APA Guidelines on Antipsychotics and Agitation & Dementia

[wolfvgang22]

What do you all think about the new APA guidelines on treating patients with dementia and agitation?

It looks ok to me, but one question I have is which quantifiable measurement tool of behavior should be used? And why do they go out of their way to recommend avoiding Haldol over some other antipsychotics?

---

Members don't see this ad.

 

[FlowRate]

And why do they go out of their way to recommend avoiding Haldol over some other antipsychotics?

From the expanded guideline document:

"For statement 14, the data on harms in observational and administrative database studies sometimes focused on specific medications and sometimes on the class of FGAs as compared with SGAs. Since haloperidol was the most commonly used agent among FGAs, it was difficult to determine whether other FGAs had a comparable risk of harms. For this reason, the group chose to recommend that haloperidol not be used as a first-line agent, rather than recommending against use of any FGA as a first-line agent."

Another article in their references mentioned risperidone having some evidence for greater efficacy/lower risks than haloperidol. In a short perusal of the supporting data from the guidelines, it looks like the available evidence (short-term agitation vs. long-term agitation; initial responders vs. nonresponders, etc.) around the issue of aggression in pw dementia is conflicting, but I don't have the time/energy this evening to really dig in to the literature.

 

[PikminOC]

Apa doesn't get paid from makers of haldol

 

[Shikima]

For my Gero's, I'll stick to SSRIs + Risperdal/Seroquel at the moment. Quite efficacious.

 

[HarryMTieboutMD]

Haldol has been consistently shown to increase all cause mortality with the highest NNH (keep in mind these are retrospective case control studies). Here is one of the latest: http://archpsyc.jamanetwork.com/article.aspx?articleid=2203833 For gero patients I like low dose risperdal or Zyprexa (if they require PRN IM and/or are orthostatic). I've also been able to minimize antipsychotic burden with ramelteon (and the usual non pharmacologic methods, etc)

 

[FlowRate]

.nvm

 

[wolfvgang22]

Yeah, low dose Olanzapine has been the medication I use the most if necessary, also. I'm just glad to hear I'm not missing some new evidence.

What about quantitative tools for measuring agitation in behavior? Is there some validated scale for this I'm not aware of?

 

[Shikima]

Yeah, low dose Olanzapine has been the medication I use the most if necessary, also. I'm just glad to hear I'm not missing some new evidence.

What about quantitative tools for measuring agitation in behavior? Is there some validated scale for this I'm not aware of?

Doctor, Mr. Smith is agitated again, do something! Can you rate the level of agitation nurse?

I can see her using the pain scale faces for her own level of distress.

 

[HarryMTieboutMD]

On a related note, for those of you who have been done with training for a while, have nurses always tried to pressure the medicine residents into demanding that these patients (delirious, behavioral problems) to psych? This happens all the time on our consult service, but thinking back to The House of God, dealing the agitated patient is something one should learn and not even wince at during an internal medicine residency... Is this more of a recent phenomenon?

 

[Shikima]

On a related note, for those of you who have been done with training for a while, have nurses always tried to pressure the medicine residents into demanding that these patients (delirious, behavioral problems) to psych? This happens all the time on our consult service, but thinking back to The House of God, dealing the agitated patient is something one should learn and not even wince at during an internal medicine residency... Is this more of a recent phenomenon?

If the agitated patient isn't in the MKSAP, then they won't bother to learn about it. However, they get really, really good at consulting psych.

 

[PistolPete]

In my experience, general IM = find a way to consult a specialty on basically every patient.

The poor IM residents are glorified social workers.

 

[wolfvgang22]

Yes, there is often attempted turfing of any patient with any suspected psychiatric issue. At the VA, any patient that answers a couple of depression screening questions the wrong way results in the EMR generating an automatic consult to psychiatry. Because who isn't in a great mood after breaking a hip or suffering acute pancreatitis? Thus, my favourite IM residents are the ones who just call me about a potential bogus consult before actually ordering it. God bless those few!

 

[WingedOx]

On a related note, for those of you who have been done with training for a while, have nurses always tried to pressure the medicine residents into demanding that these patients (delirious, behavioral problems) to psych? This happens all the time on our consult service, but thinking back to The House of God, dealing the agitated patient is something one should learn and not even wince at during an internal medicine residency... Is this more of a recent phenomenon?

I'm not old enough to answer your question, but the IM attendings where I trained who were in their 30s were REALLY bad about this. Their sh-tty attitudes had a way of filtering down to the residents on their teams too.

Same for their unplaceable rocks. If the patient is sad about being an unplaceable rock, that clearly means they're our problem.

 

[MLT2MT2DO]

Why I completely understand Seroquel or Zyprexa, why is Risperdal fairly standard of care? I've had a hard time wrapping my intern head around why a high potency antipsychotic is so readily accepted in the geriatrics.

For those attendings that have done this with regularity in my residency they've always explained it with a "that's what I'm comfortable with"

Sent from my SM-G900V using SDN mobile

 

[Guyton]

In my experience, general IM = find a way to consult a specialty on basically every patient.

