Gabapentin for disruptive behaviour in an elderly demented patient

Gabapentin and pregabalin to treat aggressivity in dementia: a systematic review and illustrative case report

AIMS

The prevalence of dementia is rising as life expectancy increases globally. Behavioural and psychological symptoms of dementia (BPSD), including agitation and aggression, are common, presenting a challenge to clinicians and caregivers.

METHODS

Following PRISMA guidelines, we systematically reviewed evidence for gabapentin and pregabalin against BPSD symptoms of agitation or aggression in any dementia, using six databases (Pubmed, CINHL, PsychINFO, HealthStar, Embase, and Web of Science). Complementing this formal systematic review, an illustrative case of a patient with BPSD in mixed Alzheimer's/vascular dementia, who appeared to derive benefits in terms of symptom control and functioning from the introduction of gabapentin titrated up to 3600 mg day^-1 alongside other interventions, is presented.

RESULTS

Twenty-four relevant articles were identified in the systematic review. There were no randomized trials. Fifteen papers were original case series/case reports of patients treated with these compounds, encompassing 87 patients given gabapentin and six given pregabalin. In 12 of 15 papers, drug treatment was effective in the majority of cases. The remaining nine papers were solely reviews, of which two were described as systematic but predated PRISMA guidelines. Preliminary low-grade evidence based on case series and case reviews suggests possible benefit of gabapentin and pregabalin in patients with BPSD in Alzheimer's disease. These benefits cannot be confirmed until well-powered randomized controlled trials are undertaken. Evidence in frontotemporal dementia is lacking.

CONCLUSION

Gabapentin and pregabalin could be considered for BPSD when medications having stronger evidence bases (risperidone, other antipsychotics, carbamazepine and citalopram) have been ineffective or present unacceptable risks of adverse outcomes.

Anticonvulsant Use in Treating Dementia-Related Agitation

Dementia is often accompanied by disturbances in behavior which require treatment with medications. Traditionally, antipsychotics and benzodiazepines have been used. Their modest beneficial effects must be balanced against toxicities such as drug-induced parkinsonism which leads to falls, and worsened cognitive function. Anticonvulsant medications have been used in the past to treat agitated and aggressive behaviors from various conditions. Recent reports attest to their usefulness in treating behavioral problems secondary to dementia. Carbamazepine and divalproex sodium have proven effective in treatment while newer agents like gabapentin may be useful as well. These agents may be preferable because they target a broad variety of symptoms and diseases, are less likely to induce extrapyramidal reactions and some have a low drug interaction profile.

Mood stabilizers for the treatment of behavioral and psychological symptoms of dementia: an update review

Behavioral and psychological symptoms of dementia (BPSD) are common and debilitating problems, but current treatments are limited. Antipsychotic agents show some efficacy on BPSD, but their use is limited by the associated risk of cerebrovascular events and mortality. Reports have shown the efficacy of mood stabilizers on BPSD, but systemic reviews on this issue are scant. This article aims to review studies of the efficacy of mood stabilizers on BPSD, and the quality of the available evidence. We searched for articles published in English during the period 1990 to 2010 and included in the PubMed database that concerned treatment of BPSD with mood stabilizers, such as carbamazepine, valproate, gabapentin, topiramate, lamotrigine, oxcarbazepine and lithium. The quality of the studies was assessed by considering the trial designs, analyses, subjects and results. We found one meta-analysis and three randomized controlled trials (RCTs) supporting the efficacy of carbamazepine in managing global BPSD, particularly aggression and hostility. With regard to valproate, current evidence from one meta-analysis and five RCTs did not strongly support its efficacy for global BPSD, including agitation and aggression. Only open trials or case series showed some efficacy of gabapentin, topiramate and lamotrigine in controlling BPSD. The single RCT investigating the effect of oxcarbazepine on agitation and aggression showed negative results. Case series reports on lithium tended to show it to be ineffective. Thus far, among mood stabilizers, carbamazepine has the most robust evidence of efficacy on BPSD. More RCTs are needed to strengthen evidence regarding the efficacy of gabapentin, topiramate and lamotrigine. Valproate, oxcarbazepine and lithium showed low or no evidence of efficacy. Large and well designed RCTs focusing on specific symptoms of BPSD are needed to deal with the issue.

