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Australian Journal of Pharmacy : October 2006
pharmacy ed counselling casebook • approved CPE Table Two: Alternatives to restraint—some examples4,6 • Environmental Adjust lighting—too bright or too dim, regular exposure to bright light, clear pathways and corridors, easy access to safe outdoor areas, activity areas, lowered bed height, access to appropriate mobility aids, orientation aids—use of pictures, use of pictures to create a family environment, noise, safe wandering areas inside and out • Nursing care options Increased staffing, staff training, individualised routines—toileting, naps, check ‘at risk’ residents regularly, appropriate footwear, hip protectors, better communication strategies • Physiological strategies Physical check-up, medication review, treat infections, pain management, physical alternatives to sedation (for example warm milk, soothing music) • Psychological programs and therapies Companionship, active listening, validation therapy, visitors, photos, video or audio tapes of family, staff/resident interaction, familiar staff, therapeutic touch, massage, relaxation programs, reality orientation, sensory aids, sensory stimulation, decreased sensory stimulation, pet therapy, music therapy • Activities Exercise, physical activities, walking, occupational and recreational therapies—singing, knitting, board games, entertainment, night-time activities, social activities, facilitate safe wandering behaviour, offer a change of seating arrangement, falls prevention program, activities box, ‘work’ outlets (for example gardening, folding linen) control behaviour? Delirium and dementia are common condi- tions where antipsychotics are used in aged care home residents without a prior mental illness. Use of antipsychotics in delirium Most delirious patients do not need treatment with sedatives or psychotropic drugs, but pharmacotherapy is sometimes required to control anxiety, agitation, aggression, delusions and/or hallu- cinations. The cause of the delirium should be identified and treated if possible. If delusions or hallucinations are causing dis- tress, or if behavioural disturbance threatens the patient’s treat- ment or care or is causing significant threat to others, Psychotropic Guidelines3 suggest: • Haloperidol 1.5–10mg orally, in an adult (0.5mg in the very old or frail) titrated to clinical response. • If oral administration is impossible and symptoms are severe, use haloperidol 5mg IM, in an adult (0.5–1.5mg in the very old or frail) as a single dose. • If haloperidol is ineffective in controlling agitation consider the possible use of benzodiazepines. • If the patient is intolerant of haloperidol, the alternative use of low-dose risperidone (0.5–2mg/day), olanzapine (2.5– 10mg/day) or quetiapine (25–200mg/day) may be considered. It is important to review the medications they already take before adding more. Sometimes behavioural problems are 80 ? THE AUSTRALIAN JOURNAL OF PHARMACY VOL.87 OCTOBER 2006 caused by sub-acute delirium or other types of toxicity due to prescribed medication. Drugs that are particularly prone to cause behavioural problems in older people include those with anticholinergic properties, for example tricyclic antidepressants such as amitriptyline, oxybutynin, or benzodiazepines such as diazepam, and analgesics such as tramadol.7 Use of antipsychotics in dementia ‘If we spent as much time on trying to understand behaviour as we spend trying to manage or control it, we might discover that what lies behind it is a genuine attempt to communicate.’8 Dementia is commonly associated with distressing behavioural problems. Agitation and resistance to care interventions are com- mon. These features of dementia are sometimes referred to as behavioural and psychological symptoms of dementia (BPSD). Both non-pharmacological and pharmacological interventions can be considered. The best available evidence is for the use of low-dose antipsychotic medication in patients with agitated or aggressive behaviour with or without associated psychotic symp- toms. There is less evidence to support the use of antidepressants, anticonvulsants and cholinesterase inhibitors in patients whose dementia is complicated by behavioural problems. When psy- chotropic medication is prescribed to people with dementia, it should be regularly reviewed with a view to stopping it or assess- ing the patient after a trial off the medication.7 There is some evidence for the efficacy of both typical (for example haloperidol) and atypical (for example risperidone,9 olanzapine10 ) antipsychotic drugs in the treatment of psychotic symptoms in people with dementia. There is also some evidence for the use of these drugs in people with dementia who are aggres- sive or agitated but who do not have overt psychotic symptoms. Although the atypical antipsychotic medications (risperidone, olanzapine, quetiapine, amisulpride, aripiprazole) have safer adverse effect profiles than typical antipsychotic medications, most of them are not subsidised by the Pharmaceutical Benefits Scheme (PBS) for people with dementia in the absence of schizo- phrenia. The best evidence is for low-dose risperidone, which has been approved for the management of behavioural disturbance in dementia. The usual starting dose of risperidone in older peo- ple with dementia is 0.25–0.5mg daily, with the final dose gener- ally 1–2mg per day. Risperidone, and some other antipsychotics, may increase the risk of cerebrovascular events, hyperglycaemia and diabetes mellitus and causes dose-related extrapyramidal side-effects, postural hypotension and somnolence.6 A Cochrane review found that haloperidol was useful for aggression, but not for other aspects of agitation in people with dementia.11 If haloperidol is to be used in the treatment of either psychotic symptoms or agitation/aggression, it is important to use the lowest effective dose. The usual starting dose of haloperi- dol in older people is 0.5mg daily, with the final daily dose gen- erally 1–2mg per day. Three large randomised placebo controlled trials in nursing home settings with residents with challenging behaviours have shown risperidone (mean dose 1mg) to offer improvement in agi-