Behandling av demens Friederike Fritze

overlege alderspsykiatrisk poliklinikk

SUS

03.10.12

Innhold

• Generelle tanker om temaet

• Nasjonale retningslinjer

• Internasjonale retningslinjer

• Cochrane

• Medisiner

• Klinisk erfaring

• Personsentrert omsorg

Skuffete Forventninger

• H. Lundbeck ilegges reklamegebyr for Ebixa

”Effekten kan måles allerede etter 4 uker": 07.05.2012:

Rådet (for legemiddelinformasjon) mener at slik

påstanden fremstår i reklamen gir den inntrykk av at

klinisk målbar effekt oppnås hos den enkelte pasient

etter 4 uker. Rådets konklusjon er at reklamen fremstår

som villedende. Klager gis medhold. H. Lundbeck

ilegges gebyr kr. 40.000,-

www.legemiddelverket.no

www.medscape.com

ww.nrk.no

Skuffende Forskningsresultater

• Juli 2012: Bapineuzumab (J and J og Pfizer) an

investigational monoclonal antibody that targets amyloid-ß

fails in Phase 3 Alzheimer's Trial (www.medscape.com)

• Status 03.10.2012: www.clinicaltrials.gov: 971 studies on

Alzheimer, 1896 studies on dementia

• Efficacy of psychosocial intervention in patients with mild Alzheimer's

disease: the multicentre, rater blinded, randomised Danish Alzheimer

Intervention Study (DAISY). Waldorff FB, Buss DV, Eckermann A,

Rasmussen ML, Keiding N, Rishøj S, Siersma V, Sørensen J, Sørensen LV,

Vogel A, Waldemar G. BMJ. 2012 Jul 17;345:e4693: did not have

significant effect

Skuffende omsorgstilbud

• NRK 02.10.12: STOR SPØRREUNDERSØKELSE AVDEKKER: Ikke ute av huset på ett år. Kun 26 prosent av pleierne svarer at gamle og

syke får dekket sine behov for sosial kontakt og aktiviteter

www.nrk.no

Noe generelt: Evidens

Evidence is knowledge produced by

research; it needs to be linked to the

knowledge produced form data analysis,

sometimes called statistics, and knowledge

from the experience of clinicians and

patients. Gray,M: Best current evidence strategy. NHS 2006

«Level of evidence» og «Grad of recommendation(good risk –

benefit ratio)»

Nasjonale retningslinjer

• Norge har som første land lansert en nasjonal demensplan (Demensplan 2015 -

”Den gode dagen”, en delplan til Omsorgsplan 2015) som skal vare fra 2007 til

2015 (revidert i 2011): Utbygging av dagaktivitetstilbud. «Smått er godt». «Større

bredde»

-Standardisert utredningsverktøy anbefalt av Helsedirektoratet og Nasjonalt

. kompetansesenter for aldring og helse (helsepersonell, leger og sykehjem)

-Veileder

- Håndbok for demensteam.

• Å utarbeide retningslinjer vil kunne være en måte å sikre god standard på de

tjenestene som ytes, samt å sikre at ressursene som settes inn brukes på en best

mulig måte.

• Norge har så langt ikke utviklet retningslinjer, og i den grad det har vært

diskutert så har det først og fremst vært snakk om retningslinjer for demensutredning

www.aldringoghelse.no

www.kvalitetogprioritering.no

Nasjonale retningslinjer

• Medikamentell behandling av atferdsforstyrrelser og

psykologiske symptomer (BPSD) hos personer med

demens 2005. Statens legemiddelverk 24-12-23:

Finnes ikke lenger på nettsiden

• For oppdatering av aktuelle/fremtidige retningslinjer sjekk

www.helsebiblioteket.no

www.aldringoghelse.no

Internasjonale retningslinjer

• World Federation of Societies of Biological Psychiatry

(WFSBP)Guidelines for the Biological Treatment of

Alzheimer ’ s disease and other dementias 2011

• Storbritannia: NICE pathways dementia 2011

• Tyskland: S 3 Leitlinie Demenz 2009

• USA : American Psychiatric Association (APA) 2007.

American College of Physicians and the American Academy of

Family Physicians. American Academy of Neurology (AAN).

The American Geriatrics Society (AGS).

• Sverige, Kanada, Scotland, Taiwan

NICE guidelines ( pathway dementia)

NICE guidelines ( pathway dementia)

• Donepezil, galantamine, rivastigmine and

memantine

1. The three acetylcholinesterase (AChE) inhibitors…are recommended as

options for managing mild to moderate Alzheimer's disease under all of the

conditions specified in paragraphs 3 and 4 below.

2. Memantine is recommended …for people with moderate Alzheimer's

disease who are intolerant of or have a contraindication to AChE inhibitors or

severe Alzheimer's disease. Treatment should be under the conditions

specified in paragraph 3.

NICE guidelines ( pathway dementia)

3. Treatment should be under the following conditions:

• Only specialists in the care of patients with dementia (that is, psychiatrists,

neurologists, and physicians specialising in the care of older people) should

initiate treatment. Carers' views on the patient's condition at baseline should

be sought.

