Category Archives: Caregiving – Dementia

Treating psychosis in PD and use of antipsychotics

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This post will interest those dealing with hallucinations or delusions, or those using atypical antipsychotics, such as Seroquel. This contains a nice summary of why antipsychotics are used and which ones are preferred.

This was posted yesterday on the National Parkinson Foundation’s “Ask the Doctor” online forum. I believe it’s an excerpt from a larger publication on treatment of PD. I learned three things. First, “double-blinded trials of quetiapine have been disappointing.” (quetiapine = Seroquel) Second, “odansetron (a rather expensive anti-nausea medication used mainly for patients undergoing chemotherapy)” is a treatment option for psychosis in PD. I’m pretty sure that’s a typo and what is meant is ondansetron or Zofran. Third, the effects of electroconvulsive therapy (ECT) in treating psychosis are short-lived.

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http://forum.parkinson.org/forum/viewtopic.php?t=8846

Posted by Dr. Hubert H. Fernandez
Posted on 1/30/10

What medications can be used to treat psychosis in Parkinson’s disease?

Just like the management of cognitive decline, prior to starting any treatment, one has to search for urinary tract infections, pneumonia, metabolic derangements, sleep disturbances, brain insults (such as strokes) and social stressors, such as changes in the environment, as possible explanations for hallucinations or delusions. Medications that can alter brain mechanics because of their ability to penetrate the brain’s “iron curtain” (termed the “blood brain barrier”) that is designed to keep away unwanted substances, such as narcotics, hypnotics, antidepressants, and anxiolytics are also common culprits. If psychotic symptoms persist despite the withdrawal of other psychotropic medications, anti-Parkinson’s disease medications may be gradually reduced or, if necessary, discontinued. As mentioned in Module 4, most authorities recommend “peeling off” these medications in the following order: anticholinergic agents, amantadine, monoamine oxidase inhibitors, dopamine agonists, catechol-O-methyltransferase inhibitors, and finally, levodopa. Regular or short acting formulations of levodopa are preferred in patients prone to hallucinations over sustained-release formulations because their pharmacokinetics are more predictable and there is less potential for cumulative side-effects. If psychosis improves, the patient is then maintained on the lowest possible dose of anti- Parkinson’s disease medications. However, if the withdrawal of anti-PD drugs significantly worsens other Parkinson’s disease symptoms or does not control psychosis one must consider the addition of antipsychotic agents.

The choice of an antipsychotic agent is based largely on its ease of use and side effect profile as most antipsychotics have comparable efficacy in improving psychosis. “Atypical” antipsychotics (or newer generation antipsychotics) are generally preferred given the significant risk of motor complications and anticholinergic side effects with older, conventional antipsychotics. The use of an appropriate atypical antipsychotic agent may allow the clinician to control psychosis with fewer motor side effects and, in some cases, without the need for significantly cutting back on anti- Parkinson’s disease medications. Clinicians should be aware that the FDA issued a “black box” warning for the use of these agents in the treatment of psychosis associated with dementia due to increased cardiac mortality. However, the majority of clinicians treating these patients continue to use these medications because these medications are efficacious, the absolute risk of increased mortality is low and the risk appears to be present in the older antipsychotics as well.

The main difference in the antipsychotics lies in their propensity to worsen motor functioning in this frail and already vulnerable population. Quetiapine has been studied in Parkinson’s disease patients and appears to have less potential for worsening motor function than risperidone, aripiprazole, olanzapine and ziprasidone. While double-blinded trials of quetiapine have been disappointing, it remains the first-line agent used for drug-induced psychosis in Parkinson’s due to its tolerability and good track record in several open-label trials .

The use of clozapine is generally limited to patients who have failed other agents, despite its superior efficacy over all other antipsychotic drugs, because of its very uncommon risk of agranulocytosis (meaning, sudden drop in white blood cell count—our body’s first defense against ordinary infections). The chances of this complication developing are less than 1%. Nonetheless, in the United States, for the first six months, each patient on clozapine must undergo a weekly white blood cell count and can receive only one week’s supply of the drug at a time. After 6 months the process becomes bi-weekly.