Profitability pressures play a large contributing factor in the trend of overabundant consultations placed in recent years. The hospital employed physician is increasingly dependent on generating ridiculous RVU numbers to maintain their income. Thus, there is a strong motivation to cover an increasingly large census. When a physician has 76 patients on their service and is in the rotation for ED admissions, he or she cannot adequately formulate thoughtful assessments. So, the internist turns to a division of labor. If the patient comes in with six medical problems, at least five consults are ordered. Not only does this increase the hospitalist's income, it also generates revenue for the hospital- especially when the surgery/cards/gastro rain-makers get involved. Everyone benefits... except the patient.

Why I completely understand Seroquel or Zyprexa, why is Risperdal fairly standard of care? I've had a hard time wrapping my intern head around why a high potency antipsychotic is so readily accepted in the geriatrics.

Higher potency antipsychotics are associated with less anticholinergic activity and are thus an attractive alternative to the lower potency agents which geriatric patients often tolerate poorly.

 

[MLT2MT2DO]

Profitability pressures play a large contributing factor in the trend of overabundant consultations placed in recent years. The hospital employed physician is increasingly dependent on generating ridiculous RVU numbers to maintain their income. Thus, there is a strong motivation to cover an increasingly large census. When a physician has 76 patients on their service and is in the rotation for ED admissions, he or she cannot adequately formulate thoughtful assessments. So, the internist turns to a division of labor. If the patient comes in with six medical problems, at least five consults are ordered. Not only does this increase the hospitalist's income, it also generates revenue for the hospital- especially when the surgery/cards/gastro rain-makers get involved. Everyone benefits... except the patient.




Higher potency antipsychotics are associated with less anticholinergic activity and are thus an attractive alternative to the lower potency agents which geriatric patients often tolerate poorly.

Ah yes, clearly had a moment of forgetfulness, as that had been explained to me prior. For some reason my brain lumps Risperdal in as Haldols SGA cousin

Sent from my SM-G900V using SDN mobile

 

[vistaril]

[QUOTE="PistolPete, post: 17783076, member: 107651"

The poor IM residents are glorified social workers.[/QUOTE]

ummm....no.

 

[HarryMTieboutMD]

To be clear, this isn't a knock on IM residents - most of the ones at my institution are great midway through intern year, and I absolutely do not mind being consulted for delirium (actually I appreciate it when the management gets complicated). This is more of a nursing/nursing admin/admin issue that is really stupid.

 

[WisNeuro]

To be clear, this isn't a knock on IM residents - most of the ones at my institution are great midway through intern year, and I absolutely do not mind being consulted for delirium (actually I appreciate it when the management gets complicated). This is more of a nursing/nursing admin/admin issue that is really stupid.

I'm ok with this knock. I used to get consulted all of the time for delirium when the IM residents are "absolutely sure" it's due to something else like Wernicke encephalopathy or etc, despite the lack of clinical correlation (labs, imaging, etc). I have yet to be wrong on the delirium call.

 

[HarryMTieboutMD]

I'm ok with this knock. I used to get consulted all of the time for delirium when the IM residents are "absolutely sure" it's due to something else like Wernicke encephalopathy or etc, despite the lack of clinical correlation (labs, imaging, etc). I have yet to be wrong on the delirium call.

Hah... the "absolute sureness" is just overconfidence from a resident after he or she sees enough patients and learns enough basic medicine to be somewhat better than completely incompetent (as nearly all interns are July 1). Wernicke's is actually a pretty reasonable ddx, and in a delirious pt with a drinking history I am often inclined to start high dose IV thiamine even without ataxia, nystagmus, etc along with a benzo taper because the emerging thought is that there is a withdrawal delirium (not just hallucinosis) that is distinguished from DTs.

What SOMETIMES irks me is when a non psychiatry resident (usually intern) insists that the delirium is "new onset primary psychotic disorder" and that it would be "great" if I could transfer the pt to psychiatry

 

[Shikima]

Hah... the "absolute sureness" is just overconfidence from a resident after he or she sees enough patients and learns enough basic medicine to be somewhat better than completely incompetent (as nearly all interns are July 1). Wernicke's is actually a pretty reasonable ddx, and in a delirious pt with a drinking history I am often inclined to start high dose IV thiamine even without ataxia, nystagmus, etc along with a benzo taper because the emerging thought is that there is a withdrawal delirium (not just hallucinosis) that is distinguished from DTs.

What SOMETIMES irks me is when a non psychiatry resident (usually intern) insists that the delirium is "new onset primary psychotic disorder" and that it would be "great" if I could transfer the pt to psychiatry

Damn the work-up and full speed ahead Mr. Sulu!

 

[whopper]

These guidelines are only about 20 years later than they should've been. Sedating people into oblivion is the MO of so many bad psychiatrists to the point where any psychiatrist with half a brain and just a few years of experience will see way too many of their colleagues doing this type of practice.

 

[GUH]

These guidelines are only about 20 years later than they should've been. Sedating people into oblivion is the MO of so many bad psychiatrists to the point where any psychiatrist with half a brain and just a few years of experience will see way too many of their colleagues doing this type of practice.

I saw this with an elderly relative and it felt wrong even before medical school. What stuck out to me was that he was only able to really communicate when he, for one reason or another, had not been given his psychiatric medication as prescribed. Otherwise he pretty much just sat there apparently oblivious to anything around him, including family.

 

[whopper]

Time and time again I see several doctors doing this type of practice.

 

[notdeadyet]

Time and time again I see several doctors doing this type of practice.

There is an old adage in the business consulting world that applies here:

"If you can't solve the problem, you can make a lot of money prolonging it."