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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 ¹.

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Agitation in The Demented Patient

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

  2. 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.

  3. 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

  4. 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?

  5. 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 !°

  6. MMSE vs Systolic BP

  7. STEP 3. • STEP 3. Is There an Exacerbation of Medical Condition ? • Diabetes • UTI/ URI • Sepsis • Dehydration/ Hypovolemia • Trauma/Fractures/ Dislocations • Electrolyte Disturbances

  8. 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meds” ( meaning well ), only to find out later pt well maintained on “Haldol; low dose” for 8 years and now drug is withdrawn, & pt agitated….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 )

  9. STEP 5. “NEUROBEHAVIORAL PARADIGM’S” & Treatment Options

  10. 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”

  11. 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”

  12. 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”

  13. “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”

  14. 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

  15. 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)

  16. 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 !

  17. 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

  18. 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

  19. 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

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