It remains unclear how long antipsychotic medications should be continued once they are initiated. There are some data that show persistence of hallucinations in Parkinson’s disease patients with drug-induced psychosis after its initial occurrence. At the University of Florida, we prospectively followed our own patients with Parkinson’s disease on successful long-term treatment with quetiapine or clozapine to see if they could be successfully weaned off their antipsychotic drugs. The study was aborted after enrollment of only six patients due to an unacceptably high rate of psychosis recurrence (five patients, 83%).

Other treatment options include acetylcholinesterase inhibitors, odansetron (a rather expensive anti-nausea medication used mainly for patients undergoing chemotherapy) and electroconvulsive therapy (ECT). Several open-label studies have found that cholinesterase inhibitors may improve hallucinations and psychosis in Parkinson’s disease subjects. Similarly, an open-label trial with 16 Parkinson’s disease patients showed marked improvements in the areas of visual hallucinations, confusion, and functional impairment with no adverse effects on motor function. This result has yet to be reproduced by other investgators. ECT should be reserved for patients who are unresponsive to, or intolerant of, other treatments, especially if the psychosis is associated with severe depression. In general, ECT’s effects are short-lived, and repeated treatments and/or the help of other medications are required to maintain benefits.

[Robin’s note: I think the open-label trial with 16 PD patients above is a trial with ondansetron. And I think there’s a typo above in the drug’s name: an N is missing. The brand name is Zofran.] [Brand names for some of the antipsychotic medications referred to include:
quetiapine = Seroquel
risperidone = Risperdal
aripiprazole = Abilify
olanzapine = Zyprexa
ziprasidone = Geodon
clozapine = Clozaril ]

 

The 6 R’s of Managing Difficult Behavior (from The 36-Hour Day)

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The Johns Hopkins Health Alert from Monday may be of interest to those dealing
with challenging behavior. It’s on “The 6 R’s of Managing Difficult Behavior,”
according to Dr. Peter Rabins and Nancy Mace, as discussed in their book The
36-Hour Day, which I highly recommend to anyone dealing with dementia.

The 6 R’s are:
* Restrict
* Reassess
* Reconsider
* Rechannel
* Reassure
* Review

You can sign up for these health alerts (they come to your email) here:
http://www.johnshopkinshealthalerts.com

Robin

http://www.johnshopkinshealthalerts.com/alerts/memory/JohnsHopkinsHealthAlertsMemory_3178-1.html

The 6 R’s of Managing Difficult Behavior
Johns Hopkins Health Alert: Memory
Dated 1/4/10

Restrict, Reassess, Reconsider, Rechannel, Reassure, Review

In their groundbreaking book on Alzheimer’s caregiving — The 36-Hour Day — Peter Rabins, M.D. (author of the Johns Hopkins Memory White Paper) and Nancy Mace discuss the six R’s of managing difficult behavior in people with dementia. Here they are…

People with dementia often exhibit behaviors that are frustrating, embarrassing, and sometimes even dangerous to the caregiver and others. These may include angry outbursts, agitation, aggression, wandering, vocalizations, hoarding or hiding things, and inappropriate sexual behavior.

For many caregivers, these difficult behaviors are the most challenging and exhausting aspect of caring for a person with dementia. Unfortunately, the available medications to treat Alzheimer’s disease have little effect on behavioral problems.

Here are Dr. Rabins’ six coping strategies:

Dementia Strategy 1 — Restrict. First, calmly attempt to get the person to stop the behavior, especially if the behavior is potentially dangerous.

Dementia Strategy 2 — Reassess. Consider what might have provoked the behavior. Could a physical problem (toothache, urinary tract infection, osteoarthritis) be behind the agitation or anger? Is a particular person or the noise level in the room triggering the negative reaction? Could the time of day and fatigue be contributing to the problem?

