para>Black box warning on antipsychotics due to increased mortality in elderly with dementia
- Depression and insomnia
- Depression
- Selective serotonin reuptake inhibitors (SSRIs): Initiate low doses, citalopram (Celexa) 10 mg/day; escitalopram (Lexapro) 5 mg/day; sertraline (Zoloft) 25 mg/day.
- Adverse events: nausea, vomiting, agitation, parkinsonian effects, sexual dysfunction, hyponatremia
- Venlafaxine, mirtazapine, and bupropion are also useful.
- Sleep disturbances
- Low-dose antidepressants (e.g., Remeron) have significant sedative properties at 7.5 or 15 mg.
- Trazodone 25 to 100 mg is frequently used because of better side effect profile.
- Psychosis and agitation/aggressive behavior
- Some data for SSRIs
- Benzodiazepines if agitation with anxiety; in elderly, use PRN
Geriatric Considerations
Initiate pharmacotherapy at low doses and titrate slowly up if necessary.
- Benzodiazepine are potentially inappropriate for older adults, yet their use persists
ALERT
Benzodiazepine use is associated with increased fall risk (5)[B].
- Watch decreased renal function and hepatic metabolism.
ISSUES FOR REFERRAL
Neuropsychiatric evaluation particularly helpful in early stages or mild cognitive impairment
ADDITIONAL THERAPIES
Behavioral modification
- Socialization, such as adult daycare, to prevent isolation and depression
- Sleep hygiene program as alternative to pharmaceuticals for sleep disturbance
- Scheduled toileting to prevent incontinence
COMPLEMENTARY & ALTERNATIVE MEDICINE
- Vitamin E is no longer recommended due to lack of evidence
- Ginkgo biloba is not recommended due to lack of evidence.
- NSAIDs, selegiline, and estrogen lack efficacy and safety data.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Worsening physical health issues
- Psychiatry admission may be required because of safety concerns (self-harm/harm to others), self-neglect, aggressive behaviors, or other behavioral issues.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- Progression of cognitive impairment by use of standardized tool (e.g., MMSE, ADAS-Cog)
- Development of behavioral problems: sleep, depression, psychosis
- Adverse events of pharmacotherapy
- Nutritional status
- Caregiver evaluation of stress
- Evaluate issues that may affect quality of life.
PATIENT EDUCATION
- Safety concerns
- Long-term issues: management of finances, medical decision making, possible placement when appropriate; legal guardianship, if necessary, to avoid capacity and competency issues
- Advance directives
- National Institute on Aging. About Alzheimer's disease: other dementias. http://www.nia.nih.gov/alzheimers/topics/other-dementias
PROGNOSIS
- AD: usually steady progression leading to profound cognitive impairment
- Average survival of AD is about 8 years.
- VaD: incrementally worsening dementia, but cognitive improvement is unlikely
- Secondary dementias: Treatment of the underlying condition may lead to improvement. Commonly seen with normal pressure hydrocephalus, hypothyroidism, and brain tumors.
COMPLICATIONS
- Wandering
- Delirium
- Sundowner syndrome: It is frequently common in older people (who are sedated) and also in people who have dementia (adverse reaction to small dose of psychoactive substances).
- Falls with injury
- Hip fracture
- Head trauma/hematomas
- Neglect and abuse
- Caregiver burnout
REFERENCES
11 McGuinness B, Craig D, Bullock R, et al. Statins for the prevention of dementia. Cochrane Database Syst Rev. 2009;(2):CD003160.22 Blass DM, Rabins PV. In the clinic. Dementia. Ann Intern Med. 2008;148(7):ITC4-1-ITC4-16.33 van Harten AC, Kester MI, Visser PJ, et al. Tau and p-tau as CSF biomarkers in dementia: a meta-analysis. Clin Chem Lab Med. 2011;49(3):353-366.44 Birks J. Cholinesterase inhibitors for Alzheimer's disease. Cochrane Database Syst Rev. 2006;(1):CD005593.55 Softic A, Beganlic A, Pranjic N, et al. The influence of the use of benzodiazepines in the frequency falls in the elderly. Med Arch. 2013;67(4):256-259.
ADDITIONAL READING
- Lyketsos CG, Colenda CC, Beck C. Position statement of the American Association for Geriatric Psychiatry regarding principles of care for patients with dementia resulting from Alzheimer disease. Am J Geriatr Psychiatry. 2006;14(7):561-572.
- National Collaborating Centre for Mental Health. Dementia: The NICE-SCIE Guideline on Supporting People with Dementia and Their Carers in Health and Social Care. London, United Kingdom: British Psychological Society, Royal College of Psychiatrists; 2007. (National clinical practice guideline number 42). http://www.nice.org.uk/nicemedia/live/10998/30320/30320/pdf
- Rabins PV, Blacker D, Rovner BW, et al; APA Work Group on Alzheimer's Disease and Other Dementias. American Psychiatric Association practice guideline for the treatment of patients with Alzheimer's disease and other dementias. Second edition. Am J Psychiatry. 2007;164(12)(Suppl):5-56.
SEE ALSO
Algorithm: Dementia
CODES
ICD10
- F03 Unspecified dementia
- G30.9 Alzheimer's disease, unspecified
- F01.50 Vascular dementia without behavioral disturbance
- G31.83 Dementia with Lewy bodies
ICD9
- 331.0 Alzheimer's disease
- 290.40 Vascular dementia, uncomplicated
- 290.42 Vascular dementia, with delusions
SNOMED
- 52448006 Dementia (disorder)
- 429998004 Vascular dementia
- 191464005 Arteriosclerotic dementia with delirium (disorder)
- 191466007 arteriosclerotic dementia with depression (disorder)
- 371024007 Senile dementia with delusion (disorder)
- 191461002 Senile dementia with delirium
- 15662003 Senile dementia (disorder)
CLINICAL PEARLS
- Medications for AD show a small, statistically significant improvement in some cognitive measures, but it remains unclear if the improvement is clinically significant.
- Do not forget the role of adult protective services in case of elderly abuse.
- A particular concern in nursing homes relates to the use of physical restraints and antipsychotic medication, which are regulated in the United States by the Omnibus Reconciliation Act of 1987.