Persons older than 65 years numbered 39.6 million in 2009 representing 12.9% of the U.S. population. There will be roughly 72 million older persons by 2030, more than twice their number in 2000.1 Babyboomers entered this category in 2011 largely accounting for this increase in the older population. This growth will have wide-ranging implications for the country including in health care management. Treatment of dementia has become a higher priority in the last 10 years as the risks compound with the aging population. Along with the aging population and better recognition of dementia, the prevalence of dementia has
In 2012, the American Geriatrics Society (AGS), along with a panel of 11 experts, updated the Beers Criteria which has evolved significantly since its inception in 1991. The Beers Criteria, in general, classifies medications/medication classes as: (1) potentially inappropriate for use in all older adults, (2) potentially inappropriate for older adults with certain diseases or symptoms and (3) requiring extra caution when used in older adults. Although each patient must be evaluated individually, the Beers Criteria is a useful clinical tool that can be used when initiating pharmacologic agents in both ambulatory and institutionalized patients. The concept behind use of the Beers Criteria is that it allows prescribers to readily identify, and avoid, medications associated with negative outcomes in older adults therefore decreasing the risk of adverse drug events (ADEs). Within this review article, there will be a highlight of potentially inappropriate medications (PIMs) commonly seen in clinical practice settings such as antipsychotics, benzodiazepines, non-benzodiazepine sedative-hypnotics, anticholinergics and sliding scale insulin. The focus will be to outline the risk-benefits of these drug classes within the context of persons with dementia. Furthermore, the use of PIMs has both clinical and financial implications in Medicare Star ratings and Healthcare Effectiveness Data and Information Set (HEDIS) measures.
Behavioral and psychiatric symptoms of dementia (BPSD) refer to a heterogeneous group of symptoms that represent non-cognitive complications of Alzheimer's disease (AD) and other dementias. Currently, there are no FDA-approved antipsychotic medications for management of BPSD in the United States. Second generation antipsychotics (SGAs) should only be used for appropriate and justified BPSD targets including distressing and severe physical aggression and/or disturbing hallucinations or delusions that pose a risk of harm to self or others after non-pharmacologic interventions have failed. At best, SGAs provide only modest effects and are associated with increased risk for mortality and cerebrovascular complications in addition to other agent-specific side effects. Current evidence and recommendations support use of risperidone, aripiprazole or olanzapine for Alzheimer's disease (AD) and vascular dementia (VaD), and use of quetiapine or clozapine for Lewy body dementia (LBD) and Parkinson's disease dementia (PDD). Any SGA should be initiated at low dosages with slow titration; and the lowest effective dose should be used as a maintenance dose only for a short period of time. Patients should be monitored for clinical response and adverse effects and should be periodically evaluated for continued need for medication. Appropriate use of SGAs for management of BPSD is critical to increase safety for our growing elderly population with dementia.
Alzheimer's disease (AD) and other dementias are associated with symptoms that extend far beyond cognitive deficits. The most distressing of these symptoms are known as the behavioral and psychological symptoms of dementia (BPSD) and include delusions, hallucinations, agitation and aggression, misidentification, and sexually inappropriate behaviors. As a result of BPSD, AD patients suffer a poorer quality of life, as do their caregivers.1 Behavioral and psychological symptoms can be so distressing to the caregiver that they are a common reason for families placing their loved ones in long-term care. Approximately 60% and 80% of dementia patients living inINTRODUCTION
Review of antidepressants in the treatment of behavioral and psychiatric symptoms in dementia (BPSD)
Behavioral disturbances are commonplace among patients with dementia. Management of these symptoms has proved difficult.1,2 Currently, there are no FDA approved pharmacologic treatments for the treatment of BPSD.3 Traditionally, atypical antipsychotics have been used to treat behavioral disturbances despite modest efficacy and undesirable adverse effects.34,5 Because of the increase in mortality, there is a continued push to reduce antipsychotic utilization in this population.9,10 Thus, many clinicians are using alternative agents such as antidepressants and mood stabilizers to help treat BPSD, while avoiding using antipsychotics. The goal of this review is to review, analyze, and discuss the current literature available on the use of antidepressants to treat BPSD.
Objective. To review the evidence for the pharmacologic and non-pharmacologic management of sundowning in patients with dementia.
