Demented Patient with Psychosis

Author: V. Dimov, M.D.
Reviewer: R. Christie, M.D.

A 76-year-old African American female (AAF), a nursing home (NH) resident with a past medical history (PMH) of dementia, typically very pleasant, started to be very agitated and to attack the caregivers. She is hearing voices and thinking that people want to kill her.

Problem list from the chart: Alzheimer's dementia, diabetes type 2 (DM 2), end-stage renal disease on hemodialysis (ESRD on HDZ), hypertension (HTN), cerebrovascular accident (CVA), deep vein thrombosis (DVT) 10 years ago, neuropathy, glaucoma and cataract, incontinence, goiter, peripheral vascular disease (PVD), Hyperlipidemia.

Medications

Diovan, furosemide (Lasix), metoprolol, insulin (Lantus and Novolin, amlodipine (Norvasc), gabapentine (Neurontin), Xalatan eye drops.

Drug allergy and intolerances


Aricept (hallucinations).

What is the most likely diagnosis?

Psychosis in a demented patient.

What would you suggest for evaluation and management?

Haloperidol (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 higher incidence of extrapyramidal symptoms (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 haloperidol (Haldol) 0.5 mg IM q 6 hr PRN extreme agitation

The 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 haloperidol (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). Consider starting antipsychotic medications at a very low dose and monitor for AE.

Risperdal M-tab (Mouth tablet) is a "kinder" and simpler choice than Haldol IM. The 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 useful in noncooperative or severely demented patients.

Antipsychotics should be used only if 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.

Related 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
FDA Approves "Alzheimer's CT scan" by Eli Lilly - radioactive agent florbetapir tags clumps of sticky amyloid in brain. WSJ, 2012.

Published: 03/05/2005
Updated: 03/02/2012

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