listener NCD and delirium

Treatment of Aggressive Behaviors Related to Neurocognitive Disorders (NCD) and Delirium

Mark E. Schneiderhan

  • Qualifications:
      - Doctor of Pharmacy (PharmD)
      - Board-Certified Psychiatric Pharmacist (BCPP)
      - Fellow of the American Association of Psychiatric Pharmacists (FAAPP)
      - Associate Professor at University of Minnesota, College of Pharmacy, Duluth, MN

Overall Learning Objectives

  1. Differentiate between Delirium, Dementia, and Depression in older adults:
       - Delirium: Acute change in cognition, often reversible.
       - Dementia: Progressive cognitive decline, often irreversible and may present as Alzheimer's.
       - Depression: Mood disorder; may be persistent and affect cognitive function.

  2. Identify underlying causes that can predispose, precipitate, or exacerbate Neuropsychiatric Symptoms (NPS):
       - Medications: Certain medications can increase risk of NPS (e.g., anticholinergics, opioids).
       - Co-occurring conditions: Other health issues that may elevate risks (e.g., cancer, heart disease).

  3. Assess the safety and benefits of commonly prescribed medications for acute management of delirium and aggression related to NCD:
       - Medication categories include:
         - Acetylcholinesterase Inhibitors (AChE-I)
         - NMDA antagonists (e.g., Memantine)
         - Antidepressants
         - Antipsychotics (e.g., FDA approved: Brexpiprazole, unapproved agents)
         - Alpha-1 antagonists (e.g., Prazosin)
         - Antiseizure medications (ASM)

  4. Formulate Treatment and Care Plans:
       - Focus on:
         - Indications for treatment
         - Effectiveness of medications
         - Safety profiles
         - Convenience for older adults in administration and dosage.

Learning Objectives – Flex

  1. Identify and Differentiate between delirium, NCD, and major depressive disorder which may trigger or mimic NPS.

  2. Assess risk factors and potential causes of delirium in both out-patient and in-patient settings.

  3. Describe appropriate management and prevention of NPS due to delirium.

  4. Describe and Utilize a treatment algorithm for non-delirium NPS in patients with NCD.

Nodes (Steps) of Treatment Algorithm:

  1. Continue, Taper, or Discontinue Potentially Inappropriate Medications (PIMs).

  2. Optimize Sleep Quality: Address insomnia.

  3. Pharmacological agents include:
       - Acetylcholinesterase Inhibitors (AChE-I)
       - NMDA antagonists like Memantine (Namenda®)
       - Antidepressants
       - Antipsychotics
       - Alpha-1 antagonists (Prazosin – Minipress/Prazo)
       - Antiseizure medications (ASM)

Framework for Assessment and Management of Agitation in NCD

  1. Identification of agitation:
       - Types: Acute (due to delirium) vs chronic (possibly Alzheimer’s related).

  2. Differential Diagnosis: Assess for causes outside NCD.

  3. Current Clinical Practice: Use DICE (Describe/Investigate/Create/Evaluate) for caregiver/staff assessment and IPA (Investigate/Plan/Act) for provider treatment.

  4. Treatment:
       - Non-pharmacologic treatments as first-line.
       - Pharmacologic treatments: weigh benefits vs risks, including both FDA approved and off-label options.

  5. Communication: Regular follow-ups to assess:
       - Treatment effectiveness and goals.
       - Caregiver/staff burden and stress levels.

Background on Neurocognitive Disorders (NCD)

Alzheimer’s disease Overview - Step 1

  • Characteristics:
      - Gradual Onset/Pervasive cognitive impairments affecting memory, executive function, language, and motor skills.
      - High risk of developing delirium due to NPS and medications.
      - Agitation/aggression can accelerate cognitive decline and increase mortality risks:
        - Associated risks include polypharmacy, falls, fractures, infections, injurious behaviors towards self or others.
      - Prevalence of NPS in nursing homes: 60%.
      - NPS can overwhelm both family members and trained caregivers.

Gradual Onset: Neuropsychiatric Symptoms (NPS) - Step 1

  1. Symptoms:
       - Behavioral:
         - Wandering (25-50% in mid-stage Alzheimer's).
         - Assessment for psychosis, depression (25%), pain (commonly missed), and akathisia.
         - Inappropriate sexual behavior and acute aggressive behavior.
       - Psychotic Symptoms:
         - 25% may experience visual/auditory hallucinations or delusional thoughts.
       - Mood Symptoms:
         - Depression (20%), anxiety (prominent finding), irritability, and apathy.
       - Agitation:
         - Includes pacing, insomnia, and aggression, both verbal and physical.
         

Recognizing Age/Symptom-Related Differences – Depression Features

Adult Patients (18–64) vs Geriatric Patients (65+)

  1. Primary Mood:
       - Adults: Profound sadness.
       - Geriatrics: Lack of motivation, may deny feeling