Geropsych clinical pearls

what's the most common sxs of depression in elderly?

the most common depression-related psychotic feature is auditory hallucinations. If Grandma is hearing voices, rule out depression. If you are already treating depression, now is the time to add a pinch of antipsychotic.

how is the onset of depression important?

If your first episode of major depression is early in life, you actually do better with it as you age. You know what it's like, you recognize it, etc. But if your first episode of MDD is in your 70s-90s, you are more likely to have very severe symptoms, including psychotic features. (So go get depressed NOW! Your mind will thank you later. J/K.)

if a pt is having AH and on an SSRI who could you refer to? what else could you do with the SSRI?

Grandma hearing a bunch of voices, or a choir, may actually be SSRI-induced musical ear syndrome (MES), which is not a psychosis at all. Kind of like the auditory version of Charles Bonnet Syndrome. Tx is a referral to audiology for amplification. Scaling back the dose of the SSRI might also help.

algorithm for depression tx in elderly

1. Start with monotherapy, usually an SSRI. I like sertraline for a starter.

2. If no improvement, try a different SSRI; eg citalopram or escitalopram. Paroxetine can be cognitively-blunting, and fluoxetine has a higher fall risk than other SSRIs.

3. If no improvement, AND if they have concurrent insomnia OR if you also want them to gain weight, add mirtazapine.

4. If partial response switch to venlafaxine or duloxetine (avoid duloxetine if kidney probs).

5. If depression severe, SI, or psychosis, add a second-generation antipsychotic (SGA) - best evidence supports quetiapine, olanzapine, aripiprazole.

6. If still no improvement, add buspirone, lithium, or lamotrigine.

what's California rocket fuel and what's the concern with it in elderly tx?

"California Rocket Fuel" refers to the combo of a triphasic + biphasic (eg venlafaxine + mirtazapine). It's overly stimulating because you are boosting NE from 2 separate agents. CRF can be useful for pts with severe vegetative sx, but be cautious. You don't want to fix depression so aggressively that they have a stroke.

For example, duloxetine + mirtazapine. Or bupropion + venlafaxine. can cause your frail elder to become very, very, very agitated

who has the highest risk for suicide in elderly?

Highest risk are white males with military service that own firearms.

what antidepressants can cause bruxism?

All SSRIs

what antidepressants are best for cognition?

Best: sertraline

Worst: paroxetine (fairly anticholinergic)

what antidepressants are best for anxiety in elderly?

Best: sertraline, citalopram, escitalopram

Worst: Bupropion

what antidepressants are best for panic attacks?

Half doses of escitalopram good. Paroxetine also good if they don't have cog probs

which antidepressants should you use with COPD? what drugs should you avoid?

Sertraline good for respiratory-related anxiety, use less nebs and PRN inhalers.

Avoid benzos, reduces resp. drive.

what antidepressant is best for cardiotoxicity?

Sertraline

rule of thumb if on antidepressants and has a seizure disorder?

Avoid bupropion entirely

keep all SSRIs low

what antidepressant combo should you use to improve sexual activity?

Wellbutrin + Zoloft = "Well-off"

what to do if on SSRI and having nightmares?

all SSRIs can cause bad dreams. Lower the dose

what are the best antidepressants for OCD?

Fluvoxetine best, sertraline also good

best, moderate, and worst antidepressants for withdrawal effects in elderly?

Worst: paroxetine> venlafaxine

Intermediate: Sertraline > fluvoxetine > bupropion > mirtazapine

Minimal: citalopram > escitalopram > fluoxetine

best to worst antidepressants in terms of activation for the elderly

Most activating: bupropion > fluoxetine > sertraline

Not too bad: paroxetine > venlafaxine > duloxetine

Most sedating: mirtazapine >fluvoxetine > citalopram

how do you dose sertraline? what's the 90/90 club? how do you know if they're on too high of a dose?