Dementia Strategy 3 — Reconsider. Put yourself in the dementia patient’s shoes. Try to imagine what it must be like to not understand what is happening to you or to be unable to accomplish a simple task. Consider how frustrating or upsetting the current situation or environment might be for a person with dementia.

Dementia Strategy 4 — Rechannel. Try to redirect the behavior to a safer, less disruptive activity. For example, if the person constantly disassembles household items, try finding simple unused devices, such as an old telephone or a fishing reel, that can be taken apart and put back together repeatedly. For someone who hoards or hides things, put away valuables and replace them with an array of inexpensive items.

Distraction often works well to curtail disruptive repetitive behaviors and restlessness. For example, try asking the person you’re caring for to “help” with simple tasks, such as holding spoons or potholders while you cook.

Dementia Strategy 5 — Reassure. The demented person’s brain injury and the resulting confusion and frustration can lead to anger, anxiety, and outright fear in certain situations. Calmly reassure the person that everything is okay and that you will continue to take care of him or her.

Dementia Strategy 6 — Review. After an unsettling experience with your loved one, take time to review how you managed the problem and what you might have done differently. Think about what may have triggered the problem, how it might have been avoided, and what you might try the next time a similar situation arises.

It also helps to create a patient-friendly environment. This might include soothing music in the background; pictures, words, or arrows to help orient the person in the house; or a secure place to sit outside or walk in the backyard.

Checklist on Family Matters

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This helpful “Checklist on Family Matters” allows families to review:

  • legal matters, such as durable power of attorney
  • family business, such as regular business, emergency plans, bank accounts, etc.
  • insurance
  • supervision of patient, including identity bracelet, safety locks on doors, etc.
  • items in the event of death, such as cemetery lot deed, funeral arrangements, etc.

Find it online here:

alzonline.phhp.ufl.edu/en/reading/CHECKLIST.pdf

Checklist on Family Matters
by L. Doty, University of Florida Memory Disorders Clinic
AlzOnline.net
2006?

This seems like an easy-to-use tool for a family discussion.

Robin

 

Dealing with anosognosia (unawareness of decline or difficulties)

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AlzOnline.net is a caregiver support forum for Alzheimer’s caregivers.  They have an interesting article on their website about anosognosia, which is a lack of self-awareness about one’s decline or condition.  The best part of the article are “examples of how to approach, interact and speak to someone who has anosognia.”

Here’s the summary from the article:

“The person who has anosognosia is unaware of deficits or the progressive decline in abilities to manage tasks and self-care. The person with anosognosia is not in denial; they have limited awareness or are unaware of the decline. When people with anosognosia confabulate, they believe what they are saying; they are not lying. Their remarks should be treated with respect, followed by a smooth transition to whatever tasks or activities need to occur next. Regular help for the home and family, planning ahead and working with a positive, partnership approach will help with the long-term, daily care management.”

Here’s a link to the full article:

alzonline.phhp.ufl.edu/en/reading/Anosognosia.pdf

Anosognosia (Unawareness of Decline or Difficulties)
By Leilani Doty, PhD, Director, University of Florida Cognitive & Memory Disorder Clinics (MDC), McKnight Brain Institute
AlzOnline.net
2007

Below, I’ve provided a few more excerpts.  This article is definitely worth checking out!

Robin

Excerpts from
Anosognosia (Unawareness of Decline or Difficulties)
By Leilani Doty, PhD, Director, University of Florida Cognitive & Memory Disorder Clinics (MDC), McKnight Brain Institute
AlzOnline.net
2007

“A lack of awareness of impairment, not knowing that a deficit or illness exists, in memory or other function is called anosognosia. The term anosognosia refers to brain cell changes that lead to a lack of self-awareness. … The impairment may be in memory, other thinking skills, emotion, or movement.”

“Anosognosia differs from denial. Denial is a strategy used to reject something that a person wants to ignore, partially avoid, or reject outright because it is too difficult or causes too much stress. The person may minimize a problem or accept part of the truth, for example, the person may accept the fact of being chronically ill but want to avoid dealing with it by not taking medicine. Sometimes a person is in denial in order to avoid taking any responsibility for an issue or situation. Anosognosia is not denial.”

