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!