Sertraline is well-tolerated in older adults: Start with 25mg daily, go as low as 12.5mg if they are in the 90/90 club (older than 90 or weigh less than 90). Higher doses can be overly activating. Think of sertraline as an upside-down U (kind of like your golf score when drinking). Your pt might start to look better when you push the dose, but it's easy to over-shoot your goal, and then it's all downhill. How do you know when you've gone too far? Watch for bad dreams, worsening of anxiety, they can look a bit tremulous.

what risks do all Antipsychotics have esp in the elderly?

Risk of neuroleptic malignant syndrome.

Risk of tardive dyskinesia.

Risk for weight gain, diabetes, hyperlipidemia (monitor glucose on all of them)

Risk of Enhancing effect of antihypertensives.

what 2 classes do you watch out for with antipsychotics use and why?

Beware the "dines" and the "tines" (ranitiDINE, paroxeTINE, etc.) --> block primary pathways of many antipsychotics --> increased blood levels

best and worst antipsychotics for hyperprolactinemia

Risperidone is worst.

Aripiprazole only antipsychotic that doesn't increase prolactin (best).

in terms of EPS what antipsychotics are worst to best?

Worst: risperidone > ziprasidone = olanzapine > quetiapine (best)

worst to best antipsychotics in respect to QT prolongation

Worst: haloperidol > quetiapine > ziprasidone > risperidone > olanzapine (not bad) > lurasidone (best)

worst to best antipsychotics in respect to sedation

Worst: olanzapine> quetiapine> risperidone > ziprasidone > aripiprazole (best)

worst to best antipsychotics in regard to orthostatic hypotension

Worst: Clozapine > quetiapine = olanzapine > risperidone (best)

worst to best antipsychotics in regard to cardiotoxicity

Worst: quetiapine > olanzapine = risperidone > lurasidone (best)

worst to best Antipsychotics for anticholinergic effects (constipation, dry mouth, urinary hesitancy)

Worst: quetiapine > risperidone = olanzapine > ziprasidone (best)

worst to best Antipsychotics in respect to hyperlipidemia

Worst: clozapine > olanzapine > risperidone > ziprasidone > aripiprazole (best)

what's the concern with olanzapine in smokers?

Olanzapine binds to tar in cigarettes. Nicotine patch won't prevent this. If pt stops smoking, beware of EPS. Smoking Cuts dose by half.

what do you think about with olanzapine in men vs women?

Olanzapine better metabolized in women than in men, women can go with lower doses and still get a decent effect.

starting doses for elderly and 90/90 clubs for: olanzapine, risperidone, aripiprazole, ziprasidone, lurasidone, quetiapine, haldol? how does quetiapine and haldol change with Parkinson's?

olanzapine: 2.5mg BID if they are good sturdy Norwegians. Lower them to 2.5mg qHS if they are in the 90/90 club (older than 90 or weigh less than 90).

Risperidone: 0.25mg BID for GSN, 0.125mg BID for 90/90

Aripiprazole: 2.5mg daily for GSN, 1-2mg for 90/90

Ziprasidone: 20mg BID WM for GSN, titrate to 40mg.

Lurasidone: 40mg qHS, titrate to 60mg

Quetiapine 25mg qHS for GSN; 12.5mg QID for 90/90, 6.25mg QID if they have parkinsons

Haloperidol: 0.5mg BID for GSN, 0.25mg for 90/90, avoid in parkinsons

what's the general rule of thumb for dosing antipsychotics in elderly?

Take the smallest pill that it comes in, and cut it in half if they are GSN, or into quarters if they are in the 90/90 club.

uses for anticonvulsants in elderly

mood stabilization, aggression and impulsivity management in dementia. But all of these are off label.

what anticonvulsants should you consider using and what ones shouldn't you use? why? what are SEs of all to watch out for?

Use:

- gabapentin: good mood stabilizer, but they will gain wt, can be sedatingm and cause peripheral edema

- pregabalin: like gabapentin but cleaner with less metabolites. Still ahve to watch for wt gain, edema, rare angioedema, PR prolongation. More expensive.

- Carbamezepine: useful but increased SJS in asians. Screen for HLA-B1502 allele.