• Treatment should be continued only when it is considered to be having a

worthwhile effect on cognitive, global, functional or behavioural

symptoms.

• Patients who continue on treatment should be reviewed regularly using

cognitive, global, functional and behavioural assessment. Treatment should

be reviewed by an appropriatespecialist team, unless there are locally agreed

protocols for shared care. Carers' views on the patient's condition at follow-

up should be sought.

NICE guidelines (pathway dementia)

If a person with dementia develops distressing non-cognitive

symptoms or behaviour that challenges, offer an early assessment to

identify factors that may influence the behaviour. Include:

• physical health

• depression

• possible undetected pain or discomfort

• side effects of medication

• individual biography

• psychosocial factors

• physical environmental factors

• behavioural and functional analysis in conjunction with carers and care

workers.

NICE guidelines (pathway dementia)

Address environmental, physical health and psychosocial

factors that may increase the likelihood of behaviour that challenges. These

include:

• overcrowding

• lack of privacy

• lack of activities

• inadequate staff attention

• poor communication between the person with dementia and staff

• conflicts between staff and carers

• weak clinical leadership

Principles of pharmacological control of

violence, aggression and extreme agitation • Use drugs to calm the person and reduce the risk of violence

and harm, rather than to treat any underlying psychiatric

condition. Aim to reduce agitation or aggression without

sedation.

• Use the lowest effective dose. Avoid high doses and drug

combinations, especially in elderly or frail people.

• Use drugs for control of behaviour with caution, particularly if

the person has been restrained, because of the following risks:

• loss of consciousness instead of sedation

• over-sedation with loss of alertness

• damage to the relationship between the person with dementia, their

carers and the care team

NICE guideline (pathway dementia) Use of antipsychotics • Risks and benefits have been fully discussed; assess cerebrovascular risk

factors and discuss possible increased risk of stroke/transient ischaemic

attack and possible adverse effects on cognition

• Changes in cognition are regularly assessed and recorded; consider

alternative medication if necessary

• Target symptoms have been identified, quantified and documented, and

changes are regularly assessed and recorded

• Comorbid conditions, such as depression, have been considered

• The drug is chosen after an individual risk–benefit analysis

• The dose is started low and titrated upwards

• Treatment is time limited and regularly reviewed (every 3 months or

according to clinical need).

Copyright © NICE 2011. Pathway last updated: 25 October 2011

The Cochrane Library 2008 og 2009

• Evidence suggests that risperidone and olanzapine are useful in reducing

aggression and risperidone reduces psychosis, but both are associated

with serious adverse cerebrovascular events and extrapyramidal

symptoms. Despite the modest efficacy, the significant increase in adverse

events confirms that neither risperidone nor olanzapine should be used

routinely to treat dementia patients with aggression or psychosis unless

there is severe distress or risk of physical harm to those living and working

with the patient.

• No evidence of the efficacy of vitamin B12 supplementation for

cognitive function

• Haloperidol (<3.5 mg/d), risperidone (1 mg), and olanzapine ( 2,5 mg)

were equally effective in treating delirium, with few adverse effects.

The Cochrane Library 2009

• Cholinesterase inhibitors (ChEIs), donepezil, galantamine and

rivastigmine are efficacious for mild to moderate Alzheimer's disease.

More patients leave ChEI treatment groups, 29%, on account of adverse

events than leave the placebo groups (18%)

• The analyses did not support the use of melatonin for treatment of

cognitive impairment associated with dementia. Meta-analysis of

psychopathologic behavior scale scores suggested that melatonin may be

effective in treating these dementia-related disturbances .

• There is insufficient evidence from randomised trials to allow any

conclusion about the efficacy of validation therapy for people with

dementia or cognitive impairment

• There is insufficient evidence to assess the value of light therapy for

people with dementia.

• Inconclusive evidence of the efficacy of reminiscence therapy for

dementia

The Cochrane Library 2010

• Evidence suggests that haloperidol was useful in reducing aggression, but was associated with adverse effects; there was no evidence to support the routine use of this drug for other manifestations of agitation in dementia. The present study confirmed that haloperidol should not be used routinely to treat patients with agitated dementia. Treatment of agitated dementia with haloperidol should be individualized and patients should be monitored for adverse effects of therapy.

• There is insufficient evidence to recommend statins for the treatment of dementia ( better effect: serum cholesterol was high at baseline, MMSE was higher at baseline or if they had an apolipoprotein E4 allele present)

• There is no substantial evidence to support nor discourage the use of

music therapy in the care of older people with dementia • No evidence of benefit of Ibuprofen for the treatment of Alzheimer's

disease • D-cycloserine has no place in the treatment of patients with Alzheimer's

disease.

The Cochrane Library 2011

• Currently there are relatively few studies of antidepressants for the

treatment of agitation and psychosis in dementia. The SSRIs sertraline

and citalopram were associated with a reduction in symptoms of

agitation when compared to placebo in two studies.

