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04. Pharmacologic and Nonpharmacologic Treatment Approaches

Published on April 1, 2022 Certification expiration date: April 1, 2028

Lauren B. Gerlach, D.O., M.S.

Health Services Researcher - University of Michigan Department of Psychiatry

Key Points

Knowing the underlying cause of BPSD helps direct the appropriate treatment.
Infections, problems with caregivers, trouble with the environment, and psychosis should all be approached very differently.
Persons with dementia are often prescribed psychotropic medications despite evidence for a modest treatment effect.
Although antipsychotics do have the best evidence for treatment of BPSD, they are associated with significant risks.

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Slides and Transcript

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Next, we’re going to spend some time talking about both pharmacologic and nonpharmacologic treatment approaches.

Pharmacologic and Nonpharmacologic Treatment Approaches Slide 1 of 15

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And when trying to understand how to best address a behavioral and psychological symptom in dementia, it’s really important to understand what the underlying etiology is and that will really help you direct treatment. So a urinary tract infection, pain, issues with the caregiver, or psychosis should all be addressed very differently.

References:

Schneider, L. S., Pollock, V. E., & Lyness, S. A. (1990). A Metaanalysis of controlled trials of neuroleptic treatment in dementia. Journal of the American Geriatrics Society, 38(5), 553-563
Gerlach, L. B., & Kales, H. C. (2020). Managing behavioral and psychological symptoms of dementia. Clinics in Geriatric Medicine, 36(2), 315-327.

Pharmacologic and Nonpharmacologic Treatment Approaches Slide 2 of 15

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Slide 3 of 15

However, in real-world treatment, patients with behavioral and psychological symptoms of dementia often receive antipsychotics. Now, while antipsychotics do have the best evidence for treating these symptoms, their effects, meaning the magnitude of their treatment size, are moderate at best and they have an effect size of 0.13 to 0.16. And any benefits with an antipsychotic must be balanced against the risk of adverse events including mortality as outlined by the US FDA box warning.

References:

Schneider, L. S., Pollock, V. E., & Lyness, S. A. (1990). A Metaanalysis of controlled trials of neuroleptic treatment in dementia. Journal of the American Geriatrics Society, 38(5), 553-563
Gerlach, L. B., & Kales, H. C. (2020). Managing behavioral and psychological symptoms of dementia. Clinics in Geriatric Medicine, 36(2), 315-327.

Pharmacologic and Nonpharmacologic Treatment Approaches Slide 3 of 15

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So many of you are probably aware of the US FDA black box warning related to use of the antipsychotics for dementia-related behaviors. And that’s based off of numerous randomized clinical trials that showed that elderly patients with dementia-related psychosis who are treated with antipsychotic drugs are at an increased risk, and generally we say 1.6 to 1.7 times increased risk of death, as compared to placebo.

References:

Schneider, L. S., Pollock, V. E., & Lyness, S. A. (1990). A Metaanalysis of controlled trials of neuroleptic treatment in dementia. Journal of the American Geriatrics Society, 38(5), 553-563.
Gerlach, L. B., & Kales, H. C. (2020). Managing behavioral and psychological symptoms of dementia. Clinics in Geriatric Medicine, 36(2), 315-327.

Pharmacologic and Nonpharmacologic Treatment Approaches Slide 4 of 15

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And folks often ask, what are the causes of death related to antipsychotic treatment? And generally, that tends to be a cardiovascular event like a ventricular arrythmia or prolonged QTc. It can be a cerebrovascular event like a stroke or a pneumonia like an aspiration event.

References:

Schneider, L. S., Pollock, V. E., & Lyness, S. A. (1990). A Metaanalysis of controlled trials of neuroleptic treatment in dementia. Journal of the American Geriatrics Society, 38(5), 553-563.
Gerlach, L. B., & Kales, H. C. (2020). Managing behavioral and psychological symptoms of dementia. Clinics in Geriatric Medicine, 36(2), 315-327.

Pharmacologic and Nonpharmacologic Treatment Approaches Slide 5 of 15

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It’s important to remember though that antipsychotics have many other side effects other than just the increased mortality risk which can also cause distress for patients. And those can include things like extrapyramidal side effects, falls, sedation as well as worsening cognition.

References:

Schneider, L. S., Pollock, V. E., & Lyness, S. A. (1990). A Metaanalysis of controlled trials of neuroleptic treatment in dementia. Journal of the American Geriatrics Society, 38(5), 553-563.
Gerlach, L. B., & Kales, H. C. (2020). Managing behavioral and psychological symptoms of dementia. Clinics in Geriatric Medicine, 36(2), 315-327.

