1. Medication management of Behavioral Problems in Patients with End Stage Dementia

2. Clinical Features in Late Stage Dementia  Alzheimer's – Delusions, agitation  Frontotemporal - Personality changes, disinhibition, Impulsivity  Lewy Body – Visual Hallucinations, Falls, Syncope, Sensitivity to Antipsychotic Meds  Vascular – Abrupt onset, stepwise, prominent aphasia, severe depression

3. Partnership  Crucial to form a partnership with family and caregivers  Neuropsychiatric Inventory and Behavioral Pathology for Alzheimer Disease – standardized measures for assessing behavioral disturbances

4. Behaviors – Distress related  Falls, wandering, repetitive questions, physical and verbal aggression, resisting cares, alterations in sleep, agitation, delusions, hallucinations  Educate caregivers that some behaviors don’t respond to pharmaceuticals : wandering, rummaging, repetitive questions, calling out

5. Environmental Triggers  Lack of social interaction  Sensory overstimulation  Crowded areas  Large spaces  Moves

6. Assessment  Copy of History and Physical  Labs: CBC with platelets, CMP, UA, B12, Folate, Vitamin D3, TSH, Free T4  Patient’s Med List  History of underlying psychiatric illness  Social History (abuse)  Course of dementia  POOP, PEE PAIN

7. Questions I ask the caregivers  Course of dementia?  Recent medical/drug changes – exacerbation of chronic disease  Sleep?  Eat? Weight Loss?  Do they ever say they want to die? Tearful?  Delusions (stealing from them, poisoning them)?  Hallucinations (talking to people not there, visual)?  Worse in the afternoon – Sundowning?

8. Delirium  Acute Onset  Inattention  Disorganized thinking or Altered Level of consciousness

9. Commonly used Drugs with Anticholinergic effects which can increase confusion  Benadryl – (tylenol sleep)  Bladder antispasmodics – oxybutynin  Tricyclic antidepressants  SNRIs (cymbalta, effexor xr)  Paxil!  Olanzapine (Zyprexa)  Muscle Relaxants – flexeril  Lasix

10. Other drugs which cause confusion and possibly delirium in the elderly  Benzodiazepines!  Gabapentin  Lasix  Parkinson drugs – sinemet, requip, miralax  Opiates, other pain meds  ANY DRUGS

11. Drugs with and indication for managing behavioral disturbances in dementia  NONE

12. Categories of Medications used to treat - all off label  Antidepressants  Mood stabilizers  Antipsychotics  Benzodiazepines  Cognitive enhancers - Anticholinesterase inhibitors, Namenda

13. SIG  Routine is usually better than prn

14. Antidepressants  SSRIs – Celexa (Citalopram) up to 20mg Lexapro – up to 10mg Zoloft – up to 100mg NOT – Paxil or Prozac NOT - Tricyclic's SNRIs – Remeron start with 15mg, Cymbalta, Effexor - rarely Wellbutrin XL – morning dose

15. Serotonin syndrome  Potentially fatal, Begins in hours after new medication  Confusion  Alterations in blood pressure and/or temperature  Rapid heart rate  Shivering  Twitching

16. Mood Stabilizers  Depakote – usually sprinkles – up to 500mg divided BID or TID - not much evidence ?(underlying seizure/bipolar)  Tegretol - some evidence  Levels not accurate in elderly although required by Medicare, monitor platelets and LFTs  Lamictal – Fast spreading rash (underlying seizure/bipolar)  NOT LITHIUM

17. Black Box Warning  Elderly patients with dementia related psychosis treated with an antipsychotic drug are at an increased risk of death – they are not approved for the treatment of dementia related psychosis  Three fold greater risk of thrombolytic complications when used for dementia related behaviors

18. Antipsychotics  Risperdal – 0.25-2mg (ODT)  Seroquel – 50-200mg  Zyprexa – 2.5- 10mg (ODT)  Abilify, Geodon, Latuda, Saphris, Fanapt  Improvement in patients with psychosis and global neuropsychiatric disturbance

19. Comparative Risk of antipsychotics  Retrospective study of a large cohort of elderly veterans with dementia  Death rate per 100 person – years:  Haldol - 46  Zyprexa and Risperdal – 27  Seroquel – 19  Am. J Psychiatry 2012; 169:71-9

20. Cognitive Enhancers  Aricept – up to 23 mg (odt) AM dose  Razadyne ER – Up to 10 mg - AM  Exelon po – UP to 12 mg q day  Exelon patch – up to 13.3 q 24 hours  Namenda 10mg bid  Side effects: nausea, diarrhea, headaches  All have titration schedules  Withdraw – taper as appropriate one at a time  Sudden taper – rebound confusion and agitation

21. Benzodiazepine equivalents and half lives- including active metabolites  Xanax 0.5mg – 6-26 hours  Ativan – 0.25 10-20 hours  Klonipin – 0.25 20-50 hours (.125mg q day)  Valium – 5mg – 20-100 hours  Side effects: Falls, increased confusion, disinhibition  Use tiny doses – frequently if necessary