Don't use:

- levetiracetam: causes aggressive behavior, irritability, increased anxiety and depression. Highest risk for psych adverse events of all AEDs. Great for seizures but not good for mood stabilization.

- topiramate: causes affective and psychotic sxs. Worsens cogniton, increases kidney stones. Have to keep them hydrated.

- oxcarbazepine: higher risk for hyponatremia than carbamezepine which hyponatremia can trigger delirium.

- valproate: not great due to risks of encephalopathy. Watch for tremor, thrombocytopenia, alopecia, elevated LFTs with higher doses. Watch for toxicity with hypoalbuminemia.

Pearls on nonbenzodiazepines for sleep

Zaleplon (Sonata): half-life is 1 hr. Good for sleep onset, not so good for sleep maintenance. Avoid long term use.

Zolpidem (Ambien): half-life is 1.5-2.5 hrs. Good for sleep onset. Some morning hangover. Avoid long-term use.

Zolpidem CR: half-life is 1.5-2.5 hrs, but released over longer duration to help with maintenance.

Eszopiclone (Lunesta): half-life is 5-7 hrs, longer in elders. Higher risk of next-day impairment.

pearls on benzos for sleep

should be last resort. Try low dose temazepam if you have to. Avoid estazolam, flurazepam, quazepam or triazolam.

pearls with melatonin for sleep

melatonin: trick is to give it at least an hr prior to sleep, even 5 hrs in some cases. Dim light melatonin onset (DLMO) is the evening increase in endogenous melatonin, and is delayed in pts with delayed sleep phase syndrome. Exogenous melatonin tx given FIVE hours before DLMO is effective for promoting sleep onset.

pearls with Ramelteon (Rozerem) for sleep

Improves sleep latency, but not sleep maintenance. Not limited to short-term use.

pearls with doxepin for sleep

FDA indication for insomnia. Keep dose at 3mg or less and watch for cognitive impairment.

pearls with amitriptyline for sleep

cognitive risk tends to outweigh potential benefit, try to avoid it.

pearls with trazodone for sleep

orthostatic hypotension risk tends to outweigh potential benefit. also disrupts REM. Has fallen out of favor in geriatrics.

pearls with mirtazapine for sleep

protects sleep architecture. Good for short term, but benefit may be short-lived. Sedating effects often normalize. Keep at 7.5mg or less.

pearls with antipsychotics for sleep

not recommended for tx of insomnia in pts without psychosis. quetiapine should not be your first-line tx.

pearls with using herbals for sleep

not regualted, stay away. Chamomile, kava, and wuling show no benefit over placebo and have risk of contaminants. Valerian causes hepatotoxicity and acts like a benzo with horrible withdrawal that can cause psychosis, do not use!

Note: only exception is melatonin which is best for pts with circaidan sleep/wake rhythm disorders or low melatonin levels.

pearls for gabapentin for sleep

is useful, one of the only agents the enhances slow-wave delta sleep which helps with chronic pain syndromes

pearls for suvorexant (Belsomra) for sleep

kepp dose low due to next day impairment. high potential for abuse and its very expensive.

what frequently happens with chronic anxiety in elderly? what causes this?

frequent worry and nervousness is replaced by somatization and perseveration on physical conditions. structures change and there is an enlargement of the amygdala and the dorsmedial PFC.

prognosis: full remission is uncommon, very little improvement is likely to be made. So you just need to hit it hard early to avoid it getting to this point.

Anxiety tx algorithm pearls

1. First line tx is SSRI, best if started right away. Not as effective once anxiety becomes chronic. Stay the course for at least 4-6 weeks before bailing.

2. Buspirone: SSRIs don't make serotonin, they just help you hang onto it. It's like Hamburger Helper without hamburger. Get some buspirone in there. I know folks like to poo-poo buspirone, but try it. Seriously, just try it.

3. Gabapentin or pregabalin: decent adjunct for treatment-resistant anxiety. Theoretically, pregabalin has better anxiolytic benefit than gabapentin or other alpha-2-delta ligands because it's cleaner, but folks can also get fat and tired. Plus it's spendy. But they say it is Most Excellent for peeps with concurrent anxiety and fibromyalgia pain.