Use of gabapentin in the treatment of behavioural and psychological symptoms of dementia: a review of the evidence

Behavioural and psychological symptoms of dementia (BPSD) have been defined as a heterogeneous range of psychological reactions, psychiatric symptoms and behaviours that may be unsafe, disruptive and impair the care of a patient in a given environment. To date, there are no US FDA-approved drugs or clear standards of pharmacological care for the treatment of BPSD. The novel antiepileptic agent gabapentin is being increasingly considered for use in the geriatric population because of its relatively favourable safety profile compared with other classes of psychiatric medications. Gabapentin has been administered to several geriatric patients with bipolar disorder and patients with dementia. It has also been reported to be successful in the treatment of a 13-year-old boy with behavioural dyscontrol, a finding that suggested a possible role for gabapentin in the treatment of other behavioural disorders. The purpose of this review was to find evidence for the use of gabapentin in the treatment of BPSD. To this end, a search was performed for case reports, case series, controlled trials and reviews of gabapentin in the treatment of this condition. The key words 'dementia', 'Alzheimer's disease' and 'gabapentin' were used. Searches were performed in PubMed, PsycINFO, Ovid MEDLINE, Cochrane Library and ClinicalTrials.gov. The search revealed that there are limited data on the efficacy of gabapentin for BPSD in the form of 11 case reports, 3 case series and 1 retrospective chart review; no controlled studies appear to have been published to date on this topic. In most of the reviewed cases, gabapentin was reported to be a well tolerated and effective treatment for BPSD. However, two case reports in which gabapentin was used in the context of agitation in dementia with Lewy bodies questioned the appropriateness of gabapentin for all types of dementia-related agitation. The dearth of available data limits support for the off-label use of gabapentin for the treatment of BPSD. Furthermore, controlled studies should be conducted before gabapentin can be clinically indicated for the successful treatment of BPSD.

Behavior problems in demented nursing home residents: a multifaceted approach to assessment and management

Behavior disturbances are common among dementia patients. Management of behavioral problems begins with the assessment of psychiatric, medical, and environmental etiologies. Treatment plans based upon behavioral or pharmacologic interventions can substantially reduce problematic behaviors.

Gabapentin for the Treatment of Behavioural Alterations in Dementia

BACKGROUND

Although the core feature of dementia is progressive cognitive disruption, non-cognitive behavioural problems are expressed in most patients with dementia during the course of their illness. While psychotropic drugs are frequently used to control behavioural symptoms, comorbidities, which are very common in the geriatric population, could often limit their use. Gabapentin may be a potential treatment in such situations.

METHODS

In this open, baseline comparison study 20 patients with probable Alzheimer's disease with behavioural alterations and serious comorbidities (paralytic ileus, open-angle glaucoma, ischaemic cardiopathy, hepatic failure or severe prostatic hyperplasia) received gabapentin for 15 months. Patients were allowed to continue any previous therapy for concurrent diseases. However, concomitant antipsychotic or benzodiazepine intake was not permitted.

RESULTS

Gabapentin appeared to be efficacious and well tolerated in this patient population, and did not appear to interact with other drugs. General benefit is reflected by a reduction of caregiver stress. No patients withdrew before the end of the study and no serious adverse events were reported.

CONCLUSION

The results of this study in patients with probable Alzheimer's disease with behavioural alterations and serious comorbidities indicate that gabapentin provides significant and sustained efficacy in terms of behaviour, with associated reductions in caregiver burden. The results of an ongoing larger, randomised, double-blind study of gabapentin are keenly awaited and may help to provide a safer and more efficacious treatment option for this group of patients.

