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Download Treating Behavioral Problems in Patients with End Stage Demetia
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Medication management of Behavioral Problems in Patients with End Stage Dementia Clinical Features in Late Stage Dementia Alzheimer's – Delusions, agitation Frontotemporal - Personality changes, disinhibition, Impulsivity Lewy Body – Visual Hallucinations, Falls, Syncope, Sensitivity to Antipsychotic Meds Vascular – Abrupt onset, stepwise, prominent aphasia, severe depression Partnership Crucial to form a partnership with family and caregivers Neuropsychiatric Inventory and Behavioral Pathology for Alzheimer Disease – standardized measures for assessing behavioral disturbances Behaviors – Distress related Falls, wandering, repetitive questions, physical and verbal aggression, resisting cares, alterations in sleep, agitation, delusions, hallucinations Educate caregivers that some behaviors don’t respond to pharmaceuticals : wandering, rummaging, repetitive questions, calling out Environmental Triggers Lack of social interaction Sensory overstimulation Crowded areas Large spaces Moves Assessment Copy of History and Physical Labs: CBC with platelets, CMP, UA, B12, Folate, Vitamin D3, TSH, Free T4 Patient’s Med List History of underlying psychiatric illness Social History (abuse) Course of dementia POOP, PEE PAIN Questions I ask the caregivers Course of dementia? Recent medical/drug changes – exacerbation of chronic disease Sleep? Eat? Weight Loss? Do they ever say they want to die? Tearful? Delusions (stealing from them, poisoning them)? Hallucinations (talking to people not there, visual)? Worse in the afternoon – Sundowning? Delirium Acute Onset Inattention Disorganized thinking or Altered Level of consciousness Commonly used Drugs with Anticholinergic effects which can increase confusion Benadryl – (tylenol sleep) Bladder antispasmodics – oxybutynin Tricyclic antidepressants SNRIs (cymbalta, effexor xr) Paxil! Olanzapine (Zyprexa) Muscle Relaxants – flexeril Lasix Other drugs which cause confusion and possibly delirium in the elderly Benzodiazepines! Gabapentin Lasix Parkinson drugs – sinemet, requip, miralax Opiates, other pain meds ANY DRUGS Drugs with and indication for managing behavioral disturbances in dementia NONE Categories of Medications used to treat - all off label Antidepressants Mood stabilizers Antipsychotics Benzodiazepines Cognitive enhancers - Anticholinesterase inhibitors, Namenda SIG Routine is usually better than prn Antidepressants SSRIs – Celexa (Citalopram) up to 20mg Lexapro – up to 10mg Zoloft – up to 100mg NOT – Paxil or Prozac NOT - Tricyclic's SNRIs – Remeron start with 15mg, Cymbalta, Effexor - rarely Wellbutrin XL – morning dose Serotonin syndrome Potentially fatal, Begins in hours after new medication Confusion Alterations in blood pressure and/or temperature Rapid heart rate Shivering Twitching Mood Stabilizers Depakote – usually sprinkles – up to 500mg divided BID or TID - not much evidence ?(underlying seizure/bipolar) Tegretol - some evidence Levels not accurate in elderly although required by Medicare, monitor platelets and LFTs Lamictal – Fast spreading rash (underlying seizure/bipolar) NOT LITHIUM Black Box Warning Elderly patients with dementia related psychosis treated with an antipsychotic drug are at an increased risk of death – they are not approved for the treatment of dementia related psychosis Three fold greater risk of thrombolytic complications when used for dementia related behaviors Antipsychotics Risperdal – 0.25-2mg (ODT) Seroquel – 50-200mg Zyprexa – 2.5- 10mg (ODT) Abilify, Geodon, Latuda, Saphris, Fanapt Improvement in patients with psychosis and global neuropsychiatric disturbance Comparative Risk of antipsychotics Retrospective study of a large cohort of elderly veterans with dementia Death rate per 100 person – years: Haldol - 46 Zyprexa and Risperdal – 27 Seroquel – 19 Am. J Psychiatry 2012; 169:71-9 Cognitive Enhancers Aricept – up to 23 mg (odt) AM dose Razadyne ER – Up to 10 mg - AM Exelon po – UP to 12 mg q day Exelon patch – up to 13.3 q 24 hours Namenda 10mg bid Side effects: nausea, diarrhea, headaches All have titration schedules Withdraw – taper as appropriate one at a time Sudden taper – rebound confusion and agitation Benzodiazepine equivalents and half lives- including active metabolites Xanax 0.5mg – 6-26 hours Ativan – 0.25 10-20 hours Klonipin – 0.25 20-50 hours (.125mg q day) Valium – 5mg – 20-100 hours Side effects: Falls, increased confusion, disinhibition Use tiny doses – frequently if necessary
