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) mg risperidone (Risperdal) mg olanzapine (Zyprexa) mg 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) –~ 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/ involuntary evaluation 32 - involuntary committment

Referral Shands at UF Inpatient Geriatric Psychiatry Unit Intake Coordinator

GO GATORS!