BPSD - Devon Partnership NHS Trust

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Pharmacological Management: The expected benefits must outweigh the potential risks/side effects of medication for each individual. Pharmacological management of severe BPSD (agitation and aggression in particular) should only be considered if behaviours cause severe distress to the individual and/or there is immediate risk of harm to other patients or carers. Remember- wandering behaviour does NOT respond to medication. Medication prescribed for the management of BPSD should be considered as an individual therapeutic trail, with the choice of medication based upon an individual risk-benefit analysis. Always “START LOW AND GO VERY SLOW”. Treatment choice and duration: Once a decision has been reached to start medication for the management of BPSD the first choice of treatment considered should be; Risperidone Initial dose of 250micrograms twice a day recommended. This may be increased according to response in steps of 250micrograms twice a day on alternate days. Usual dose 500micrograms twice a day (but doses up to 1mg twice a day may be beneficial for some individuals). Risperidone is the only medication with UK Marketing authorisation for this indication, licensed for “the short-term treatment (up to 6 weeks) of persistent aggression in patients with moderate to severe Alzheimer's dementia unresponsive to non-pharmacological approaches and when there is a risk of harm to self or others”. Antipsychotic drugs are known to be harmful and can have severe side-effects and it is vital that any person prescribed risperidone (or other antipsychotic) is monitored for side-effects and progression of symptoms. Exercise caution if risperidone is prescribed together with furosemide (higher incident of mortality observed although mechanism unclear). The risks and benefits of combining risperidone with furosemide or other potent diuretics must be considered prior to use. Refer to Risperidone SPC for more information. The most important adverse effects associated with antipsychotics are parkinsonism, falls, dehydration, chest infections, ankle oedema, deep vein thrombosis/pulmonary embolism, cardiac arrhythmia and stroke (highest risk in first four weeks of treatment). Antipsychotics are also associated with increased mortality in the long term (often related to pneumonia and thromboembolic events) which can be caused by over-sedation and dehydration. Complete a cardiac risk assessment prior to initiating treatment. Weekly monitoring of sedation, fluid intake and early indicators of chest infection is strongly recommended. Caution: antipsychotics should not be used in someone with Lewy Body Dementia (LBD) Where without risperidone specialist is contraindicated advice. or where no clinical benefit is achieved and/or the individual experiences intolerable side effects, it may be appropriate to consider alternative pharmacological treatment options (to be initiated by or on the recommendation of a specialist). The available evidence base is insufficient to support specific recommendations on preferred choices of medication or the order in which different medicines/different classes of medication should be prescribed. Refer to the Decision aid for specialist treatment strategies-Severe BPSD (Appendix 1) PG 14 – Pharmacological Management of BPSD Approved by Drug and Therapeutics Committee: September 2013 Review date: September 2015 Page 4 of 10
Initiation of medication (by, or on the recommendation from, a specialist): Identify, quantify & document target symptoms including severity and level of distress caused to the individual (and family/carers where appropriate) and set realistic treatment goals. Suitable assessment tools include Adapted Cohen –Mansfield Agitation Inventory (Adapted CMAI) or Neuropsychiatric Inventory (NPI). The Adapted Cohen–Mansfield Agitation Inventory is available here Document which non-pharmacological interventions have been used and/or offered to the individual (as appropriate) and level of effectiveness. Complete baseline physical monitoring, appropriate to the individual drug prescribed. Complete baseline assessment of cognition. Clearly record rationale for treatment and choice of medication in the clinical notes, including agreed start date and initial treatment review date (& person responsible for completion). It is recognised that when medication is prescribed for the management of BPSD it will generally arise from a ‘best interest decision’. The prescriber must ensure that a formal record of capacity assessment is completed (using RiO capacity assessment form) and a summary of multi-professional team discussion and rationale for treatment clearly documents in the notes (including information provided to family and/or carers where applicable). Communication of information to family/carers: The prescriber must discuss the possible treatment options with the individual and/or family/carers, including the anticipated benefits and potential risks of treatment (in particular, cerebrovascular risk factors should be assessed and the possible increased risk of stroke/transient ischaemic attack and possible adverse effects on cognition discussed). Provide information in an appropriate format to support discussion about expected benefits and possible risks of treatment (see user-friendly resources). A summary of the discussion (and note of any additional information provided) must be clearly documented in the clinical notes. During treatment: Regularly monitor response to treatment/changes in target symptoms & document in notes Assess cognition at regular intervals, and document any required action(s)/treatment plan to address any deterioration in cognition in the notes Monitor for emergence of side effects associated with mediation. Discuss with individual and/or carer and review treatment if side effects intolerable or severe. (NB people with DLB have increased sensitivity to antipsychotic side effects, including acute & severe physical deterioration- monitor carefully). Ensure on-going physical monitoring is carried out appropriate to the medication prescribed. Document subsequent treatment review dates (& person responsible) in the clinical notes at each clinical review. Treatment should be time-limited and regularly reviewed. Reviewing and stopping treatment: Treatment should be reviewed at 6 and/or twelve weeks (with more frequent review considered according to clinical need). Following review, unless there is severe risk or extreme distress, the recommended default management is to discontinue antipsychotic medication. When stopping medication, if the daily dose of risperidone is 500micrograms or less immediate discontinuation is recommended. For higher doses a gradual reduction is preferable to abrupt withdrawal, i.e. reduce dose by 50% of total daily dose every 1-2 weeks until dose of 500micrograms or less/day reached, then stop minimum dose after 1-2 weeks. PG 14 – Pharmacological Management of BPSD Approved by Drug and Therapeutics Committee: September 2013 Review date: September 2015 Page 5 of 10
Page 1 and 2: Prescribing Guideline Pharmacologic
Page 3: No further intervention needed at t
Page 7 and 8: Appendix 1 Decision aid for special
Page 9 and 10: BENZODIAZEPINES Intervention Ration

BPSD - Devon Partnership NHS Trust

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