use of antipsychotic drugs in dementia josepha a. cheong, md university of florida departments of...
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Use of Antipsychotic Drugs in Dementia
Josepha A. Cheong, MD
University of Florida Departments of Psychiatry and Neurology
Chief, Division of Geriatric Psychiatry
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What are common behavioral disturbances?
• Agitation– Physical– Verbal– Resistiveness
• Mood – Depression– Anxiety
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What are common behavioral disturbances?
• Psychosis– Disruption in the ability to differentiate real
from unreal– Hallucinations– Illusions
• “Sundowning”
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Assessment
• Rule out any environmental disturbance– change in home setting– change in the staff/family members– death of a pet
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Assessment
• R/o any possible medical illness– urinary tract infection– dehydration
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Assessment
• R/o drug-drug interactions or drug intolerance
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Assessment
• When does the behavior occur– constant regardless of stimuli– specific time of day– with caregiving activity
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Assessment
• Endocrine
• Iatrogenic - consider non-prescription medications
• Injury
• Intoxication
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Treatment
• Behavioral Intervention
• Antidepressant medications
• Antipsychotic medications
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What is Psychosis?
• The state in which a person is unable to differentiate “real” from “unreal”
• Misperception of stimulus
• Hallucinations
• Illusions
• Delusions
• Agitation
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Antipsychotic Medications(doses adjusted for the geriatric age group)
• haloperidol (Haldol) .5 - 2.0mg
• risperidone (Risperdal) .5 - 6.0mg
• olanzapine (Zyprexa) 2.5 - 10.0mg
• ziprasidone (Geodon) 20-40mg
• quetiapine (Seroquel) 25mg - 300mg***
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General Guidelines
• Monitor very carefully for side effects
• Monitor for benefit
• Consider decreasing the dose if symptoms improve
• Monitor for increased sedation and adjust the time of dosing
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FDA Warning – April 2005
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Deaths with Antipsychotics in Elderly Patients with Behavioral Disturbances
• 15 out of 17 placebo-controlled trials showed numerical increases in mortality in the drug-treated group compared to the placebo-treated patients – N = 5106 involving Risperidone (7 trials), Olanzapine (5 trials),
Aripiprazole (3 trials) and Quetiapine (2 trials)
– ~1.6-1.7 fold increase in mortality in active treatment over placebo
• Specific causes of these deaths:– Heart related events (e.g., heart failure, sudden death) or
infections (mostly pneumonia)
FDA Public Health Advisory (4/05)
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Adverse Effects with Atypical Antipsychotics
• Dyslipidemia
• Glucose metabolism change
• Possibility of sudden death secondary to heart failure, cardiac event or infection
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Adverse Effects with Atypical Antipsychotics
Clinical Considerations:
• What are the risk factors of this particular patient? (history of cardiac problems, diabetes, and or hypertension?)
• What alternative treatments have been tried – what was the response?
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Adverse Effects with Atypical Antipsychotics
Clinical Considerations:
• What benefits does the patient receive from the particular antipsychotic vs. how is the patient’s behavior without or prior to the initiation of the medication?
• Have other intervention methods or medications been tried already?
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Adverse Effects with Atypical Antipsychotics
Recommendations for management:
• Document need
• Discussion of alternate treatments
• Patient/Family consent
• Use lowest possible doses – monitor for side effects
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Rules of Thumb
• Not everything needs to be treated with a
medication
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Rules of Thumb
• Not everything needs to be treated with a
medication
• Start at a low dose and titrate slowly
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Rules of Thumb
• Not everything needs to be treated with a
medication
• Start at a low dose and titrate slowly
• Not everything needs to be treated with a
medication
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Baker Act - 52/32
• 52 - involuntary evaluation
• 32 - involuntary committment
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Referral
Shands at UF
Inpatient Geriatric Psychiatry Unit
Intake Coordinator 352-265-5411
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GO GATORS!