Nonneuroleptic Treatment of Disruptive Behavior in Organic Mental Syndromes

Systematic management approach to pharmacotherapy for people with learning disabilities

With progressive deinstitutionalisation in many countries, the general psychiatrist is now more frequently requested to provide assistance with behavioural problems in people with learning disabilities. There are a range of challenges in providing quality care for these people. There are challenges in assessment and diagnosis, in coordinating behavioural and social interventions with pharmacotherapy, and in the lack of psychopharmacological research in this population, which results in a diminished evidence base. In addition, there are numerous factors beyond the patient. These include legal consent requirements and the complex system of carers surrounding those with disabilities with whom the practitioner may need to interact.

Buspirone for the treatment of dementia with behavioral disturbance

Behavioral disturbances are common but serious symptoms in patients with dementia. Currently, there are no FDA approved drugs for this purpose. There have been case reports and small case series of the use of buspirone. In this retrospective study, we review 179 patients prescribed buspirone for treatment of behavioral disturbance in dementia to better characterize the efficacy and potential side effects. All patients prescribed buspirone for behavioral disturbance due to dementia from a geropsychiatric outreach program were reviewed. Data was collected and analyzed using SPSS. One hundred-seventy-nine patients met criteria for the study with a mean age of 83.8 + 7. Alzheimer's dementia was the most common dementia (n = 61; 34.1%) followed by mixed dementia (n = 50, 27.9%) then vascular type (n = 31; 17.3%). Behavioral disturbances were mainly verbal aggression (n = 125; 69.8%), and physical aggression (n = 116; 64.8%). Using the Clinical Global Impression scale, 68.6% of patients responded to buspirone, with 41.8% being moderately to markedly improved. The mean dose of buspirone was 25.7 mg ± 12.50. Buspirone appears to be effective in treating behavioral disturbances in dementia. Future prospective and double blinded studies are needed.

The Pharmacotherapy of Human Aggression: A Review

Aggression is a common treatment problem that may be associated with several disorders including schizophrenia, schizoaffective disorder, acute mania/bipolar disorder, personality disorders, substance abuse disorders, medical disorders, neurological disorders, and medication misadventures. Aggression is not a linear entity, it is a multidimensional problem influenced by a patient's environment and biological, psychological, and/or neurological status. It follows that if one has a multidimensional treatment problem, then a compre hensive treatment plan must be used to achieve optimal management. The comprehensive treatment of aggression should include a thorough baseline evaluation, regular objective measurement of aggression severity using a rating scale (eg, Overt Aggression Scale), psychological interventions, behavioral interventions, pharmacotherapy and, if necessary, seclusion and/or restraint. The pharmacotherapy of aggres sion includes the traditional antipsychotics and benzodiazepines, which are most commonly used; other pharmacotherapies frequently selected include the β-blockers, carbamazepine, and lithium. Despite these pharmacotherapeutic options and despite a pharmacological rationale for each one, the medications used for the treatment of aggression are at least in part nonspecific for aggression. The nonspecificity of these pharmacotherapies is best exemplified by the common use of multiple drug regimens. This may then lead to drug misadventures either in the form of drug-drug interactions, adverse effects, or toxicity. The serenics are a class of phenylpiperazine compounds that have exhibited some promise as being more selective anti- aggression drugs. Eltoprazine, the first member of this new class, is in early phases of human investigation. Copyright © 1996 by W.B. Saunders Company

Alternatives to atypical antipsychotics for the management of dementia-related agitation

