Dementia vs med issues

[WisNeuro]

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Any of you other neuropsychs seeing more and more elderly patients who seem to have med mismanagement (by their PCP's) as a likely source of cognitive issues rather than an underlying dementia? Just seems more and more often I have people coming in on a benzo or ambien, along with a slew of anti-cholinergics, and the PCP is somehow astounded when they start to develop cognitive issues after some med changes.

 

[Therapist4Chnge]

Indeed!

I only see a handful of community referrals per yr, but the majority have some pretty questionable combos of meds: scheduled benzo+ prn benzo, long-term benzo+ Ambien use, etc. Don't get me wrong, benzos are great....at certain things and in limited doses.

In my Recommendations section I'll write a blurb about whichever current meds may impact cognition.

 

[AcronymAllergy]

It's not the primary suspected cause of impairment for all of the folks I see, but it's an issue for probably >90% of them. Unfortunately, even though many of the docs with whom I work realize these issues now (at least in psychiatry re: benzos; the anti-cholinergics and opiates in primary care are still up in the air) and are attempting to minimize/reduce usage, the majority of the patients coming through have seemingly already been taking these meds for 10+ years.

 

[Ollie123]

Given the amount of this I'm seeing in a traditional outpatient psychotherapy clinic...I can only imagine what it looks like by the time they make it to neuro. I think half my "concentration difficulties due to depression/anxiety" are at least partially due to the obscene drug cocktails I'm seeing.

 

[PsyDr]

All the damn time. And utis causing delirium.

 

[AcronymAllergy]

Given the amount of this I'm seeing in a traditional outpatient psychotherapy clinic...I can only imagine what it looks like by the time they make it to neuro. I think half my "concentration difficulties due to depression/anxiety" are at least partially due to the obscene drug cocktails I'm seeing.

And I've had more than one patient tell me that when they start to come off some of they meds, miraculously their cognition clears (or at least feels like it does). When you're taking xanax and hydrocodone 3x/day and come off one or both, I'd certainly believe you're feeling a bit clearer...

The anti-cholinergics I worry more about from a long-term/chronic damage perspective.

 

[smalltownpsych]

The evidence is pretty clear that opiates and benzos can cause significant cognitive impairments in the elderly. I have seen this both professionally and personally. I have seen an increase in risk for falls as well. When you are 70 plus and you fall, that could mean the end of your independence. Two of my relatives had to figure this out for themselves after several falls. Fortunately they were both in excellent health and didn't get hurt badly, but scared the heck out of them. I have seen this fear arise in older patients after a fall and then they are prescribed benzos for it and then they start having "sudden onset dementia". Ugh.

 

[WisNeuro]

Yeah, I've seen an increasing number of elderly patients started on xanax for mild anxiety from outside providers. Simply astounds me. But also an unwillingness to consider obscene anticholinergic loads while telling the patient that it will be ok because they're going to get some Aricept too. Why do people still believe that Donepezil monotherapy does anything at all besides possibly relieve constipation?

 

[sctm2]

I am interested in learning more about this, but the scope is rather daunting. Can you recommend a good starting point for becoming more informed?

 

[WisNeuro]

Learning more about what, specifically?

 

[AcronymAllergy]

Yeah, I've seen an increasing number of elderly patients started on xanax for mild anxiety from outside providers. Simply astounds me. But also an unwillingness to consider obscene anticholinergic loads while telling the patient that it will be ok because they're going to get some Aricept too. Why do people still believe that Donepezil monotherapy does anything at all besides possibly relieve constipation?

Sigh, yep. At least here, though, they're really trying to minimize initiation of benzos and co-Rx of benzos and opiates across all age groups. And the PCPs generally don't want to touch the benzos anymore, which has been frustrating for psychiatry when it was the PCPs who'd started and managed it for years.

If PCMHI does nothing else but decrease the number of people unnecessarily started on benzodiazepines, it'll be worth its weight in gold.

 

[sctm2]

Learning more about what, specifically?

About which medications (or classes of medications) can interact and mimic dementia symptoms.

 

[Therapist4Chnge]

The biggest culprits are benzos, anti-chol, opiates, non-benzo hynotics, other sleep meds for cog blunting/confusion. Withdrawal from many of these can be just as problematic, so seeing someone who terminated w. a provider may have different associated risks. Steroids, psychostimulants, and similar can cause acute mood change/increased irritability that can be associated with FTD. There are a laundry list of other possible symptoms and meds, but those are the most common I've seen.

 

[sctm2]

Thank you. The withdrawal piece is also helpful.

 

[WisNeuro]

Not too mention the dozens of metabolic disturbances and neurologic conditions that must be ruled out in dementia cases.

 

[smalltownpsych]

Not too mention the dozens of metabolic disturbances and neurologic conditions that must be ruled out in dementia cases.

I'd be happy if they would just rule out and then treat the UTIs.