Successful treatment of behavioural symptoms in severe dementia: the use of morphine

1. Case Histories illustrating the use of morphine in the management of behavioural symptoms of severe dementia. Mrs White – is an 81 year old lady who has been in nursing home for 9 months, having moved from dementia specific hostel. She has moderately severe dementia, ischaemic heart disease and some osteoarthritis. She has been quite agitated and distressed over the past 3 months, calling out constantly and banging her hands on the table or against the bed rails. Constant one on one attention relieved the distress somewhat and she was walked regularly and given gentle massage to her hands once or twice daily. She was treated with haloperidol and then risperidone, alprazolam and valproate (all together). She was also given regular paracetamol and a short course of ibuprofen for management of possible arthritic pain. However the agitation and constant calling out and banging continued. So despite reasonable attempts at non pharmacological management, and treatment with 2 antipsychotics, a benzodiazepine, a mood stabiliser, a nonsteriodal anti inflammatory and an analgesic, she remained distressed. Following further consultation with staff from the local aged care psychiatry team, she was given 2.5mg of mist morphine every 4 hours and within 24 hours she appeared less distressed. She stopped banging the table and her calling out decreased. She appeared more settled and occasionally smiled and interacted more with staff and family. Her risperidone continues, but her haloperidol and alprazolam have been ceased and her valproate reduced. She is currently on 5mg mist morph every 4 to 6 hours with a maximum of 20mg over 24 hours. She has now been on this for 4 months with no increase. An attempt was made to withdraw the morphine and Mrs White had an increase in symptoms within a day. Her appetite has improved and she has gained 2 kgs. Both family and nursing home staff are very pleased with her progress Mr Black – is a 72 year old man currently resident in a CADE (Confused and Disturbed Elderly) unit as he was not able to be managed in a dementia specific hostel. He has a history of chronic schizophrenia, alcohol related brain damage, and moderately severed dementia. He is quite mobile around the unit but requires assistance with most activities of daily living. He is generally resistant to care and can become quite violent and aggressive towards staff members and towards other residents. His medication included clozapine, haloperidol, clonazepam, mirtazepine, and paracetamol. His aggression remained present despite this treatment and attempts to manage his behaviour using non pharmacological methods. He was started on mist morph 5mg q4h almost as a last resort. Over two days of regular administration there was a ‘gentling’ of behaviour, and this effect has continued with only the occasional outburst of aggression (now usually verbal) less than daily. Mr Black has now been on morphine for 6 months and he continues to take it in the form of tablets (MSContin 10mg BD). His haloperidol dosage has been reduced and he continues on his other medications

2. Successful treatment of behavioural symptoms in severe dementia: the use of morphine Dr Susan Kurrle, Geriatrician Hornsby Ku-ring-gai Hospital Hornsby NSW 2007 skurrle@nsccahs.health.nsw.gov.au

3. Mrs White • 82 year old lady, lives in nursing home • Agitation, calling out, banging bed rails • On haloperidol, risperidone, alprazolam, valproate, paracetamol, ibuprofen • Commenced on mist morph 2.5 mg q4h • Now on 5mg q4-6h with good management of symptoms and minimal side effects • Haloperidol, alprazolam ceased

4. Mr Black • 72 year old man, in CADE unit • Chronic schizophrenia, alcohol related brain damage, moderate dementia • Very mobile, violent and aggressive towards other residents and staff • On clozapine, haloperidol, clonazepam, mirtazepine, paracetamol • Started on mist morph 5mg q4h with marked “gentling” of behaviour, continues on MSContin 10mg BD 6 months later

5. Use of morphine for management of behaviour in dementia • Morphine is well documented for management of pain in many conditions, and for shortness of breath and anxiety in chronic airways limitation and cardiac failure • Very few references to use of morphine for management of behaviour (JAGS 1989, Int J Ger Psych 2003)

6. Use of morphine for management of behaviour in dementia • Noted request to NSW Guardianship Tribunal for consent for use of morphine to manage behavioural symptoms in patients with moderate to severe dementia • Agitation, aggression, inappropriate vocalisations, distress were symptoms treated • Many patients had been taking between 10 and 20 mg morphine daily for up to 4 years

7. Case series of use of morphine for behavioural symptoms • 39 patients: 14 males, 25 females • Mean age 79 years • Resident in nursing home, diagnosis of severe dementia (CDR 3.0) • Agitation in 16 aggression in 10, inappropriate vocalisation in 8, distress in 5 • All taking at least one psychotropic medication, many taking more

8. Use of morphine for behavioural symptoms • Median starting dose of mist morphine 2.5mg, initial daily dose of 12.5mg • Median maximum daily dose 25mg • Continued from 1 to 45 months (median duration of treatment 6 months) • Satisfactory response (“more happy”, “contented”, “more settled”)

9. Use of morphine for behavioural symptoms • Improved quality of life of patients noted by staff and families • Reduction of other medications occurred • Side-effects: constipation, drowsiness, nausea/vomiting

10. Use of morphine for behavioural symptoms • Mist morphine may be useful in the management of distressing behaviour in late stage dementia • Morphine is effective in small to moderate dosages and continuing increases in dose do not seem to be necessary • Next step is a prospective case series with standardised outcome measures