Numerous recent studies have challenged the widely held belief that atypical antipsychotics are safe and effective options for the treatment of behavioural problems such as agitation in patients with dementia. Accordingly, there is a need to reconsider the place of atypical antipsychotics in the treatment of patients with dementia. The present article is intended to assist clinicians with the assessment and pharmacological management of agitation in patients with dementia. We review the risk-benefit evidence for the use of atypical antipsychotics in patients with dementia-related agitation (DRA). Emerging evidence indicates that, for patients with dementia, the risks associated with atypical antipsychotics may outweigh the benefits except for patients with severe agitation who require short-term chemical restraint. We then discuss the importance of a careful assessment to rule out potentially reversible factors contributing to DRA. Finally, we summarize the evidence supporting the use of medications other than antipsychotics to treat DRA. There is wide variability in the levels of evidence supporting the use of non-antipsychotic medication for the treatment of DRA. The best evidence currently exists for cholinesterase inhibitors and serotonin-specific reuptake inhibitor antidepressants. Emerging reports suggest that numerous other medications, for example, antiepileptics, lithium, anxiolytics, analgesics, beta-adrenoceptor antagonists, cannabinoid receptor agonists and hormonal agents, may prove to be viable alternatives to antipsychotics for the treatment of severe DRA and more research is urgently needed to help assess the effectiveness of these agents. A comprehensive biopsychosocial assessment and treatment plan is likely the most effective way to manage DRA.

Antipsychotic medication versus placebo for people with both schizophrenia and learning disability

BACKGROUND

Antipsychotic medication is the standard treatment for people with learning disability and schizophrenia.

OBJECTIVES

To determine the effects of any antipsychotic medication compared with placebo for treating people with a dual diagnosis of learning disability and schizophrenia.

SEARCH STRATEGY

For this update we searched the Cochrane Schizophrenia Group's Register of trials (July 2004), relevant reference lists and sought unpublished data from pharmaceutical companies.

SELECTION CRITERIA

We included all randomised clinical trials of longer than one month's duration, involving people with both schizophrenia and learning disability (a measured IQ of 70 or less) that evaluated antipsychotic medication versus placebo.

DATA COLLECTION AND ANALYSIS

We reliably selected and assessed studies for methodological quality. Two reviewers, working independently, extracted data. We would have analysed dichotomous data on an intention-to-treat basis and presented continuous data with 65% completion rate. For dichotomous outcomes, our intention was to estimate a fixed effect relative risk (RR) with the 95% confidence interval (CI) together with the number needed to treat/harm (NNT/H).

MAIN RESULTS

We found only one relevant randomised trial using our search method and this had to be excluded. This study included four people with a dual diagnosis of schizophrenia and learning disability, but results were only available for two of the participants. It was unclear as to which groups the other two people were allocated. In order to display the data, we would have had to have made too many assumptions about these two people and any results would be uninformative and potentially misleading.

REVIEWERS' CONCLUSIONS

Using the methods described we found no randomised controlled trial evidence to guide the use of antipsychotic medication for people with both learning disability and schizophrenia. Until the urgent need for randomised controlled trials is met, clinical practice will continue to be guided by extrapolation of evidence from randomised controlled trials involving people with schizophrenia, but without learning disability, and non-randomised trials of those with learning disability and schizophrenia.

Nonpharmacologic treatment of behavioral disturbance in dementia

This article provides an overview of the current literature on non-pharmacologic treatment of behavioral problems in patients with dementia, and offers practical guidelines for healthcare professionals interested in using this approach with their patients. Because effective treatment begins with accurate assessment, we provide a brief discussion of the state-of-the-art in assessment of behavioral problems. The article discusses current trends in clinical care along with specific strategies for treating and preventing some of the most common and debilitating behavioral problems of dementia patients: depression, agitation/aggression, wandering, and sleep disturbance. Because caregivers are essential informants and participants in patient care, we conclude by addressing the role of the caregiver in nonpharmacologic treatment.

Assessment and management of behavioral disturbances in Alzheimer disease

This article provides an update and review of strategies for assessing and treating behavioral changes in patients with Alzheimer disease. It discusses the impact of behavioral disturbances on patients, presents guidelines for identifying and monitoring behavioral changes, and presents behavioral treatment approaches.

