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22 Pages·2010·0.58 MB·English

Chapter 8

BPSD and the Use of Psychotropic
Medications

Dr. Ken Le Clair
Dr. Marie-France Rivard

BPSD – Handbook for Family Physicians
BPSD – Handbook for Family Physicians
Chapter Index

Introduction to Pharmacological Treatment of BPSD ............................. 1
Key Questions Related to the Use of Psychotropics in BPSD ............... 1
Main Indications for the Use of Psychotropics ........................................ 2
Important Basic Principles to Consider when Prescribing
Medications for BPSD ................................................................................. 3
Selecting the Right Medication .................................................................. 4
Classes of medications commonly used in BPSD ................................................... 5
Treatment of Depressive and Anxiety Disorders/Symptom Clusters .... 5
Duration of Antidepressant Treatment...................................................... 7
A Word about Benzodiazepines in the Treatment of Depressive &
Anxiety Disorders ........................................................................................ 8
Treatment of Persistent Psychotic Symptoms and Severe Agitation .. 10
The Newer Atypicals: Potential Concerns .............................................. 10
Treatment of Dementia: Cognitive Enhancers and Glutaminergic
Agents ........................................................................................................ 11
Treatment of Severe Agitation Likely Due to Delirium .......................... 12
Treatment of Behavioural Problems Due to Lewy Body Dementia ...... 15
Treatment of Inappropriate Sexual Behaviour ....................................... 15
Treatment of Sleep Disturbances ............................................................ 15
High-Risk Situations: Capacity is an Issue and Psychotropics
are Required .............................................................................................. 16
Conclusion ................................................................................................. 16
References ................................................................................................. 17

BPSD – Handbook for Family Physicians
BPSD – Handbook for Family Physicians
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Introduction to Pharmacological Treatment of BPSD

The goal of this chapter is to assist family physicians in the effective use of psychotropics in
the treatment of persons with BPSD. We will review how to:
1. Identify conditions that may be responsive to medications and those that will only
respond to environmental or caregiving approaches.
2. Select the right medication for a particular situation and individual, minimizing the risk of
side effects and maximizing its benefits.
3. Use recommended pharmacological treatments for specific clusters of BPSD.

The U.R.A.F. problem-solving and collaborative care approach provides a vehicle for
defining the problem and coming to a common understanding of the causes of each
problem, their impact, and severity in the context of the patient and family, including the
evaluation of RISKS. This foundation helps physicians to establish a shared set of goals,
expected outcomes and specific roles for each care provider in regards to the actions that
need to be taken and follow-up required.

Key principles to keep in mind throughout this chapter are:

• Use psychotropics within the context of the overall clinical assessment framework,
described in chapter 1 (U.R.A.F. and P.I.E.C.E.S.).

• Use psychotropics with the appropriate non pharmacological approach(es).

• Use psychotropics with an informed, involved patient and family working with an
informed interdisplinary team or circle of care.

Key Questions Related to the Use of Psychotropics in BPSD

The following questions have been used as part of the P.I.E.C.E.S. training to help health
care professionals identify appropriate use of pharmacological treatments. Physicians, with
the help of information provided by partners in care, are responsible for the identification of a
clear indication for the use of medication (diagnosis), selection of the right medication and
monitoring of response and side effects.

Three-Questions for Detecting, Selecting and Monitoring
the Use, Risk and Benefits of Psychotropics

1. Detect: When should a psychotropic be used or considered?

2. Select: How do I contribute to the selection of the right medication?

3. Effect: How do I monitor the response and side effects?

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The P.I.E.C.E.S. educated health care providers can provide family physicians with
information that will assist in identifying patients that may be responsive to psychotropics
and establishing a baseline frequency and intensity of symptoms that will require monitoring
during treatment. Monitoring of the benefits/response and emerging or troublesome side
effects can also be done collaboratively through instruments contained in the Toolkit section.

Main Indications for the Use of Psychotropics

Psychotropic medications may be considered during the course of dementia for:

• Specific treatment for a mental disorder (e.g., a major depressive disorder, anxiety
disorder or chronic psychotic or delusional disorder);
• Specific treatment for an associated behaviour or mental health problem in dementia
(e.g. persistent agitation or psychosis not responsive to non-pharmacological
interventions);
• Adjunctive, temporary treatment (e.g. delirium with significant agitation and psychosis
where short-term use of an antipsychotic may be required).