Strategies for optimizing antiepileptic drug therapy in elderly people

The elderly take more antiepileptic drugs (AEDs) than all other adults. This extensive use directly correlates with an increased prevalence of epilepsy in a growing population of older people, as well as other neuropsychiatric conditions such as neuropathic pain and behavioral disorders associated with dementia and for which AEDs are administered. The agents account for nearly 10% of all adverse drug reactions in the elderly and are the fourth leading cause of adverse drug reactions in nursing home residents. Numerous factors associated with advanced age contribute to the high frequency of untoward drug effects in this population; however, strategies are available to ensure optimal outcomes.

Assessment and management of behavioral disturbances in nursing home patients with dementia

Behavioral disturbances among nursing home patients with dementia are common and substantially affect patients and caregivers. Assessing the environmental, medical, and psychiatric causes of problematic behaviors and implementing a plan of behavioral, medical, and psychiatric management can reduce difficult target behaviors. This article presents a multifaceted approach to assessing patients with dementia who have behavioral problems, reviews medical and pharmacological management of these problems, and presents a multidisciplinary approach to developing treatment plans aimed at reducing such behaviors among nursing home patients with dementia.

Gabapentin for treatment of behavioral and psychological symptoms of dementia

OBJECTIVE

To report the use of gabapentin in the treatment of behavioral and psychological symptoms of dementia (BPSD) and to review the available literature relating to the use of gabapentin in this population.

CASE SUMMARY

A 62-year-old white man was admitted to the hospital due to a worsening state of confusion, anxiety, depressed mood, insomnia, and verbal and physical aggressiveness toward his wife. He had a past medical history significant for vascular dementia. He had been intolerant of or had failed to respond to numerous antidepressants, benzodiazepines, and neuroleptics. The addition of gabapentin to the patient's medication regimen resulted in reduced agitation, sexual inappropriateness, and lability. He was discharged to his home on a dose of gabapentin 300 mg three times daily.

DATA SOURCES

A MEDLINE search (1966-August 2000) was performed to identify case reports and clinical trials discussing the efficacy of gabapentin in the treatment of BPSD.

DISCUSSION

Gabapentin, like other anticonvulsants, has been used with success in several psychiatric illnesses. Available literature indicates that the drug may have some efficacy in the treatment of BPSD. It has a favorable adverse effect profile in the elderly, which makes it an attractive altemative to standard therapies, including benzodiazepines and neuroleptics. Optimal dosing remains unclear.

CONCLUSIONS

This case suggests that gabapentin is a reasonable alternative therapy for patients whose behavioral symptoms do not respond to conventional agents.

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.

Gabapentin: a review of published experience in the treatment of bipolar disorder and other psychiatric conditions

Successful therapy with valproate and carbamazepine in patients with psychiatric disorders led to investigation of other anticonvulsants for similar indications. Gabapentin is a relatively new anticonvulsant being investigated for potential use in the treatment of bipolar disorder (BD), anxiety disorders, behavioral dyscontrol, and substance use disorders. Its favorable side effect profile, absence of the need for therapeutic drug monitoring, and minimal drug interactions give gabapentin a potential role in these indications. Computer searches of the biomedical literature were undertaken to identify all pertinent case reports, case series, and studies of the drug as monotherapy or adjunctive therapy for BD; 10 reports were retrieved. In the treatment of various anxiety disorders, one study, one case report, and one case series were identified. At least one case series described gabapentin therapy for alcohol withdrawal and one case report of the drug for agitation associated with dementia. Published, well-designed studies evaluating the agent's effectiveness as monotherapy for BD are lacking. Its benefit as an adjunctive treatment with other mood stabilizers is also unestablished. Data regarding its efficacy in the treatment of anxiety disorders or manifestations of substance abuse are limited. These areas may deserve further investigation.