Transcript Use lowest possible doses – monitor for side effects

Use of Antipsychotic Drugs in
Dementia
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
Assessment
• R/o any possible medical illness
– urinary tract infection
– dehydration
Assessment
• R/o drug-drug interactions or drug
intolerance
Assessment
• 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
• Antidepressant medications
• Antipsychotic medications
What is Psychosis?
• The state in which a person is unable to
differentiate “real” from “unreal”
• Misperception of stimulus
• Hallucinations
• Illusions
• Delusions
• Agitation
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***
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
FDA Warning – April 2005
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)
Adverse Effects with Atypical
Antipsychotics
• Dyslipidemia
• Glucose metabolism change
• Possibility of sudden death
secondary to heart failure, cardiac
event or infection
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?
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?
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
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!