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 100mgNOT – Paxil or ProzacNOT - Tricyclic'sSNRIs – Remeron start with 15mg, Cymbalta, Effexor - rarelyWellbutrin 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