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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 - PowerPoint PPT Presentation
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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 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
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