4. Second generation antipsychotics (SGA) are indicated in treatment-resistant anxiety. Risperidone is best, then quetiapine. Olanzapine, ziprasidone, and aripiprazole don't have much of an anxiolytic benefit.

5. Exercise, particularly resistance training, is associated with increased rates of remission.

6. If you are fortunate enough to achieve remission, treat for at least 12 months, as anxiety disorders have very high rates of relapse

Things to avoid:

- When to start a benzo? Never. Ever. Unless you absolutely have to. The effect of benzos on GABA-receptors is the same as alcohol. Would you give Grandma a shot of Jack Daniels to calm down? Sure, she might liven up a little, but then she is going to be drunk and disorderly, dancing on the tables, digging thru the ashtrays for cigarette butts, and will eventually trip over the microphone cord. Benzos are all fun and games until someone breaks a hip.

- Hydroxyzine: helpful for young whippersnappers, but not geriatric peeps. Likely to cause delirium and memory probs.

- Diphenhydramine: also avoid like the plague. Makes 'em goofy, then they fall down. Plus, it is notorious for causing delirium.

Geriatric Anxiety tx algorithm

1. Start with SSRI. I like sertraline, but citalopram or escitalopram also good. Lower doses are better. Keep in mind that higher doses of any antidepressant can be overly activating, which worsens anxiety.

2. If no response, try a different SSRI

3. If still no response, try venlafaxine

4. Add buspirone.

5. If still no improvement, bail on the buspirone, keep the venlafaxine, and add gabapentin. Or sertraline + gabapentin. Or SSRI + pregabalin.

6. Do not use SGA until third trial. Then augment with quetiapine or risperidone. No olanzapine.

7. If all else fails, stabilize on clonazepam, with plan to slowly taper off. But first, raise your right hand and repeat after me: "I promise to taper off the benzo. I promise to taper off the benzo. I promise to taper off the benzo." Now say it like you mean it.

with anxiety what electrolyte are you monitoring?

Monitor for hyonatremia, as even the slightest dip in sodium can worsen anxiety in elders. New onset of hand-wringing anxiety in a pt that is not normally a Nervous Nellie is very frequently hyponatremia. Fix that first.

how does blood sugar contribute to anxiety?

hypoglycemia can induce anxiety d/t secretion of epinephrine. Fix that too.

what OTC tx can you try initially for anxiety?

Plain old acetaminophen has a very nice anxiolytic benefit. Truly. A little bit of APAP goes a long ways.

How common is ADHD in geriatrics?

most people with ADHD in childhood continue to have it in adulthood which includes geriatrics.

what are concerns with stimulant therapy for ADHD in elderly?

cardiac risk, a 1.8x increase in sudden death d/t ventricular arrhythmia. If txing for HTN, get off the stimulant and use something else.

Note: stimulants don't require a taper, just switch or stop.

pearls with atomoxtine use in ADHD for elderly

non-stimulant, less risk for ventricular arrhythmia. Can prolong QT. Won't provide immediate effect like stimulants, takes a few wks for full benefit. Inform pts of this as they will stop it saying its not helping.

pearls with bupropion for ADHD in elderly

off label but works ok esp if concurrent depression

pearls with clonidine for ADHD in elderly

too cognitively blunting to use. Can also cause delirium. Stay away in elderly.

pearls with venlafaxine and paroxetine for ADHD in elderly

off label, doesn't work as well as burpropion and theres very little evidence to support its use.

pearls with TCAs for ADHD in elderly

off-label and cognitive SEs make them less desirable for elders, don't use.

pearls with modafinil for ADHD in elderly

good for narcolepsy, but not real benefit in ADHD. Don't use.

when assessing for a delusional disorder what will likely be present?

- delusions aren't bizarre, they involve situaitons that occur in real life.

- delusions last a month or longer

- pt doesn't meet criteria for schizophrenia

- behavior is normal, they aren't bizarre or odd.

