Smerter, demens og atferdsendring
Atferdsforstyrrelser er vanlig hos demente påsykehjem 50 % 40 30 20 10 0 Aggresjon Apati Hemningsløshet Irritabilitet Motorisk uro Symptom Klin.sign.symptom Alvorlig symptom Selbæk et al Int J Ger Psych 2007
Konsekvenser av APSD Tidlig institusjonalisering Økte kostnader Ulovlig tvang Skadelig medisinbruk APSD Pårørende stress Redusert livskvalitet Funksjonssvikt Pasienter Omsorgspersoner APSD: Atferdsmessige og psykologiske endringer ved demens
Årsaker til APSD Strukturell hjerneskade Gener Nevrokjemiske forandringer Psykologiske faktorer APSD Miljøfaktorer Medikamenter Somatisk sykdom Smerter
Antipsykotika ved APSD: Tid til seponering - CATIE studien Withdrawal due to adverse events Withdrawal due to lack of efficacy Schneider et al. NEJM 2006
Antipsykotika gir økt mortalitet: The CALM-AD study Cumulative percentage of survival 0 20 40 60 80 100 Log-rank P=0.03 Continue Placebo 0 6 12 18 24 30 36 42 48 54 Time since randomisation (months) Log rank p=0.02 At risk (No. of deaths) in subsequent 12 months: Continue Placebo 83 (21) 82 (17) 62 (14) 65 (4) 23 (8) 32 (6) 10 (2) 21 (2) Ballard et al 2009 Lancet Neurology The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial. www.thelancet.com/neurology. 09 Jan 2009 4 (0) 9 (2)
Smerter og demens Smertelidelser øker med alderen (muskel skjelett, neuropathisk smerte, cancer, vaskulær sykdom, fraktur) Demens assosiert med mer smerte (Husebø 2008) Men oppdages ikke pga redusert språk & forståelse Derfor: Mindre smertestillende til demens (Husebø 2008) Smerte uttrykkes ved uro/aggresjon? (Cohen- Mansfield 1990; Snow 2009; Kunik 2010) Hypotese: Smertebehandling gir redusert uro
RCTs of pain-mangement for agitation in dementia Manfredi 2003 Chibnall 2005 N Design Drug Results Comment 47 Double-blind, placebo cross-over 25 Double-blind, Placebo, cross-over Morphine 20mg/ day Acetamino phen1 g x 3/d Negative Negative Reduced agitation in very old (>84 years) More activities, media and social interaction Kovach 2006 114 Double-blind, parallelgroup Analgesic at Step 4 (n=27) Negative Analgesics reduce discomfort
Setting: 60 sykehjemsavdelinger, 352 beboere Design:Kluster-randomisert, 8 ukers studie Inklusjonskriterier: 65+, sykehjem >4 uker, demens, klinisk signifikant uro/aggresjon > 1 uke (ie CMAI >38) BMJ 2011
Intervention: Stepwise pain treatment protocol* Step 1: Oral paracetamol, (max 3 g/d) or, if they were already receiving treatment were adjusted to either Step 2:Oral morphine retard, max 20 mg/d, Step 3:Buprenorphine transdermal patch, max 10 µg/h, or Step 4: Oral pregabaline, max 300 mg/d Fixed dose regimen throughout the eight week treatment period. In those who were not able to tolerate this treatment, the dosagewas either reduced or the participant was withdrawn from the study and treated as clinically appropriate. *following the recommendations of the American Geriatrics Society (J Am Geriatr Soc 1998;46:635-51)
RESULTATER: CMAI Cohen-Mansfield Agitation Inventory 60 55 50 45 40 Reduction of behavioural disturbances by pain treatment (Wash-out) Control Stepwise Protocol for treatment of Pain 0 2 4 6 8 10 12 Week Repeated measurement ANCOVA (LOCF):p<0.001 Average reduction 17%; Treatment effect 7.0 (95% CI 3.7-10.3)
Neuropsychiatric Inventory-NH Sign difference in favour of active treatment (ANCOVA: P<0.001)
Bivirkninger og frafall Active Control p Deaths 6 (3.4%) 8(4.5%) ns Drop-out 28(16.0%) 20(11.3%) 0.3 Causes of drop-out in active group: Døsighet (n=3) Kvalme (n=1) Hudallergi reaksjon (n=2) Akutt lumbal prolapse (n=1) Redusert allmenntilstand (n=2) Administrativ (13)
Konklusjoner Smerte-evaluering viktig ved uro og annen APSD Smertebehandling bør vurderes ved uro, også der det ikke er påvist smerter Paracetamol, ikkje Haldol
Takk til: Bettina S Husebø, MD, PhD, postdoctor fellow Clive Ballard, MD, professor Reidun Sandvik, MSc, registered nurse Odd Bjarte Nilsen, statistician Nursing home staff and administrators Finansiering : Norwegian Research Council (Protocol nr.: 189439) University of Bergen (09/1568) Kavli s Research Centre for Ageing, Bergen