Recommendations for the management of behavioral and psychological symptoms of dementia

BACKGROUND

The behavioral and psychological symptoms of dementia (BPSD) are common, serious problems that impair the quality of life for both patient and caregiver. In order to provide recommendations based upon the best available evidence, a qualitative literature review was performed.

METHODS

A search of the English language medical literature published between 1966 and 2000 was performed. The quality of the studies was assessed by considering the subjects, trial design, analysis and results. Final recommendations were based upon the quality of available evidence.

RESULTS

The management of BPSD begins with a thorough assessment to search for underlying causes of behaviour change. Concomitant medical illness should be treated and sensory impairment ameliorated. Nonpharmacological approaches should be instituted prior to medication use. These interventions include music, light, changes in level of stimulation and specific behavioral techniques. Antipsychotics are the best studied pharmacological intervention for agitation and aggression and have demonstrated modest but consistent efficacy. Antidepressants such as trazodone and selective serotonin re-uptake inhibitors, as well as anticonvulsants such as carbamazepine and valproic acid have also demonstrated efficacy. Benzodiazepines can be used for short-term treatment as p.r.n. agents when necessary. Pharmacotherapy must be monitored closely for both effectiveness and side effects, with consideration of medication withdrawal when appropriate.

CONCLUSION

The management of BPSD can significantly improve the quality of life for the patient and caregiver. Their assessment and management are essential components of the treatment of dementia.

Pharmacotherapy of behavioral and psychological symptoms of dementia: time for a different paradigm?

Behavioral and psychological symptoms of dementia can occur in 60-80% of patients with Alzheimer's disease or other dementing illnesses, and are important in that they are a source of significant caregiver stress and often precipitate nursing home placement. These symptoms, namely, aggression, delusions, hallucinations, apathy, anxiety, and depression, are clinically managed with a variety of psychotropic drugs such as antipsychotics, antidepressants, antiepileptic drugs, and benzodiazepines. Various advances in the neuropathophysiology and pharmacotherapy must be considered in the optimal design of regimens for patients with these symptoms.

Pharmacological treatment of mood disturbances, aggression, and self-injury in persons with pervasive developmental disorders

Aggression, self-injury, and mood disturbances in persons with autistic disorders, while not uncommon, do not constitute core features of autism. Moreover, these problems can occur for a variety of reasons, which need to be assessed in order to plan appropriate and frequently combined (behavioral-pharmacological) treatments. Drugs acting primarily in the dopaminergic, serotonergic, adrenergic, opioidergic, and glutamatergic systems all have been explored in the treatment of aggression and self-injury. While no single drug or class of medication has yet emerged as consistently effective, a number of drugs appear promising. Advances in the assessment of aggressive behaviors, the identification of predictors of drug response, and additional controlled clinical drug trials specifically aimed at these target behaviors are essential in improving the approach to these problematic behaviors in the context of autistic disorder.

Antipsychotic medication for those with both schizophrenia and learning disability

BACKGROUND

Antipsychotic medication is the standard treatment for people with learning disability and schizophrenia.

OBJECTIVES

To determine the efficacy of any antipsychotic medication for treating people with a dual diagnosis of learning disability and schizophrenia.

SEARCH STRATEGY

Electronic searching of Biological Abstracts, the Cochrane Schizophrenia Group's Register of trials, the Cochrane Library, EMBASE, PsycLIT and MEDLINE. Unpublished data were sought from pharmaceutical companies. Both authors independently selected the relevant studies from the reports identified in this way.

SELECTION CRITERIA

1. All randomised controlled trials of antipsychotic medication, regardless of dosage, versus a placebo control, of longer than one month's duration. 2. Anyone over 18 years of age with both learning disability and schizophrenia. Learning disability was defined as a measured IQ of 70 or less. Any mode of diagnosis of schizophrenia was acceptable.

DATA COLLECTION AND ANALYSIS

The two reviewers independently attempted to select and then extract data but it was not possible to do this with the single study that met the inclusion criteria.

