Transcript No Slide Title

Management of Behavioral
Difficulties in Dementia Patients
Josepha A. Cheong, MD
University of Florida Departments of Psychiatry and
Neurology
Chief, Division of Geriatric Psychiatry
What are common behavioral
disturbances?
• Agitation
– Physical
– Verbal
– Resistiveness
• Mood
– Depression
– Anxiety
What are common behavioral
disturbances?
• Psychosis
– Disruption in the ability to differentiate real
from unreal
– Hallucinations
– Illusions
• “Sundowning”
Assessment
• Rule out any environmental disturbance
– change in home setting
– change in the staff/family members
– death of a pet
• R/o any possible medical illness
– urinary tract infection
– dehydration
Assessment
• R/o drug-drug interactions or drug
intolerance
• When does the behavior occur
– constant regardless of stimuli
– specific time of day
– with caregiving activity
Assessment
• Endocrine
• Iatrogenic - consider non-prescription
medications
• Injury
• Intoxication
Treatment
• Behavioral Intervention
– redirection
– no-fail environment
• adjusting the environment to meet the needs and the
limitations of the patient
– structure and consistency
– avoid overstimulation
Treatment
• Antidepressants
– start at a lower dose (1/3 or 1/2) of the
recommended usual starting dose
– increase the dose very gradually, be aware of
the side effects profile and sensitivity of patient
What and How?
Paroxetine
Q2weeks or
as tolerated
25 – 50 mg
Q 2 weeks or 100 – 150mg
as tolerated
20 mg
Q 2 weeks or 40 – 60 mg
as tolerated
15 mg
Q weeks or
as tolerated
37.5 mg
Q week or as 150 mg – 225
tolerated
mg
(Paxil)
Sertraline
(Zoloft)
Citalopram
(Celexa)
Mirtazipine
(Remeron)
Venlafaxine
(Effexor XR)
30 – 40mg
5-10 mg
30 – 45 mg
Sample Regimen
Antidepressant treatment
Sertraline 25mg or Paroxetine 5-10mg
increase to 50mg or 20mg gradually
Patient improves
continue at current dose
Pt does not improve, cannot tolerate SFx
Consider change to venlafaxine or mirtazapine
Venlafaxine 37.5mg
Mirtazepine 15mg
Gradually increase venlafaxine to 150 - 225mg/day
or mirtazepine 15-45mg
Assess for anxiety - treat with low doses of lorazepam
time limited
monitor closely
Pt improves but continues with symtpoms
Inc dose to 100mg or 30-40mg
assess for psychotic features
Antipsychotic Medications
•
•
•
•
•
haloperidol (Haldol) .5 - 2.0mg
risperidone (Risperdal) .5 - 6.0mg
olanzapine (Zyprexa) 2.5 - 10.0mg
ziprasidone (Geodon) 20-40mg
quetiapine (Seroquel) 25mg - 300mg
Rules of Thumb
• Not everything needs to be treated with a
medication
Rules of Thumb
• Not everything needs to be treated with a
medication
• Start at a low dose and titrate slowly
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
Baker Act - 52/32
• 52 - involuntary evaluation
• 32 - involuntary committment
Referral
Shands at UF
Inpatient Geriatric Psychiatry Unit
Intake Coordinator 352-265-5411
GO
GATORS!