- if delusional beliefs are transient, they probably don't have a delusional disorder

- if paranoia/delusions worsen around 60-70 y/o then ask a family member if they were alwas a bit paranoid/suspicious (they may previously have been able to cover it up and in this case they likely have a delusional disorder) and if this is fairly new for pt (abrupt onset means delirium vs slow onset means this could be dementia)

pearls about tx for delusional disorders in elderly

antipsychotics don't work for pure delusional disorders, so the goal is to reduce distress. But if delusions interefere with sleep you could try some quetiapine qHS and if the delusions are really bad, you could try low dose risperidone because it has anxyoltic benefit.

note: adding an antipsychotic can make is seem like they get worse because before they were quietly delusional and now they are more loose and verbal. This is still an improvement so don't just DC it, its working. Wait and cautiously increase the dose.

what is seen with elderly sleep?

progressively worse sleep cycles with numerous arousals and poor REM sleep. Poor sleep is the norm. And there is no 1 size fits all sleep med either.

pearls for sleep tx in elderly

1. avoid trazodone. It disrupts REM. Can be orthostatic causing falls. Used to be the go-to but has fallen out of favor for geriatrics.

2. melatonin or ramelteon is always worth a shot

3. Mirtazapine tends to do a good job of protecting sleep arhcitecture. Use very low doses, usually 7.5mg qHS and 3.75mg for the 90/90 club

4. Avoid OTC sleepers like unisom, tylenol PM, advil PM or anything with diphenhydramine or other antihistamine. They are linked to confusion, urinary retneion and increased falls.

5. Hands down best tx is to get them tired during the day, if laying in bed all day they aren't sleeping at night.

- get them up and out of bed at same time every morning.

- Maximize sunlight (have breakfast in sunniest room).

- write an order to staff to take pt outside daily.

- If they can't walk have staff help them stand at bedside with ees on the horizon.

- No naps after 4PM.

- No TV, computer/LED screen for an hr before bed.

sleep algorithm for elderly

1. Minimize medications that disrupt sleep, such as SSRIs or SNRIs. If they are on 100mg of sertraline, they are going to have insomnia. Taper down the SSRI first.

2. Sleep hygiene. Exercise. CBT. Sleep diary.

3. Screen for OSA, RLS, PLMD. Sleep study, esp if they snore.

4. Sleep onset vs maintenace

- For sleep onset insomnia, use a short-acting med such as melatonin, or ramelteon, low dose zolpidem or zaleplon

- For sleep maintenance insomnia, use a longer-acting med such as zolpidem ER, eszopiclone, LOW dose doxepin, or extended release melatonin. Temazepam if you must. Counsel pt about hangover sedation

what is the difference between aMCI and nonaMCI?

aMCI: amnestic MCI is a dementia prodrome, has higher conversion rates to dementia than non-amnestic MCI.

overview of dementia tx

- Cholinesterase inhibitors (donepezil, galantamine, rivastigmine) or NMDAantagnoists (memantine) aren't indicated for MCI

- NonaMCI needs annual screening for conversion to aMCI

- aMCI needs SLUMs or MoCA q6months and start a ChEI at first sign of conversion to dementia

how does AD present?

looks like a brain rolling down a hill. Insidious onset, progressive course. Lang, visual/spatial, executive functiona re all impaired. VH are common. Earlier the onset, worse the prognosis.

Tx algorithm for AD

1. Start ChEI ASAP before they burn out the synapses and theres nothing left to latch onto. Donepezil or rivastigmine is best. Galantamine is okay, but is renally cleared so we avoid it if planning to add memantine. ChEIs contribute to conduction delays so get an EKG.

2. once ChEI on board, add NMDA receptor antagonist. Memantine has calming effect because it blocks glutamate.

3. Tx any Vit D insufficiency. Studies indicate 21% increase risk of AD with D25OH levels less than 50.

what do you do if they are agiated after starting a ChEI?

good sign, means they're stimulating neruons that have been dormant for a while.

what doses do you need to give of ChEIs and why?

starting doses, i.e. low doses aren't therapeutic. If they can't tolerate higher doses then change agents. Otherwise you're just giving expensive placebo with SEs.

can you start memantine on its own?

no, memantine requires glutamate to work. So either wait for mod-severe AD or give with a ChEI.

what are the highest risk factors for AD?

