdrawn 02/2009) PMID: [1]
  3. Sultzer, D. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 25-28, 2002
  4. Journal Watch 24(17):133, 2004 Lee PE, Gill SS, Freedman M, Bronskill SE, Hillmer MP, Rochon PA. Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: systematic review. BMJ. 2004 Jul 10;329(7457):75. Epub 2004 Jun 11. Review. <PubMed> PMID: [2] <Internet> [3]
  5. Rovner BW, German PS, Broadhead J, Morriss RK, Brant LJ, Blaustein J, Folstein MF. The prevalence and management of dementia and other psychiatric disorders in nursing homes. Int Psychogeriatr. 1990 Spring;2(1):13-24. PMID: [4]
  6. FDA Public Health Advisory Deaths with Antipsychotics in Elderly Patients with Behavioral Disturbances [5] [6]
  7. Prescriber's Letter 12(6): 2005 Deaths with Antipsychotics in Elderly Patients with Behavioral Disturbances Detail-Document#: [7] (subscription needed) [8]
  8. Journal Watch 25(12):96, 2005 Ballard C, Margallo-Lana M, Juszczak E, Douglas S, Swann A, Thomas A, O'Brien J, Everratt A, Sadler S, Maddison C, Lee L, Bannister C, Elvish R, Jacoby R. Quetiapine and rivastigmine and cognitive decline in Alzheimer's disease: randomised double blind placebo controlled trial. BMJ. 2005 Apr 16;330(7496):874. Epub 2005 Feb 18. PMID: [9]
    - Gauthier S Drugs for Alzheimer's disease and related dementias. BMJ. 2005 Apr 16;330(7496):857-8. No abstract available. <PubMed> PMID: [10] <Internet> [11]
  9. Wang PS, Schneeweiss S, Avorn J, Fischer MA, Mogun H, Solomon DH, Brookhart MA. Risk of death in elderly users of conventional vs. atypical antipsychotic medications. N Engl J Med. 2005 Dec 1;353(22):2335-41. PMID: [12]
    - Ray WA. Observational studies of drugs and mortality. N Engl J Med. 2005 Dec 1;353(22):2319-21. No abstract available. PMID: [13]
  10. Schneider LS Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease N Engl J Med 2006, 355:1525 PMID: [14]
    - Karlawish J Alzheimer's disease - Clinical trials and the logic of clinical purpose. N Engl J Med 2006, 355:1604 PMID: [15]
  11. Ballard C, Waite J. The effectiveness of atypical antipsychotics for the treatment of aggression and psychosis in Alzheimer's disease. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD003476. Review. PMID: [16]
  12. Cummmins JL et al, for Memantine MEM-MD-02 Study Group Behavioral effects memantine in Alzheimer disease patients receiving donepezil treatment. Neurology 2006, 67:57 PMID: [17]
  13. Schneeweiss S et al, Risk of death with use of conventional versus atypical antipsychotic drugs among elderly patients. CMAJ 2007, 176:627 PMID: [18]
  14. Howard RJ et al, Donepezil for the treatment of agitation in Alzheimer's disease. N Engl J Med 2007, 357:1382 PMID: [19]
  15. Kales HC, Valenstein M, Kim HM, McCarthy JF, Ganoczy D, Cunningham F, Blow FC. Mortality risk in patients with dementia treated with antipsychotics versus other psychiatric medications. Am J Psychiatry. 2007 Oct;164(10):1568-76. PMID: [20]
  16. Yaffe K. Treatment of neuropsychiatric symptoms in patients with dementia. N Engl J Med 2007, 357:1411 PMID: [21]
  17. Rochon PA et al, Antipsychotic Therapy and Short-term Serious Events in Older Adults With Dementia Arch Intern Med 2008 168:1090 PMID: [22]
  18. FDA MedWatch [23]
  19. Sultzer DL et al. Clinical symptom responses to atypical antipsychotic medications in Alzheimer's disease: Phase 1 outcomes from the CATIE-AD effectiveness trial. Am J Psychiatry 2008 Jul; 165:844 PMID: [24]
    - Kuehn BM. FDA: Antipsychotics risky for elderly. JAMA 2008 Jul 23/30; 300:379 PMID: [25]
  20. Douglas IJ and Smeeth L. Exposure to antipsychotics and risk of stroke: Self controlled case series study. BMJ 2008 Aug 28; 337:a1227. PMID: [26]
  21. Ballard C et al The dementia antipsychotic withdrawal trial (DART-AD): Long-term follow-up of a randomised placebo-controlled trial. Lancet Neurol 2009 Feb; 8:151. <PubMed> PMID: [27] <Internet> [28]
  22. Tariot PN et al. for the Alzheimer's Disease Cooperative Study Group. Chronic divalproex sodium to attenuate agitation and clinical progression of Alzheimer disease. Arch Gen Psychiatry 2011 Aug; 68:853. PMID: [29]
  23. Prescriber's Letter 18(10): 2011 CHART: Pharmacotherapy of Dementia Behaviors CHART: Pharmacotherapy of Dementia Behaviors Algorithm GUIDELINES: American Psychiatric Association Dementia Guideline Detail-Document#: [30] (subscription needed) [31]
  24. National Guideline Clearinghouse Non-pharmacologic management of agitated behaviors in persons with Alzheimer disease and other chronic dementing illnesses. ngc-guideline: [32]
    - Delirium and acute problematic behavior in the long-term care setting. American Medical Directors Association ngc-guideline: [33]

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