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Treating Psychiatric and Behavioural Symptoms in People with Alzheimer s Disease

Short term prescribing. Up to 3 months. Non AD dementias. Vascular dementia (VaD) Some VaD patients in 2 of the risperidone studies, but no separate analysis and no specific trials of VaDDLB/PDD only 1 RCT (with quetiapine), showing no significant benefit. Serious potential concerns re neurole

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Treating Psychiatric and Behavioural Symptoms in People with Alzheimer s Disease

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    1. Treating Psychiatric and Behavioural Symptoms in People with Alzheimers Disease Clive Ballard Professor of Age Related Diseases, Kings College London and Director of Research, Alzheimers Society

    2. Short term prescribing Up to 3 months

    3. Non AD dementias Vascular dementia (VaD) Some VaD patients in 2 of the risperidone studies, but no separate analysis and no specific trials of VaD DLB/PDD only 1 RCT (with quetiapine), showing no significant benefit. Serious potential concerns re neuroleptic sensitivity Marked need for treatment studies examining treatment of neuropsychiatric symptoms in non-AD dementias

    4. Risperidone for Neuropsychiatric Symptoms: Efficacy

    6. Schneider et al 2006 Aripiprazole

    7. Risperidone for Neuropsychiatric Symptoms: Adverse Outcomes

    9. Mortality and neuroleptics in people with dementia FDA: meta-analysis of 17 placebo-controlled trials of atypical neuroleptics in AD: significant 1.7-fold increase in mortality with neuroleptics Schneider et al, JAMA 2005 : meta-analysis of 15 trials, with significant 1.54-fold increased mortality risk, with absolute increase of 1% Mortality risk less clear from case register studies Yang et al, NEJM 2005: mortality risk even higher with typical neuroleptics

    11. Longer term prescribing 6-12 months

    15. Neuroleptic withdrawal studies Bridges-Parlet et al, 1997 Cohen-Mansfield et al, 1999 Ballard et al, 2002 RCT studies, 6 weeks3 months Total >180 participants No significant worsening of BPSD in any of the studies

    16. DART-AD Ballard, Jacoby, Margallo-Lana et al 2008 12 month placebo controlled neuroleptic withdrawal trial for Nursing home residents with dementia on neuroleptics for > 3 months (most participants 12-24 months) Primary outcome at 6 months Follow-up for up to 54 months to examine mortality 165 participants randomized, 102 completed 6 months, 109 included in analysis with imputation

    17. Change from Baseline to 6 months

    18. Change from Baseline to 6 months

    19. Month 12

    21. Real Life Prescribing

    23. FITS: Baseline Prescribing Data 12 nursing homes, 348 people with dementia. 168 (48%) prescribed 1 antipsychotic, 22 (6%) prescribed 2 antipsychotics, 3 (1%) prescribed 3 antipsychotics Average annual cost for each nursing home 13, 189. Extrapolated UK annual cost 80M

    24. Illbeing (N-112)

    25. Other Pharmacological Treatments

    26. Neuropsychiatric Symptoms in AD: Alternative Pharmacological Therapies

    29. Evidence for Psychological Therapies 1,632 references, 162 were included. (Livingston 2005). Few RCT studies for specific treatments

    30. Validation Therapy Pragmatic therapy aiming to improve communication, provide empathy, restore dignity and respect the individuals reality Usually delivered in groups with elements such as communication, activities, singing and music Cochrane review (Neal 2008) 3 trials116 patients, but difficult to combine in meta-analysis Validation significantly greater improvement in behaviour than usual care (P=0.007), but equivalent to social contact.

    31. Standardized tailored psychological treatment Cohen-Mansfield 2007 (n=167) Placebo controlled trial of personalized non-pharmacological interventions for 4 hours over days resulted in significant reduction in agitation (p=0.002) Cohen-Mansfield 1997 (N=58) Placebo controlled trial of social interaction, music or simulated presence resulted in significant 25% reduction in abnormal vocalizations over 6 weeks

    32. c

    33. Conclusion Atypical antipsychotics have short term efficacy for the treatment of aggression, but have considerable adverse effects There are several candidate alternative pharmacological therapies, but better evidence is urgently needed Aromatherapy with melissa or lavender are evidence based alternatives Psychological therapies are a safe alternative, with emerging evidence of efficacy

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