EXPERT ANALYSIS FROM THE AAGP ANNUAL MEETING

NEW ORLEANS (FRONTLINE MEDICAL NEWS) –An individualized, step-by-step plan is the best way to treat psychiatric and behavioral problems that might arise in patients with dementia.

But, according to Dr. Rajesh R. Tampi, “There’s no one silver bullet” for these symptoms, which can make things very hard not only on the patient but [also on] the family and caregiving staff.

No medications are approved for treating these symptoms in dementia patients, Dr. Tampi said at the annual meeting of the American Association for Geriatric Psychiatry. Furthermore, some of the most commonly used medications simply aren’t effective, and those that are often come at the price of side effects that prompt discontinuation.

Benzodiazepines, which are still quite often employed, are usually much more harmful than useful, he said. “The data for using benzodiazepines for behavioral problems in dementia simply do not exist. And given the new data we have on worsening of cognition, and a fivefold increase in the risk of falls, I do not think they are useful. I use them only for alcohol- or benzodiazepine-withdrawal or as an intramuscular injection to sedate but never for continuing management.”

Prevention is always the best medicine, said Dr. Tampi, chief of geriatric psychiatry at MetroHealth, Cleveland. Behavioral and psychiatric symptoms often arise as dementia worsens, so delaying disease progression may delay symptom onset as well. Cholinesterase inhibitors and memantine are the only medications approved for this purpose, and studies have found that donepezil, galantamine, and memantine also seem to exert some modest benefit on existing behavioral symptoms. These drugs generally are well tolerated, too, he added.

Prevention also can come in the form of a general physical and psychiatric health assessment. “Just because a person has dementia doesn’t mean there can’t be other psychiatric or physical conditions going on as well. For example, about 20% of dementia patients have a comorbid depression.” Pain, too, is common in these patients and can cause or exacerbate behavioral problems. Getting a handle on these underlying issues is the first step in building an effective treatment paradigm.

Most behavioral symptoms that occur in dementia patients are nonemergent. Because an emergency behavioral situation, like dangerous aggression, is rare, time is on everyone’s side. After making sure the proper cognition-enhancing medications are on board and pain or underlying illnesses addressed, psychological and behavioral interventions should be next in line.

But as dementia progresses, these lower-order approaches may become less and less effective. Eventually, medical therapy may be necessary. Dr. Tampi shared a treatment algorithm that he and his Veterans Affairs colleagues developed. The algorithm, published in 2011, divides behavioral symptoms by clinical presentation: depressed/anxious, hypomanic/manic, psychotic, and agitation/aggression.

In line with moving from least to highest treatment intensity, Dr. Tampi suggested always starting with low-dose monotherapy. For mood disorders in dementia patients, data support the use of SSRIs. For mania/hypomania, the algorithm recommends carbamazepine or divalproex, or an atypical antipsychotic. He also uses atypical antipsychotics for patients with psychotic symptoms. For those who exhibit agitation or aggression, the algorithm suggests carbamazepine, SSRIs, divalproex, or trazodone.

“If monotherapy doesn’t work, some drug combinations – like an SSRI with an antipsychotic or a mood stabilizer, do make sense and are effective, but they must be used judiciously,” Dr. Tampi said. Any behavioral or psychological interventions already in place should be continued, and even reinforced, when medical therapy comes on board, he added.

Emergent behaviors, or course, need quick solutions. However, Dr. Tampi still incorporates a judicious approach to handling them. “We always use oral medications at first. We only go with intramuscular if there’s no response or if the patient refuses.”

He recommended starting with risperidone, aripiprazole, quetiapine, or olanzapine, with a second dose 30 minutes to 1 hour later if needed. “You may need one or two repeats before the patient calms down, though,” he said.

If the agitation or aggression is very severe, or if the patient refuses oral medications, Dr. Tampi said injections are in order. His preferences are aripiprazole 1.875-7.7 mg, olanzapine 2.5-5 mg, or haloperidol 0.5-2 mg.

“Again, you can repeat the dose in 30 minutes to 1 hour if needed, and you might need to repeat once or twice before the patient calms down.”

He had no financial disclosures.

msullivan@frontlinemedcom.com

On Twitter @alz_gal

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