The Cochrane Library 2012

• The currently available evidence supports the use of cholinesterase inhibitors in patients with PDD, with a positive impact on global assessment, cognitive function, behavioural disturbance and activities of daily living rating scales. The effect in DLB remains unclear

• There was consistent evidence from multiple trials that cognitive stimulation programs benefit cognition in people with mild to moderate dementia over and above any medication effects.

• There is insufficient evidence to support HBOT as an effective treatment for patients with VaD

• The effectiveness of acupuncture for vascular dementia is uncertain.

• There is no evidence that MPACs (Metal protein attenuating compounds) are of benefit in Alzheimer's dementia

• Based on the studies carried out so far, the efficacy of aspirin, steroid and NSAIDs (traditional NSAIDs and COX-2 inhibitors) is not proven. Therefore, these drugs cannot be recommended for the treatment of AD.

Retningslinjer generelt

• Utredning før behandling

• Utredning og behandling må inkludere

familie/pleiepersonalet

1. Behandling av kognitive symptomer

2. Behandling av atferdssymptomer

3. Behandling av psykiske symptomer/lidelser

• Vurder alltid ikke medikamentelle tiltak

• Gi tydelig informasjon

• Sett behandlingsmål , kontroller resultater

Medisiner. OBS: Off label bruk

• Psykose: KHE mot hallusinasjoner. Risperdal not mor

than 1 mg. Olanzapine max 5 mg x2. Quetiapin max 75

mg x2

• Depression: Antidepressiva ? Obs falltendens. GIT

blødninger. Hjerte-kar – bivirkninger. Mixed results. Lite

evidens: citalopram 20 mg ? TZA?

• Agitasjon: Ebixa 20 mg. Citlaopram 20 mg. Carbamazepin

etter speil OBS interasksjoner

• Frontotemporallappsdemens: SSRI

• Angst og søvn: foredrag 4.10.12

www.uptodate.com

Fremtidige intervensjonsmål

• Nutritional precursors and cofactors for synapse

formation: Souvenaid (omega-3 fatty acids, choline,

uridine monophosphate, and a mixture of antioxidants

and B vitamins ) RCT : significant improvement in NTB

memory scores over 24/48 weeks

• Marques-Aleixo I, Oliveira PJ, Moreira PI, Magalhães J,

Ascensão A. Physical exercise as a possible strategy for

brain protection: Evidence from mitochondrial-mediated

mechanisms. Prog Neurobiol. 2012 Aug 23.

Forebygging er målet

• Methodological challenges in designing dementia

prevention trials - The European Dementia

Prevention Initiative (EDPI). Richard, E. et al. J Neurol Sci. 2012

Jul 18

• Alzheimer's research. Stopping Alzheimer's before it

starts .Miller, G. Science. 2012 Aug 17;337(6096):790-2

• Alzheimer's Prevention Initiative: a plan to accelerate

the evaluation of presymptomatic treatments.Reiman EM,

Langbaum JB, Fleisher AS, Caselli RJ, Chen K, Ayutyanont N, Quiroz YT, Kosik KS, Lopera

F, Tariot PN. J Alzheimers Dis. 2011;26 Suppl 3:321-

Momenter fra egen praksis

• Somatisk utredning !

• Pasientens plager: Hva er det verste for deg? Hva bør bli

bedre? Ta plagene på alvor.

• Pårørende: Samspill med pasienten. Informasjon om

sykdommen. Behov for gruppetilbud, støttesamtaler.

Involver barna. Komparentinformasjon om bivirkninger,

medisininntak, hjelpebehov.

• Tilbud i kommunen : Dagssenter!! Miljøtjeneste.

• Opptrapping av KHE til maks dose pas. tåler.

Somatisk Utredning ved APSD

• Kroppslig undersøkelse inkludert BT (ortostatisk), puls, EKG,

vekt, hud, hørsel, syn, nevrologisk status, gangbildet

• Anamnese: vannlating, avføring

• CCT/CMRT: Metastaser? Angiom? Strategiske infarkter?

WML særlig frontal?

• Blodprøver: Anæmi, hypothyreose, hypovitaminose, Natrium ,

Kalsium , nyreinsuffisiens, inflammasjon (leuko , CRP),

tumormarker?

• Søvnforstyrrelser: Apnoe, RLS, REMsøvnatferdsforstyrrelse

• Kartlegging av smerter (MOBID 2 scale)

• Evaluering av aktuell medikasjon: interaksjoner, bivirkninger

Personsentrert omsorg

• Anne Marie Mork Rokstad. Nasjonalt kompetansesenter

for aldring og helse:

1.Anerkjennelse av menneskets absolutte verdi uavhengig

av alder eller kognitiv funksjon

2.En individuell tilnærming som vektlegger det unike hos det

enkelte menneske

3. Evnen til å forstå verden sett fra beboerens perspektiv

4. Støttende tilrettelegging av det psykososiale miljø på en

slik måte at den enkelte beboer kan oppleve trivsel og

velvære.

Personsentrert omsorg

Trøst Kjærlighet Identitet

Inklusjon Beskeftigelse Tilknytning