MAIN RESULTS

Only one relevant randomised trial was found by the searches. This study included four people with a dual diagnosis of schizophrenia and learning disability, but results were available for only two. The groups to which the other two people were allocated were unclear. In order to display the data, too many assumptions would have to have been made about these other two people and any results would be uninformative and potentially misleading.

REVIEWER'S CONCLUSIONS

Using the methods described the reviewers found no randomised controlled trial evidence to guide the use of antipsychotic medication for those with both learning disability and schizophrenia. Until the urgent need for randomised controlled trials is met clinical practice will continue to be guided by extrapolation of evidence from randomised controlled trials involving people with schizophrenia but without learning disability and non-randomised trials of those with learning disability and schizophrenia.

Effectiveness of antipsychotic medication in people with intellectual disability and schizophrenia: a systematic review

The aim of the present study was to determine the efficacy of any antipsychotic medication for treating people with a dual diagnosis of intellectual disability and schizophrenia. The authors performed an electronic search of Biological Abstracts, the Cochrane Schizophrenia Group's Register of trials, the Cochrane Library, EMBASE, PsycLIT and MEDLINE. Unpublished data were sought from pharmaceutical companies. Both authors independently selected the relevant studies from the reports identified in this way. Only one relevant randomized trial was found by the searches (Foote 1958). This study included four people with a dual diagnosis of schizophrenia and intellectual disability, but results were only available for two subjects. The groups to which the other two people were allocated were unclear. Using the methods described, the reviewers found no trial evidence to guide the use of antipsychotic medication for those with both intellectual disability and schizophrenia. Until the urgent need for randomized controlled trials is met, clinical practice will continue to be guided by evidence from trials involving people with schizophrenia but without intellectual disability.

Reliability and validity of the Overt Agitation Severity Scale in adult psychiatric inpatients

An instrument, that validly and reliably identifies and measures agitation is required to evaluate environmental modifications, interpersonal strategies, psychopharmacological interventions, directed toward managing these commonly occurring and highly-disabling emotions and behavior. The conceptualization of agitation on a continuum from anxiety to aggression provides a practical framework for guiding clinical practice toward the early identification and intervention of agitation. The results of this study established the reliability and validity of the Overt Agitation Severity Scale (OASS) in measuring agitation severity in young adult psychiatric inpatients based on objectifiable vocalizations and motoric upper and lower body behaviors. The OASS differs from other agitation scales in its ability to capture both the intensity and frequency of observable behavioral manifestations of agitation, as opposed to subjective interpretations and a diffuse range of symptoms and problem behaviors.

