Demented Patient with Psychosis

Author: V. Dimov, M.D., Cleveland Clinic
Reviewer: R. Christie, M.D., Case Western Reserve University (St. Vincent/St. Luke) Internal Medicine Residency Program

76 yo AAF, NH resident with PMH of dementia, very pleasant, starts to be very agitated and to attack the caregivers. She hears voices and believes that people want to kill her.

Problem list from the chart:
Alzheimer's dementia, DM 2, ESRD on HD, HTN, CVA, DVT 10 yrs ago, Neuropathy, Glaucoma and cataract, Incontinence, Goiter, PVD, Hyperlipidemia

Medications:
Diovan, Lasix, Metoprolol, Lantus, Novolin, Norvasc, Neurontin, Xalatan

Allergic:
Aricept (hallucinations)

What do you think is going on?
Psychosis in demented patient

What would you do?
Haldol is the drug of choice for acute psychosis and it can be used either PO or IM/IV.
It is not useful for long term treatment because of the incidence of EPS and its short half-life.
Risperdal is a better alternative if chronic use is likely to be needed.

What happened?
Risperdal 0.25 mg PO BID was started with Haldol 0.5 mg IM q 6 hr PRN extreme agitation

Patient was still psychotic.
Risperdal dose was increased to 0.5 mg PO BID with resolution of psychotic symptoms.
She was seen by a gero-psychiatrist who recommended stopping the Haldol and using Risperdal M-tab 1-2 mg PRN agitation.

What did we learn from this case?
Psychosis is a known association of dementia (15-30% prevalence).

Start antipsychotic medications at a very low dose and monitor for AE.

Risperdal M-tab (Mouth tablet) is a much kinder and simpler choice than Haldol IM. Route of administration matters. Note: Risperdal M-tab is a tablet that disintegrates in the mouth and does not have to be swallowed, making it very usedul in noncooperative or severely demented patients.

Use antipsychotics only when benefits outweigh the risks. Atypical drugs increase the risk for death in the elderly from an average of 2.6 percent to 4.5 percent. Typical antipsychotics (like Haldol) increase the death risk even further - 37 percent higher than atypicals (NEJM 2005)

References:
Psychotic Disorders - Merck Manual of Geriatrics
Advances in the Treatment of Alzheimer's Disease - AFP 11/98
Early Diagnosis of Dementia - AFP 02/01
Diagnostic Approach to the Confused Elderly Patient - AFP 03/98
Elderly Patients with Psychosis Pose Treatment Dilemma - Listen to NPR story 12/05
Risk of Death in Elderly Users of Conventional vs. Atypical Antipsychotic Medications - NEJM 12/05.
Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis. Stefan Leucht et al. The Lancet, Volume 373, Issue 9657, Pages 31 - 41, 3 January 2009.

Further reading:
Antipsychotic Drugs Abused as Chemical Restraints for Elderly. WSJ Health Blog, 12/2007.
The Long Road Ahead. FatDoctor.org, 09/2007.

Currently no drug has clearly been shown to be of value in the treatment of agitation in dementia - BMJ http://goo.gl/vjtNj

Published: 03/05/2005
Updated: 01/02/2009