Optimizing Outcomes in AAD in Community PCP and LTC Clinics

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Dr. Portsteinsson:
This is CME on ReachMD and I'm Dr. Anton Porteinsson. Joining me today is Dr. Brendan Montano.

Brendon, how do you incorporate new treatments for agitation in Alzheimer's disease into your clinical practice? 

Dr. Montano:
Yes. Well, it's been a very frustrating experience for we who have taken care of these very lovely but unfortunate people that suffer with agitation in Alzheimer's disease. They often end up, and almost always, going to the nursing home and the caregiver cannot provide care. They just get burned out and they can't do it anymore. And so, for their own survival, they're having to give their loved one to another facility.

We now have FDA-approved treatment for this agitation, which may, if it’s incorporated early enough, prevent them or delay them from having to go to the tertiary care facility. So, I am aggressive at using it early on if the agitation is there. No question. If it's there, I don't want that caregiver to get to a point where they and to suffer so badly that they have to, indeed, put their loved one into the tertiary care facility, the skilled nursing home. 

With that being said, I've had very good results thus far and safe results too. It's been a very well-received treatment. I guess, Anton, I'm asking you the same question. How have you used this technology in your practice?

Dr. Porteinsson:
Yeah, I find basically that exactly the same. We know that there's tremendous need for effective treatment here, be that non-pharmacological or pharmacological. We've been using medications off-label for numerous years, often medications with limited evidence-base in terms of efficacy, but well-established significant side effect burden. So, having a medication that has undergone an FDA review and been approved for marketing is critically important. I think that it basically gives us confidence that we can tell people, this is a medication that has undergone rigorous testing, has shown a fairly consistent picture of efficacy at the right doses. And I want to point out for brexpiprazole that you need to get to the right dose, and that takes titration. Half a milligram for one week, then 1 milligram for another week. And then you go to 2 milligrams, which is one of the effective doses. And if you have to push it further, you can go to 3 milligrams a day.

And then the efficacy in terms of reducing behavior, was clearly superior to placebo as measured by the so-called Cohen-Mansfield Agitation inventory, but also seen in measures of disease severity and caregiver burden.

So now, when I see people that present with agitation to my clinic, first of all, it requires a thoughtful work-up. In the previous episode, you pointed out that there can be medical conditions or previous psychiatric conditions that might be at play here, and we need to exclude that. We need to make sure that patients and families are not kind of butting heads because their communication is poor, and that the caregiver learns manage some of the non-pharmacological approaches that might be helpful. But in most situations, you need to intervene with medicines if we are at a moderate or severe degree of agitation. 

And then, I think that a lot of people still deflect to the older antipsychotics or mood-stabilizing anticonvulsants, or to benzodiazepines, and I just want to urge caution in terms of that.

Dr. Porteinsson:
Well, this has been a brief but great discussion. I hope we gave you something to think about and thanks for tuning in.

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