Psychopharmacologic treatment of pathologic aggression

Several drugs are apparently effective in treating pathologic anger and aggression. Because many of the studies on aggressive populations allowed the use of concomitant medications, it is unclear whether the efficacy of each drug in a particular population is dependent on the presence of other medications, such as antipsychotic agents. Finally, one needs to be circumspect in inferring efficacy of a particular drug in aggressive patients with neuropsychiatric conditions other than the ones in which some efficacy has been established. Lithium appears to be an effective treatment of aggression among nonepileptic prison inmates, mentally retarded and handicapped patients, and among conduct-disordered children with explosive behavior. Certainly, lithium would be the treatment of choice in bipolar patients with excessive irritability and anger outbursts, and it has been shown to be effective in this population. Anticonvulsant medications are the treatment of choice for patients with outbursts of rage and abnormal EEG findings. The efficacy of these drugs in patients without a seizure disorder, however, remains to be established, with the exception perhaps of valproate and carbamazepine. In fact, dyphenylhydantoin did not appear to be effective in treating aggressive behavior in children with temper tantrums and was found to be effective in only a prison population. There is some evidence for the efficacy of carbamazepine and valproate in treating pathologic aggression in patients with dementia, organic brain syndrome, psychosis, and personality disorders. As Yudofsky et al point out in their review of the literature, although traditional antipsychotic drugs have been used widely to treat aggression, there is little evidence for their effectiveness in treating aggression beyond their sedative effect in agitated patients or their antiaggressive effect among patients whose aggression is related to active psychosis. Antipsychotic agents appear to be effective in treating psychotic aggressive patients, conduct-disordered children, and mentally retarded patients, with only modest effects in the management of pathologic aggression in patients with dementia. Furthermore, at least in one study, these drugs were found to be associated with increased aggressiveness in mentally retarded subjects. On the other hand, atypical antipsychotic agents (i.e., clozapine, risperidone, and olanzapine) may be more effective than traditional antipsychotic drugs in aggressive and violent populations, as they have shown efficacy in patients with dementia, brain injury, mental retardation, and personality disorders. Similarly, benzodiazepines can reduce agitation and irritability in elderly and demented populations, but they also can induce behavioral disinhibition. Therefore, one should be careful in using this class of drugs in patients with pathologic aggression. Beta-blockers appear to be effective in many different neuropsychiatric conditions. These drugs seem effective in reducing violent and assaultive behavior in patients with dementia, brain injury, schizophrenia, mental retardation, and organic brain syndrome. As pointed out by Campbell et al in their review of the literature, however, systematic research is lacking, and little is known about the efficacy and safety of beta-blockers in children and adolescents with pathologic aggression. Although widely used in the management of pathologic aggression, the use of this class of drugs has been limited partially by marked hypotension and bradycardia, which are side effects common at the higher doses. The usefulness of the antihypertensive drug clonidine in the treatment of pathologic aggression has not been assessed adequately, and only marginal benefits were observed with this drug in irritable autistic and conduct disorder children. Psychostimulants seem to be effective in reducing aggressiveness in brain-injured patients as well as in violent adolescents with oppositional or conduct disorders, particu

Pharmacologic treatment of agitation in dementia: a comprehensive review

Agitated behaviors are a common and nearly universal occurrence among patients suffering from dementing illnesses. The pharmacologic treatments available for this troubling syndrome are varied, but treatment studies are limited. Clinicians are frequently faced with the challenging management of patients with disruptive behavior who fail to respond to trials with multiple agents. This review summarizes available treatment studies of agitation in dementia and offers a guide to therapy and management. Reports of therapies for agitation in dementia are limited by lack of controlled studies, variability of diagnostic criteria and outcome measures, and small sample size. The need for carefully designed, well-controlled studies of outcome in this growing population is formidable. It is imperative to identify effective and well-tolerated treatment strategies to reduce the morbidity of these distressing and burdensome symptoms.

Managing dementia-related behavior in the community

Inappropriate use or insufficient monitoring of psychotropic agents can have deleterious effects in dementia patients. HCFA regulations serve as a useful guide to the appropriate use of psychotropic agents for dementia patients in the community. A sizeable portion of caregivers are not trained to correctly identify the adverse effects of psychotropic agents. Acting in an advisory role, the pharmacist is a key member of the patient management team.

Drug Therapy of Aggressive Behaviors Accompanying Dementia

Aggressive behaviors often accompany dementia in the elderly, institutionalized patient. These may include any number of verbal or physical acts, and range from swearing, threatening, to harming self, others, or property. Identifying specific target behaviors for treatment is important in selecting the appropriate therapeutic option. The major neurotransmitters involved in aggression include gamma-aminobutyric acid (GABA) and serotonin, which inhibit aggression, and dopamine, norepinephrine and acetylcholine, which increase it. Drug therapy for control of aggressive behaviors has traditionally included the antipsychotics and benzodiazepines. However, additional, newer therapies are also useful. Among these are the anticonvulsants carbamazepine and valproic acid, various beta-blocking agents, antidepressants, and buspirone. These medications may be needed when nondrug therapy for control of behavioral problems fails or is insufficient. Determining which behaviors are problematic and need treatment, knowing which medications are indicated for those problems, and noting contraindications for particular drug therapies will lead to the best therapeutic option for a given patient.