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Medication management of Behavioral Problems in Patients with End Stage Dementia

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

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Medication management of Behavioral Problems in Patients with End Stage Dementia

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  1. Medication management of Behavioral Problems in Patients with End Stage Dementia

  2. 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

  3. Partnership • Crucial to form a partnership with family and caregivers • Neuropsychiatric Inventory and Behavioral Pathology for Alzheimer Disease – standardized measures for assessing behavioral disturbances

  4. 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

  5. Environmental Triggers • Lack of social interaction • Sensory overstimulation • Crowded areas • Large spaces • Moves

  6. 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

  7. 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?

  8. Delirium • Acute Onset • Inattention • Disorganized thinking or Altered Level of consciousness

  9. Commonly used Drugs with Anticholinergic effects which can increase confusion • Benadryl – (tylenol sleep) • Bladder antispasmodics – oxybutynin • Tricyclic antidepressants • SNRIs (cymbalta, effexorxr) • Paxil! • Olanzapine (Zyprexa) • Muscle Relaxants – flexeril • Lasix

  10. 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

  11. Drugs with and indication for managing behavioral disturbances in dementia • NONE

  12. Categories of Medications used to treat - all off label • Antidepressants • Mood stabilizers • Antipsychotics • Benzodiazepines • Cognitive enhancers - Anticholinesterase inhibitors, Namenda

  13. SIG • Routine is usually better than prn

  14. 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

  15. Serotonin syndrome • Potentially fatal, Begins in hours after new medication • Confusion • Alterations in blood pressure and/or temperature • Rapid heart rate • Shivering • Twitching

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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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