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Agitation in The Demented Patient. Michael Tino, MD Psychiatry/ Behavioral Health Preceptors: Richard Haaser, MD/ Dr.Michael Floyd . Treatment Algorhythm Approach ¹.

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agitation in the demented patient

Agitation in The Demented Patient

Michael Tino, MD

Psychiatry/ Behavioral Health

Preceptors: Richard Haaser, MD/

Dr.Michael Floyd

treatment algorhythm approach
Treatment Algorhythm Approach¹
  • Behavioral signs & symptoms in dementia tend to occur in identifiable clusters¹ or “Neurobehavioral Paradigm’s”². Proper cluster assessment lends to appropriate therapeutic intervention.
5 step algorhythm
5 STEP ALGORHYTHM
  • 1) Is there a change in External Environment
  • 2) Is there a change in Internal Environment
  • 3)Exacerbation of Existing Medical Condition
  • 4)Exacerbation of Existing Psych Condition
  • 5) Identify Cluster of Behaviors & Treat Appropriately
step 1
STEP 1
  • STEP 1. Is there a change in the patients External Environment ?
  • A.New Room-mate, Family, New Nurse
  • (Or Existing nurse or staff member assumes familiarity)
  • Example is first order of business is to remove pt’s clothing for am care
  • “Best to reintroduce self q am”
  • Is Environment excessively hot or cold ? Noisy?
step 2
STEP 2
  • STEP 2. Is There a Change in patients Internal Environment ?
  • Infection-UTI,URI
  • Medication Changes(tricyclics, H2 Blockers)
  • Constipation/ Occult Hip Fracture ?
  • Hypoxia, Hypercarbia,Hypotension/Dehydration
  • Mini Mental Status has been shown to change w High & Low B/P !°
step 3
STEP 3.
  • STEP 3. Is There an Exacerbation of Medical Condition ?
  • Diabetes
  • UTI/ URI
  • Sepsis
  • Dehydration/ Hypovolemia
  • Trauma/Fractures/ Dislocations
  • Electrolyte Disturbances
step 4
STEP 4.
  • Is There Exacerbation of Existing Psych Condition ?
  • Example: New MD on Case may try to DC “too many meds” ( meaning well ), only to find out later pt well maintained on “Haldol; low dose” for 8 years and now drug is withdrawn, & pt agitated….
  • Are pts being stimulated Physically, Socially, Emotionally ? ( Group Activity/Exercise/Musical Activity/ Religious Identity )
paradigm cluster a
Delusional/ Hallucinating

Psychosis

Treatment= Antipsychotics

Risperdal 0.25 mg/day

No Olanzapine, or other “pine” class drugs. Have been linked to DKA/Dyslipidemia/ Insulin Resistance/Avg 24 pound weight gain 1st year

Paradigm/Cluster “A”
paradigm cluster b
Withdrawn/ Not Eating/ Refusing Activities

DEPRESSION

Treatment= ANTIDEPRESSANTS

Effexor 37.5 qd start

Remeron 15 mg q d

SSRI-Prozac 10 mg qd

AVOID SSRI if Risk Factors for Microvascular Disease

Paradigm/ Cluster “B”
paradigm cluster c
Intrusive/ Not Sleeping/ Hanging Around Nurses Station

MANIA

Treatment= ANTICONVULSANTS

Valproate 125 mg bid

Trileptal 300 mg bid

Tegretol 50 mg qd

Paradigm/ Cluster “C”
paradigm cluster d
“ICTAL” Pattern/ Explosive temper/hyperorality/Disinhibition/Vulgarity”Emotional Incontinence”

Treatment= ANTICONVULSANTS

Valproate 125 mg bid

Tegretol 50 mg qd

Trileptal 300 mg bid

Paradigm/ Cluster “D”
psych medications
Psych Medications

Antipsychotics

Clozapine..12.5 mg qd

Seroquel..25 mg qd

Mellaril..10 mg qd

Risperdal…0.5 mg qd

SSRI’s

Zoloft..25-50 mg qd

Prozac..10 mg qd

Benzo’s

(May cause rebound agitation or paradoxical excitement…Try to avoid !!)

BUSPAR……..Note..

Doses of 30-60 mg frequently required

Anticonvulsants

Tegretol…50-100 mg qd

Valproate..125 mg bid

Trileptal..300 mg bid

slide15
Tricyclics

*Nortriptylline 25 mg

*Desipramine 25 mg

*=less sedating, less anticholinergic.

Amitriptyline 10 mg tid

Doxepin 25 mg qd*

BENZO’S

Lorazepam/Oxazepam

* Fastest Elimination

TETRACYCLICS

Mirtazapine (remeron) 15 qd

OTHER

Trazodone 25 mg qd

( Partially Acts by potentiating 5-hydroxytryptophan (possible sleep aid)

it s 3 am pt agitated what to do
It’s 3 am, Pt agitated, What to Do ?
  • Nursing calls, wants Ativan order.
  • Try Risperdal 0.5- 1.0 mg stat
  • Avoids rebound agitation from benzos !
review of psychotropic drug major side effects brief list of worst best profiles
ANTIHISTAMINIC= SEDATION

Worst=Olanzapine(zyprexa),Thorazine/Mellaril

BEST=Risperdal/ Haldol

ANTI-SEROTONERGIC=WEIGHT GAIN

Worst=Remeron

BEST= Risperdal

Review of Psychotropic Drug Major Side Effects & Brief List of Worst & Best Profiles
slide18
ANTI-DOPAMINERGIC= EPS,PROLACTIN RELEASE

Worst=Thorazine/Mellaril,Prolixin

Best=Seroquel, Risperdal

OTHER/ AVOID

and Olanzapine other “pine” class of drug

DKA/Dyslipidemia/Insulin Resistance

Weight Gain

ANTI-CHOLINERGIC= URINE RETENTION,DRY MOUTH,CONSTIPATION ,BLURRED VISION, H.R.INCREASE

Worst= Zyprexa

Best= Risperdal/Haldol

ANTI-ALPHA1 ADRENERGIC= ORTHOSTATIC HYPOTENSION

WORST=Mellaril/Thorazine

BEST= Risperdal

bibliography
Bibliography
  • 1. Tariot,PN. Treatment Strategies for agitation and psychosis in dementia. J Clin Psychiatry 1996:57(suppl 14):21-29
  • 2. Haaser, R. VAMC: Lecture: “Neurobehavioral Paradigm approach to therapeutic intervention”. Jan 2003.
  • 3. Drug Facts & Comparisons,2000. 54th Edition. Antidepressants,Benzodiazepines, & Antipsychotic agents comparisons. 876-934
  • 4. Skogg,et al. “15 Year Longitudinal Study of Blood Pressure & Dementia. Lancet.1996;347:1141-1145