BYRNE Parliamentary House presentation 20 June 2011 - Dementia ·...
Transcript of BYRNE Parliamentary House presentation 20 June 2011 - Dementia ·...
An#psycho#c Medica#on in People with Demen#a
GERARD BYRNE BSc (Med), MBBS (Hons), PhD, FRANZCP, MFPOA
School of Medicine, University of Queensland Mental Health Service, Royal Brisbane & Women’s Hospital
Prevalence of Demen#a By Age, Australia
Jorm et al. Acta Psychiatrica Scandinavica 1987; 76: 465-‐479
%
Propor#on Of Popula#on Aged 65+ Years Projec#ons, Australia
Probability Of Being In Permanent Aged Care By Age & Gender
DoHA Technical Paper on the changing dynamics of residen#al aged care, April 2011
Behavioural & Psychological Symptoms of Demen#a (BPSD)
• Behavioural symptoms – Noisy behaviour (screaming, calling out etc) – Agita#on & aggression (hieng, kicking etc) – Motor overac#vity (pacing, wandering) – Appe#te & sleep disturbance
• Psychological symptoms – Apathy, Anxiety, Depression, Delusions, Hallucina#ons, Misiden#fica#on
Behavioural & Psychological Symptoms Community Prevalence by Demen#a Severity (in Cache County, Utah)
Lyketsos et al. (2001) IJGP 16:1043-‐1053
% NPI*
*Neuropsychiatric Inventory
Persistence of Symptoms Maasbed Study (The Netherlands)
NPI* %
Aalten et al. (2005) Int J Geriatr Psychiatry 20: 523-‐530
N = 199 ambulatory pa#ents with demen#a; 76.4yrs; 2yr persistence means presence of symptom at all 4 assessment periods over 2 years; 80.9% had one or more BPSD at baseline; NPI administered 4 #mes over 2 years
*Neuropsychiatric Inventory
An#psycho#c Drug Use By Age & Gender, Australia
PBS Data; Hollingworth et al. (2010) ANZ J Psychiatry 44, 372-‐377
An#psycho#c Use In Sydney Nursing Home Residents (2009)
• 690 (28%) of 2,465 residents of 44 Nursing Homes were taking an#psycho#c medica#on regularly
• 537 (21.8%) were taking modern “atypical” an#psycho#cs
• 286 (11.6%) were taking risperidone • 180 (7.3%) were taking olanzapine
44 of 48 Nursing Homes in the catchment of the Sydney South-‐West Health Service par#cipated in this survey. Snowdon et al. (2011) Med J Aust 194, 270-‐271
Efficacy Of An#psycho#cs
• In clinical trials of an#psycho#c medica#on in people with demen#a complicated by psychosis, agita#on or aggression approximately 16 of every 100 persons treated showed some improvement – this is considered a small effect size
• Trials generally went for 8-‐12 weeks only, so very limited knowledge of efficacy beyond this
Common Side-‐Effects Of An#psycho#cs In Older People
• Seda#on • Parkinsonism
• Falls • Weight gain
• Diabetes • Increased lipids
Excess Mortality In NH Residents Treated With An#psycho#cs
• Meta-‐Analysis of clinical trials: – An#psycho#c 4.5% mortality
– Placebo 2.6% mortality – Rela#ve risk: 1.7
• For every 100 people with demen#a treated with an#psycho#cs, one death will occur each 10-‐12 weeks
Chahine et al. (2010) Harvard Review of Psychiatry 18, 158-‐172.
PBS Authority Rules
• Olanzapine (Zyprexa™) – Schizophrenia – Bipolar I disorder
• Risperidone (Risperdal™) – Schizophrenia – Bipolar I disorder – Behavioural disturbances characterised by psycho#c symptoms and aggression in pa#ent with demen#a where non-‐pharmacological methods have been unsuccessful
An#psycho#c Drug Use By Age & Gender, Australia
PBS Data; Hollingworth et al. (2010) ANZ J Psychiatry 44, 372-‐377
Survival Following An#psycho#c Discon#nua#on
Ballard et al. (2009) Lancet Neurology 8, 151-‐157
UK NH residents with AD
Behaviour Auer Discon#nua#on
• NH residents with mild to moderate behavioural disturbance (NPI ≤ 14) – An#psycho#c vs Placebo difference = 0.49 (95% CI: -‐5.63 – 6.60) [lixle difference but NS]
• NH residents with severe behavioural disturbance (NPI 15+) – An#psycho#c vs Placebo difference = -‐5.33 (95% CI: -‐15.82 – 5.17) [favours an#psycho#c but NS]
Ballard et al. (2008) PLoS Med 5(4): e76. doi:10.1371/journal.pmed.0050076
Non-‐Pharmacological Treatments For BPSD
• Two main evidence-‐based approaches: – Behaviour management techniques to reduce frequency of
problem behaviours – Caregiver training to reduce burden, distress & depression and to
increase coping
• Other specific interven#ons – Mainly designed to temporarily modify behaviour (i.e. for 30
minutes or so)
Ayalon et al. (2006) Arch Intern Med 166: 2182-‐2188; Logsdon et al. (2007) Psychology & Aging 22: 28-‐36; Selwood et al. (2007) J Affect Dis 101: 75-‐89; Opie et al. (1999) Aust NZ J Psychiatry 33: 789-‐799; Bird et al. (2002) Commonwealth Dept Health & Ageing; Turner S. (2005) Aging & Mental Health 9(2): 93-‐104
Alterna#ves To An#psycho#cs
• Ins#tute person-‐centred care • Include rela#ves in the care of the resident • Implement structured ac#vity programs
• Create domes#cally scaled environments
• Provide flexible care, not rigid rou#nes, thereby reducing resistance to care
• Improve professionalism of care staff
Modified from Rosenwarne et al. (1997)
Summary
• Increased longevity & popula#on structure -‐> increased demen#a
• High probability of NH placement • Challenging behaviours prevalent but tend not to persist • Inappropriate use of an#psycho#c medica#on • Increased mortality with an#psycho#cs
• Discon#nua#on ouen successful • Insufficient use of non-‐drug interven#ons
• Problems with the funding model
Some Policy Sugges#ons
• Use rate of an#psycho#c drug use in people with demen#a as a quality indicator for NH audits
• Set targets for reduced use of an#psycho#cs in people with demen#a in Commonwealth-‐supported programs
• Support targeted training programs for Registered Nurses, General Prac##oners, Psychiatrists, Physicians, Psychologists (& students of these disciplines)
• Mandate a formal curriculum for non-‐pharmacological interven#ons by NH personal care staff & an annual training budget
• Improve access to clinical psychology input to people with demen#a at home and in RACFs
More Policy Sugges#ons
• Await Produc#vity Commission report on a new NH funding model -‐ improved psychosocial treatment will have cost implica#ons
• Pursue vigorous pharmaceu#cal detailing via the Na#onal Prescribing Service (NPS)
• Augment exis#ng Demen#a Behaviour Management Advisory Service (DBMAS)
• Develop properly funded & supported psychogeriatric NHs in each region to manage the most challenging behaviours
• [Prosecute ‘off-‐label’ prescribers]