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Use of Antipsychotic Drugs in Dementia

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.

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Use of Antipsychotic Drugs in Dementia

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  1. Use of Antipsychotic Drugs in Dementia Josepha A. Cheong, MD University of Florida Departments of Psychiatry and Neurology Chief, Division of Geriatric Psychiatry

  2. What are common behavioral disturbances? • Agitation • Physical • Verbal • Resistiveness • Mood • Depression • Anxiety

  3. What are common behavioral disturbances? • Psychosis • Disruption in the ability to differentiate real from unreal • Hallucinations • Illusions • “Sundowning”

  4. Assessment • Rule out any environmental disturbance • change in home setting • change in the staff/family members • death of a pet

  5. Assessment • R/o any possible medical illness • urinary tract infection • dehydration

  6. Assessment • R/o drug-drug interactions or drug intolerance

  7. Assessment • When does the behavior occur • constant regardless of stimuli • specific time of day • with caregiving activity

  8. Assessment • Endocrine • Iatrogenic - consider non-prescription medications • Injury • Intoxication

  9. Treatment • Behavioral Intervention • Antidepressant medications • Antipsychotic medications

  10. What is Psychosis? • The state in which a person is unable to differentiate “real” from “unreal” • Misperception of stimulus • Hallucinations • Illusions • Delusions • Agitation

  11. 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***

  12. 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

  13. FDA Warning – April 2005

  14. 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)

  15. Adverse Effects with Atypical Antipsychotics • Dyslipidemia • Glucose metabolism change • Possibility of sudden death secondary to heart failure, cardiac event or infection

  16. 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?

  17. 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?

  18. 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

  19. Rules of Thumb • Not everything needs to be treated with a medication

  20. Rules of Thumb • Not everything needs to be treated with a medication • Start at a low dose and titrate slowly

  21. 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

  22. Baker Act - 52/32 • 52 - involuntary evaluation • 32 - involuntary committment

  23. Referral Shands at UF Inpatient Geriatric Psychiatry Unit Intake Coordinator 352-265-5411

  24. GO GATORS!

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