FHX or Hx of head injury with loss of consciousness. If they have a Fhx then need to protect their head like crazy (wear a helmet etc).

Presentation of lewy body dementia

looks like a brain bouncing down a hill. There is a fluctating course with frequent altered mental status, parkinsonian features, vivid VHs, fluctating mentation so much that it looks like recurrent episodes of delirium. Autonomic dysfunction is common. They fall frequently.

Tx algorithm for lewy body dementia

1. Rivastgmine patch is good due to steady distribution. Using donepezil shows increased falls.

2. Memantine is less effective so try it but if it doesn't work then just DC

3. Pts with LBD or any parkinsonian syndrome ahve neurleptic sensitivity so be extremely careful with antipsychotics. But low dose quetiapine does well because it doesn't hang around on the receptor very long. So its the best for LBD or PDD. Typically give quetiapine 6.25mg QID. This reduces parkinson's related psychosis. Do not use haldol, olanzapine, or risperidone!

how are the VHs in AD different than in LBD?

in AD they're vague like children playing in the yard. But with LBD they are very specific such as a little girl wearing a red dress.

Note: also think LBD if they look parkinsonian and is in and out of ED for AMS or has fallen for the 5th time.

How do you know if its LBD or parkinsons related dementia (PDD)?

LBD and parkinsons exists along a continuum. In general, rely on the 1 yr rule: if neuropsychiatric disturabance precedes parkinsonian sx by 1 yr its probably LBD. If parkinsonian sx precede psychaitric sx by 1 yr then its probably PDD. Also PDD tends to have more cognitive slowing and looks like severe depression but with motor features.

How does vascular dementia present?

looks like the brain going down steps. Theres a step-wise deterioration due to intermittent episodes of vascular insult. Also has cognitive slowing.

Tx pearls for vascualr dementia

- use ChEIs but they require higher doses than other forms of dementia

- NMDA antagonists have limited role but can help for dementia related sxs like anxiety

- goal of tx is to reduce risk factors for subsequent vascular event, so reduce risk for stroke as much as possible.

- use a statin if they are young and dementia is mild. If they are end stage dementia then its not worth it. In-between use best judgement. Statins can make pts mean and cranky, not sure why this happens.

How does frontotemporal lobe dementia (FTLD) present?

Looks like a brain rolling down a very, very steep hill. Onset around 60 y/o or even earlier. PErsonality changes, lots of problems with executive functioning, impulsivity. Behavioral variant form of FTLD can present with emotional dysregulation that can range from apathy/flat to manic/euphroia often mimics BPAD. Pts with bvFLD can have OCD type behaviors, overeating, fetishes, poor tact, perseveration. Memory not affected til later, so they may do fine on MoCA or SLUMs. Language deficits can include progressive or nonfluent aphasia or semantic fluent aphasia.

Tx algorithm pearls for FTLD

- no benefit with ChEIs, can actually make sxs worse

- no benefit with NMDA antagonists, don't make worse but no effect

- low dose SSRIs can occasionally help. But only low dose!

- tx is aimed toward behavioral sxs, mood stabilizers can help.

- FTLDs decline quickly and prognosis is poor, need to prepare family members and be super empathetic.

presentation of delirium

looks like the brain fell off the cliff. Theres abrpt onset of AMS. Waving.waning mental status, inattention, disordered thinking, frequent VHs.

Note: may be caused by infection, pain, med chagnes, sleep deprivation. And when you have underlying dementia so you have a fragile brain to begin with its even easier to go into delirium.

Tx options for acute delirium with antipsychotics

Haloperidol 0.5mg BID + PRN: gold standard tx, use if severe and QT isn't prolonged or if you want to avoid sedation

Risperidone 0.25mg BID: usually 1st line for elders. Use if moderate or pt also has anxiety or QT is mildly prolonged

Olanzapine 2.5mg BID + PRN: use if delirium is moderate or pt has underlying mood instability or has prolonged QT or needs something sedating

Quetiapine: In general, it's not strong enough for delirium. Use only for pts with PD or LBD

Don't use:

- Ziprasidone: avoid d/t QT prolongation

- Aripiprazole: avoid, can be overly activating

when do you tx delirium and give the antipsychotics?

