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!