Pharmacologic and Nonpharmacologic Treatment Approaches Slide 6 of 15

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Slide 7 of 15

So I’ll highlight some findings from a few studies here. The first study was done by Donovan Maust which took a look at patients with dementia who received antipsychotic medications as well as valproic acid and looked at the number needed to harm for each of these medications. So they looked at how many patients had to be treated to cause one episode of death or what they called harm.

References:

Maust, D. T., Kim, H. M., Seyfried, L. S., Chiang, C., Kavanagh, J., Schneider, L. S., & Kales, H. C. (2015). Antipsychotics, other psychotropics, and the risk of death in patients with dementia. JAMA Psychiatry, 72(5), 438.

Pharmacologic and Nonpharmacologic Treatment Approaches Slide 7 of 15

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And the numbers are far too small for these medications. And for haloperidol, it can take only eight patients treated with this medication to be associated with one death. And even for valproic acid, there is still an increased risk.

References:

Maust, D. T., Kim, H. M., Seyfried, L. S., Chiang, C., Kavanagh, J., Schneider, L. S., & Kales, H. C. (2015). Antipsychotics, other psychotropics, and the risk of death in patients with dementia. JAMA Psychiatry, 72(5), 438.

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Slide 9 of 15

The figure here shows a graph from a study from Helen Kales looking at veterans with dementia who were prescribed different antipsychotic medications and survival over time. And as we can see, patients with dementia who are prescribed these medications have decreased survival curves, meaning that each of these medications is associated with mortality. Haloperidol is the purple line here which has a steeper slope and associated with greater mortality. Quetiapine is the green line on top, a little bit less but still an increased mortality risk.

References:

Kales, H. C., Valenstein, M., Kim, H. M., McCarthy, J. F., Ganoczy, D., Cunningham, F., & Blow, F. C. (2007). Mortality risk in patients with dementia treated with antipsychotics versus other psychiatric medications. American Journal of Psychiatry, 164(10), 1568-1576.

Pharmacologic and Nonpharmacologic Treatment Approaches Slide 9 of 15

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So we know that these antipsychotic medications come with significant risk. So it’s important to think about what are other evidence-based approaches to detecting and managing these behaviors. And it’s really important to think about what are the possible etiologies that are contributing, to include caregivers in the process.

References:

Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2015). Assessment and management of behavioral and psychological symptoms of dementia. BMJ, 350(27), h369-h369.

Pharmacologic and Nonpharmacologic Treatment Approaches Slide 10 of 15

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Slide 11 of 15

As well as to think about how to integrate pharmacologic and nonpharmacologic treatment options as well as the built-in flexibility to use these types of treatments in a variety of care settings where patients are.

References:

Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2015). Assessment and management of behavioral and psychological symptoms of dementia. BMJ, 350(27), h369-h369.

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And really, the goal is to try to avoid knee jerk prescribing of medications without an assessment of underlying causes. And in the next section, I’ll kind of walk through how we think about nonpharmacologic treatment options for behavioral disturbances in dementia.

References:

Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2015). Assessment and management of behavioral and psychological symptoms of dementia. BMJ, 350(27), h369-h369.

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Slide 13 of 15

All right. So our key points. So similar to the treatment of delirium, knowing the underlying causes of behavioral and psychological symptoms of dementia will really help best direct the appropriate treatment. So again, infections, issues with caregivers, trouble with the environment and psychosis should all be approached very differently. 13

Pharmacologic and Nonpharmacologic Treatment Approaches Slide 13 of 15

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However, in real-world practice, persons with dementia are often prescribed psychotropic medications like antipsychotics despite evidence for a modest treatment effect. While antipsychotics do have the best evidence for treatment of behavioral and psychological symptoms of dementia, they are associated with significant risk including increased mortality, falls, confusion, sedation as well as motor side effects.

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Slide 15 of 15

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Next Section

05. Overview of Nonpharmacologic Treatment for BPSD

Learning Objectives:

After completing this activity, the learner will be able to:

Assess and recognize the underlying factors that contribute to the development of behavioral and psychological symptoms of dementia.
Utilize nonpharmacologic approaches to investigate and treat behavioral disturbances.
Identify the clinical scenarios where medications should be considered as first-line treatment and prescribe them accordingly.

Original Release Date: April 1, 2022

Review and Re-release Date: April 1, 2025

Expiration Date: April 1, 2028

Expert: Lauren Gerlach, M.D.

Medical Editor: Paz Badía, M.D.

Relevant Financial Disclosures:

None of the faculty, planners, and reviewers for this educational activity have relevant financial relationships to disclose during the last 24 months with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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