Most deliriums wax/wane between episodes of hyperactivity and hypoactivity. Antipsychotics are an important part of delirium tx, but only during periods of hyperactivity. Hold for sedation. Antipsychotics are not indicated for hypoactive episodes, and will only make them more sedated.

tx for sleep causing delirium

Melatonin: has been shown to have a beneficial effect in patients with delirium

Trazodone: avoid. Delirium disrupts REM, and trazodone disrupts it further

Tx for pain causing delirium

- Everyone gets scheduled APAP, since immobility is associated with MSK pain

- with calling out behavior: consider augmenting APAP with very low dose opioid, as most pts with delirium are too confused to ask for a PRN.

what cognitive enhancers can you use for delirium tx?

ChEIs: donepezil and rivastigmine for prolonged dleirium but limited success. There are studies saying that starting a ChEI increases mortalitiy in delirium but if delirium persists there are worse outcomes and so this is when using a ChEI outweighs the risk

NMDA antagonists: avoid!

Other txs needed with delirium

- straight cath q6hrs: urinary retention is a predictor and outcome of delirium. For cognitive function, straight cath is better than indwelling.

- constipation: get a daily BM. Constiaption predicts combativeness in cognitively impaired elders.

- behavioral interventions: get out of bed TID, maximize sunlight in morning, reduce evening sitmulation, apply warm blanket at HS, avoid foley, ensure BM q24hrs

where do most pts that get delirium need to go?

to a SNF, everyone needs rehab that includes your brain.

how is delirium negaitvely associated with dementia outcomes?

Delirium accelerates the pace of underlying cognitive decline. If the pt has been brewing an underlying dementia, it will declare itself. Do a MoCA or SLUMS about a month after dC from SNF.

what percentage of dementia pts get behavioral and psychological sxs?

BPSD occurs in 90% of these pts

first line tx for BPSD?

1. cholinesterase inhibitor: donepezil, galantamine, rivastigmine

2. NMDA receptor antagonist: memantine

Note: the best txs for dementia specific behavior is to tx the dementia. They aren't cognitive enhancers, they are dementia related behavior targeters.

what meds are approved for agitation?

nothing, all off label. This is why you start with ChEIs and Memantine before you do the off label stuff because at least those are on label for dementia and can help, although they don't directly target agitation or other behaviors of dementia.

note: the exception is with FTLD, then ChEIs or glutamate antagonists are not first line.

what is Rivastigmine patch good for?

dementia related hallucinations

what is good for anxiolytic effect with dementia?

memantine

- but know that all the ChEIs and memantine have anxiolytic effect

Tx of confusion with dementia

1. try taking away meds, start with anything that has anticholinergic effect (no diphenhydramine, promethazine, cyclobenzprine, oxybutynin)

2. if new onset, rule out delirium. If just arted a med stop it. If just stopped soemthing, restart it.

3. check for an infection

tx of wandering/exit-seeking

Causes: distorted memory of surroundings, disoriented, response to lifelong routine (if everyone is putting on a coat and heading out the door, they will too. They have a poor frontal lobe).

interventions:

- They often are just looking for a place to pee, bare mimum try puting on a q2-3hr toileting schedule.

- Sometimes are just oo stimulated. So get rid of clutter (visual and auditory). This is feng shui for frontal lobe.

tx for agitaiton

cause: most common is akathisia due to too much neuroleptic.

Assessment: watch if increased agitation after getting their haldol etc. If so don't repeat the dose and hydrate like crazy and walk them around to burn off energy.

tx for impulsivity

1. mood stabilizers:

- gabapentin is best esp if have neuropathic pain that can be contributing

- carbamezapine also helpful

- depakote not good due to inducing encephalopathy, but if combative then use.