Consider pharmacological treatment of BPSD when:

1. Behaviour is dangerous, distressing, disturbing, damaging to social relationships and
persistent,
AND
2. Has not responded to comprehensive non-pharmacological treatment plan including
removal of possible offending drugs.
OR
3. Requires emergency treatment to allow proper investigation of underlying problems.
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Important Basic Principles to Consider when Prescribing Medications
for BPSD

1. Physicians need to try to correct or optimize treatment for underlying diagnosable
medical conditions. For example, if the behavioural problems are clearly due to
memory deficits due to dementia and do not seem related to any other diagnosable
medical/psychiatric illness, one would consider treatment with a cholinesterase inhibitor.
If the behavioural problems seem to be the result of depression, one would vigorously
pursue antidepressant therapy. For problems that seem to be related to delirium or pain,
one would try to find the cause(s) of the delirium or pain and correct these underlying
medical problems first. Identifying medical problems, correcting them or optimizing their
treatment will not only improve the well being of the person but also improve tolerability
to psychotropic drugs that may be required.

2. Removing drugs that may be contributing to the BPSD: as noted previously, many
drugs can worsen behavioural problems and should be removed (some gradually to
avoid withdrawal symptoms).

3. Use one drug at a time, monitoring effect on target symptoms. It is usually possible to
obtain the desired effect by utilizing only one medication. Combinations of drugs
(haloperidol + lorazepam for example) tend to be less well tolerated (more side effects)
and carry a much higher potential for harmful drug interactions than using a single
medication. If side effects occur it may be difficult to sort out which element of the
combination needs to be removed/decreased.

4. Start low, go slow but optimize the dose and duration of treatment to allow an
adequate trial before switching to another medication.

5. Choose drugs that won’t worsen dementia or other medical problems of the patient,
watching particularly for the anticholinergic load of the medication list of the patient.
Within each class of psychotropic medications, we tend to chose drugs that have the
least anticholinergic activity, as much as possible. Examples: avoid tricyclic anti-
depressants and choose SSRIs that have lower anticholinergic properties; within SSRIs,
choose Citalopram over Paroxetine.

6. Check for potential drug-drug interactions before finalizing your choice. This is
particularly important with antidepressants, given that most SSRIs have the potential to
interact with drugs elderly patients commonly have to take, such as anticoagulants, other
antidepressants, beta blockers, anti-arrhythmics, benzodiazepines and calcium channel
blockers.

In addition to identifying a clear indication for the use of a specific medication and its
potential benefits, physicians usually have to explain to patients, substitute decision-
makers and care providers, the expected time to response, risks associated with and
without treatment, targeted dose range and potential side effects that would prompt a
dose reduction or discontinuation. Part of having the right indications for treatment
includes the identification of those conditions that will not respond to pharmacological
interventions.

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Behaviours NOT (Usually) Responsive to Medication
1. Aimless wandering
2. Inappropriate urination/defecation
3. Inappropriate dressing/undressing
4. Annoying perserverative activities
5. Vocally repetitious behaviour
6. Hiding/hoarding
7. Pushing wheelchair bound co-patient
8. Eating inedibles
9. Tugging at/removal of restraints
Behaviours that May be Responsive to Medication
1. Physical aggression
2. Verbal aggression
3. Anxiety and restlessness
4. Sadness, crying, anorexia, insomnia and other symptoms indicative of depression
5. Withdrawal and apathy
6. Sleep disturbance
7. Wandering with agitation/aggression
8. Elation, pressured speech and hyperactivity (manic like symptoms)
9. Persistent delusions and hallucinations
10. Sexually inappropriate behaviour with agitation

Selecting the Right Medication

The RISKS and severity of the presenting problems will help define the need for specific
immediate interventions for those behaviours that may adversely affect the individual and/or
caregiver. Physicians, by their training, are skilled at considering a full differential diagnosis,
taking appropriate action (examination and investigations) to confirm most likely diagnoses
that guide the selection of treatment. For example, the person is having significant sleep
problems in the context of a depression complicating dementia: one would select an
antidepressant (rather than a sedative) with low anticholinergic activity (to avoid worsening
dementia), taking into account possible drug interactions with cholinesterase inhibitor and
monitoring closely for gastrointestinal problems or side effects of the combined
antidepressant + cholinesterase inhibitor.

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Classes of medications commonly used in BPSD

1. Antidepressants
2. Anxiolytic (mostly SSRIs and other antidepressants)
3. Antipsychotic medications
4. Cognitive enhancers
5. Mood stabilizers

Tables regarding medications commonly used in the treatment of BPSD can be found
in the Toolkit. They outline their main indications, usual starting dose, average and
maximum recommended doses and main side effects to monitor for. Treatments used for
depressive and anxiety disorders, persistent and distressing psychotic symptoms,
delirium and dementia itself are summarized in these 2 tables.