Methods. Databases were searched using the terms sundown, circadian, chronobiological, biological clock, elderly, aged, geriatric, and senior. Studies selected for inclusion assessed potential interventions for the treatment of sundowning or nocturnal agitation.
Results. A total of thirteen individual studies and two systematic reviews were evaluated. Study design and outcomes varied, but many measured sleep and nocturnal agitation. Non-pharmacologic interventions that may be of benefit include bright light therapy, music therapy, and aromatherapy. Pharmacologic therapies generally provided minimal benefit and were associated with safety concerns. Supportive evidence was found for the use of melatonin and antipsychotics. Evidence for antidepressants, donepezil, and dronabinol was weaker. Supportive evidence for the use of benzodiazepines was not found and thus cannot be recommended in elderly patients as they are more susceptible to their adverse effects.
Conclusion. The number of studies on the management of sundowning is limited and the quality of evidence supporting its treatment is weak. Non-pharmacologic interventions are first line due to safety. Pharmacologic agents are recommended as second line treatment options, in particular antipsychotics and melatonin.
Many consumers use alternative preparations such as herbals, vitamins, and over-the-counter products in an attempt to prevent or improve the outcome of dementia. Despite use by almost half of all patients, evidence supporting their utilization is either conflicting or lacking. Omega-3 fatty acids, vitamin B6, vitamin B12, vitamin C, and beta-carotene currently do not have clinical trials showing evidence impacting the progression or treatment of symptoms associated with dementia. In addition, conflicting data exist pertaining to the beneficial utilization of ginkgo biloba and nonsteroidal anti-inflammatory drugs associated with dementia treatment. While a link to the utility of folate associated with areas of improved cognitive functioning has been suggested, further studies are needed. Vitamin E may have some benefit in patients with Alzheimer's disease, however, may also have risks in patients with comorbid diseases such as cardiovascular disease or diabetes mellitus. With limited options still existing today in the treatment of dementia, the importance of further studies to quantify alternative therapies remains an important topic.
Background: The Beers Criteria and STOPP Criteria were developed to identify potentially inappropriate medications (PIMs) in the geriatric population. Utilization of STOPP Criteria PIMs have shown a significant association with presence of avoidable adverse drug events (ADEs) as compared to utilization of Beers Criteria PIMs.
Objectives: The purpose of this study was to utilize STOPP and Beers Criteria to identify PIMs in geriatric patients at an inpatient psychiatric facility, with the goal of implementing a formal process for assessing medication regimens. This process would be expected to decrease adverse outcomes.
Methods: Both criteria were used by the pharmacist to identify PIMs and recommendations were made to address the PIMs. A retrospective chart review evaluated whether utilization of the two criteria led to a significant change in number of PIMs and associated adverse outcomes. The primary outcome was the change in number of PIMs for the Beers Criteria versus the STOPP Criteria. Secondary outcomes included the change in number of PIMs, falls, required referrals/transfers, and medication-specific ADEs for each set of criteria assessed separately.
Results: Twenty-nine patients met inclusion criteria, and 76 treatment recommendations were made. More PIMs per patient were identified at baseline utilizing STOPP (mean±SD,3.9±2.3) versus Beers Criteria (mean±SD, 2.2±1.3) (p<0.001). The number of PIMs decreased using STOPP (from 112 to 66; mean decrease per patient −1.6±1.5, p<0.0001) and Beers Criteria (from 63 to 23; mean decrease per patient −1.4±1.1, p<0.0001), although the change was not significant for STOPP vs. Beers (p=0.375). All secondary outcomes decreased using both criteria.
Conclusions: Utilization of each set of criteria by the pharmacist led to a significant decrease in PIMs and adverse outcomes decreased at follow-up using both criteria. Implementation of a process for assessing medication regimens of geriatric patients utilizing the Beers and/or STOPP Criteria would likely be beneficial to this institution.
It is estimated that about 90% of older adults with dementia experience neuropsychiatric symptoms.1 These symptoms include but are not limited to agitation, aggression, delusions, and hallucinations. Neuropsychiatric symptoms are often treated with antipsychotics. However, the use of antipsychotics in the dementia population is associated with an increased risk of death, mostly due to cerebrovascular events. All antipsychotic medications (both first generation and second generation) have a Black Box Warning for increased mortality in elderly patients with dementia-related psychosis. The Centers of Medicare and Medicaid Services (CMS) have taken steps to help reduce this risk with itsINTRODUCTION