Apologies for somewhat thread jacking, but you prefer seroquel/zyprexa over risperdal on gero unit for agitation?
I'm a PGY2 resident, and I'm still trying to figure out what to give for agitation to geriatric patients. So far, my consensus is: seroquel is bad, risperdal is good (like 0.25 qhs or BID at the most).
Your 2 cents?
1. General guidelines advise avoidance of neuroleptics in the elderly as far as possible, and I think this is good advice. Also bear in mind the risks of stroking out your older patients with atypical neuroleptics, and the sensitivity to dystonia, parkinsonism, NMS particularly with conventional neuroleptics
2. non-pharmacological methods should be used first and this is often forgotten in practice even though everyone knows this is supposed to be the case. Lazy staff or lack of staffing are not appropriate reasons for use of chemical cosh. Even when drugs are needed, the overall burden may be reduced by using additional methods. For example hugs can sometimes be appropriate for older patients.
Doll therapy or use of stuffed toys can also be helpful
3. Identifying the causes of agitation is also important and use of non-psychotropic pharmacotherapy first (i.e. analgesia, antibiotics, laxatives) UTI, pneuomonia (often without any clinical signs) constipation, dental problems, pain may be occult and significant drivers of agitation. Demented patients should have dental check ups as appropriate. Sometimes patients cannot communicate their pain. Prescribing
scheduled tylenol in patients who you suspect of pain may be helpful. Patients liable to constipation may benefit from scheduled laxatives.
4. Non-neuroleptic psychopharmacological agents are often more effective and reducing bouts of agitation. For example the recent
CitAD study showed that citalopram can significantly reduce agitation and carer distress in Alzheimer's disease. Not very helpful for depression.
Prazosin has also been used with mixed success for agitation in the setting of dementia. Patients with Lewy Body Disease can experience significant reduction in agitation with
rivastigmine. Although acetylcholinesterase inhibitors are fairly useless in Alzheimer's, LBD which involves significant cholinergic deficiency has a somewhat more robust response including reduction of confusion, hallucinations, and agitation driven by the former two.
5.Non-neuroleptic sedatives have been used to in agitated dementia (e.g. trazodone, depakote) but i'm not too impressed with them
6. Remember that neuroleptics do not have great evidence for control of agitation in patient's with Alzheimer's if you read the
CATIE-AD study. In that study olanzapine and risperidone had a significantly longer time to discontinuation compared with quetiapine but there was no significant difference in terms of clinical response.
7. Clinical wisdom holds that patient's with psychosis in dementia are better candidates for neuroleptics than simply agitated demented patients. In my experience (and the evidence), psychotic dementia does not respond very well to neuroleptics. Indeed, organic psychosis does not tend to have as robust a response to neuroleptics as primary psychotic illness.
8. Benzodiazepines are not to be forgotten. Though much vilified, and not without risks of falls, paradoxical disinhibition or delirium, they can be invaluable, particularly in involutional melancholia with prominent psychomotor agitation, and excited catatonia. In severe dementia, do not be afraid of benzodiazepines. The brain that has already degenerated cannot fall further into delirium.
9. restless leg syndrome, akathisia, catatonia, and delusional disorders are often overlooked in older patients
10. never forget alcohol withdrawal or other complications of alcoholism in older patients. When the reason for agitation is unclear, do not forget urine toxicology as older patients abuse substances too.
11. remember to look for and correct any nutritional deficiencies including iron, b12, folate, thiamine, and vitamin D
12. In severe cases of agitation - including in the setting of dementia, ECT can be considered taking into consideration the ethical issues. I always feel uncomfortable electrocuting 90 year olds who have no idea why there are in the ECT suite but sometimes the benefits do outweigh the risks. This needs constant re-evaluation.
13. Finally a sobering thought is that if you do nothing, the patient will probably be the same (or better) than if you intervened