Treatment of Depressive and Anxiety Disorders/Symptom Clusters

When a diagnosis of depression is clear and meets the DSM IV criteria for a major
depressive episode, antidepressant medications are recommended in addition to supportive
psychotherapeutic interventions. For those patients who present with depressive symptoms
that are clearly part of an adjustment reaction to a recent traumatic event and/or those for
whom the diagnosis is not as clear, a period of observation and documentation of symptoms
should be considered prior to pharmacological treatment. The length of the observational
period may range from 2 to 8 weeks, but a decision should be made in a timely manner as
to not delay treatment, particularly if symptoms are worsening. The full range of treatment
modalities should be considered, including psychosocial interventions (e.g., education,
participating in social events), psychotherapy, and pharmacological interventions. A full
review of the treatment of depressive disorders, including depression occurring in the
context of dementia is provided by the Canadian Coalition for Seniors’ Mental Health:
Guidelines on the Assessment and Treatment of Depression and can be downloaded from
the web: www.ccsmh.ca.

Selection of an appropriate antidepressant medication should be based on:

a) Previous response to antidepressant (avoiding medications that clearly failed or
gave unacceptable side effects);
b) Other medical comorbidities (e.g., selecting a drug that will not worsen dementia or
worsen a vulnerability to urinary retention);
c) Side effect profile of the antidepressant (e.g., avoiding drugs that may cause
severe hypotension and falls and drugs that have high anticholinergic properties);
d) Potential drug-drug interactions, considering other medications that have to be
taken.

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The presence of dementia or cognitive impairment dictates that we select drugs that will not
worsen the cognitive difficulties and therefore have low anticholinergic properties. Amongst
current antidepressants available, the following have the lowest anticholinergic activity:

• Venlafaxine (Effexor)
• Moclobemide (Manerix)
• Buproprion (Welbutrin)
• Citalopram (Celexa)
• Escitalopram (Cipralex)
• Sertraline (Zoloft) and Mirtazapine (Remeron) are also acceptable but probably have
a bit more anticholinergic properties ( ref: Clinical Handbook of Psychotropic Drugs,
th
17 edition, 2007)

From the above choices, one has to determine which drug is best suited for the medical
co-morbidities of the patient. For example, patients who have had difficult to stabilize
hypertension may have problems with Venlafaxine and therefore an SSRI such as
Citalopram is likely a better choice. On the other hand, patients who have significant
problems with chronic pain may benefit from the noradrenergic activity of Effexor. Another
example would be that patients who have Parkinson Disease may see a worsening of their
Parkinsonian symptoms with a pure SSRI, although not necessarily so. If other choices are
reasonable in the context of the health problems of the patient, then one would go to drugs
that have dual action or more adrenergic activity such as Venlafaxine, Bupropion or Manerix
for such a patient.

Drug interactions are also important to consider. In the example above, if a patient with
Parkinson Disease also takes Eldepryl, a MAO-B inhibitor, then utilizing Moclobemide would
be difficult as a full MAOI diet would be required to allow its safe use. Several SSRIs are
problematic to use in the elderly (e.g. fluoxetine, fluvoxamine, paroxetine) because of the
potential for serious drug interactions with other medications elderly patients have to take.

Initial dosage, average and maximum recommended doses are provided in the table
on the following page. Patients who start on serotonergic antidepressants (e.g.
Citalopram, Sertraline) should be monitored for common side effects such as nausea
headaches and diarrhea, as well as less common but potentially serious ones, such as
hyponatremia (leading to fatigue, malaise, delirium) or serotonin syndrome (with agitation,
tachycardia, tremor, hyperreflexia). Venlafaxine can cause increased blood pressure when
used in the higher dose range (beyond 150 mg daily). There is an increased risk of seizures
with higher dosages of bupropion and weight gain is more common with mirtazapine.

There is some evidence supporting the use of moclobemide as a first line agent, although
this antidepressant is not commonly used in Canada. It is particularly well tolerated with a
very acceptable side effect profile. Mirtazapine is available as a rapidly dissolving wafer
(Remeron-RD) which may be useful for residents with swallowing problems. Escitalopram
(the S-enantiomer of citalopram) is now available in Canada and may be a useful SSRI in
seniors, although initial dosage has to be low.

Tricyclic antidepressants (TCAs) may be used in the rare occasion where a patient with
dementia has a “treatment-resistant” depression that has not responded to other adequate
trials of other antidepressants. Nortriptyline and desipramine have lower anticholinergic
BPSD – Handbook for Family Physicians