“Anosognosia may occur in different progressive memory disorders. Often the progressive dementia (sometimes referred to as a progressive memory disorder) is of the Alzheimer’s disease type, sometimes it fits into the category of Lewy body disease or a frontal-temporal lobar degeneration.”

“Interaction Tips
Providing regular assistance with daily chores, transportation, and personal care and restricting unsafe activities are important. For example, someone may need to make sure that meals are readily available, that spoiled food is discarded, and that alcoholic beverages are not accessible. The controls for operating the stove and water heater should be inaccessible. Someone should be responsible for setting the home thermostat at an appropriate temperature and then locking the thermostat so that the person who is not accurately interpreting body temperature cannot reset the room temperature at too high or too low. Soiled clothing should be laundered immediately or kept unavailable (out of sight – out of mind) until the clothing is clean.”

“Examples of how to approach, interact and speak to someone who has anosognosia:

1. Down-size and decrease unnecessary chores and responsibilities.

Use a positive approach, such as, “It is time to plan ahead about moving to a retirement community where there are kind people and some of your friends so you have more time to do what you like, such as read and go for a walk every morning.”

Don’t use a negative approach, such as, “This house and yard are too much work for all of us. It is hard for you to take care of the house, the yard, and yourself. You need to move to a place where people are always around to help you.”

2. Partner with the person.

Use a positive approach, such as, “Let’s work together on the front porch, then go out for a nice dinner.”

Don’t use a negative approach, such as, “You really need to clean up that mess of old magazines, newspapers and piles of trash on the front porch.”

3. Focus on the person’s concern and subtly include your concern.

Use a positive approach, such as, “When you take this multi-vitamin, how about taking these “brain-vitamins” that the doctor prescribed to keep your memory strong?”

Don’t use a negative approach, such as, “The doctor prescribed these pills and you have to take them every morning.”

4. A gentle, positive voice should be part of a positive empathic approach.

Use a positive approach, such as, “To keep up with these bills, we should work as a team. I will come over on Saturday mornings with your favorite breakfast and we will write out the checks together. After you sign the checks, we will put them in their envelopes and take them to the mailbox.”

Don’t use a negative approach, such as, “You have to pay these bills on time. The utility companies have sent notices threatening to shut off the gas and electricity. I’ll handle the bills from now on.”

5. Provide available assistance and a structured schedule of tasks including personal care, activities including chores and leisure
activities, and “down-time” including a favorite activity or no activity.

Use a positive approach, such as, “After we walk the dog, we will finish the laundry and then sit down for some of that applesauce I cooked this morning.”

Don’t use a negative approach, such as, “There is so much to do? What do you want to do this morning? We have to walk the dog, finish the laundry, and clean the kitchen. The work really piles up fast around here.”

 

“Delirium or Dementia – Do you know the difference?” (Alz Assoc)

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This short article about delirium — prevention, causes, interventions, etc — appears in the recent issue of the Alzheimer’s Association (alz.org/norcal) regional newsletter.  Hospital-induced delirium is a big problem.

Robin
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alz.org/norcal/in_my_community_17590.asp

Delirium or Dementia – Do you know the difference?
Alzheimer’s Association Northern California Newsletter
Fall 2009

What do we mean by delirium?
Also called the acute confusional state, delirium is a medical condition that results in confusion and other disruptions in thinking and behavior, including changes in perception, attention, mood and activity level. Individuals living with dementia are highly susceptible to delirium. Unfortunately, it can easily go unrecognized even by healthcare professionals because many symptoms are shared by delirium and dementia. Sudden changes in behavior, such as increased agitation or confusion in the late evening, may be labeled as “sundowning” and dismissed as the unfortunate natural progression of one’s dementia.

When is a change in behavior delirium and not part of dementia?
In dementia, changes in memory and intellect are slowly evident over months or years. Delirium is a more abrupt confusion, emerging over days or weeks, and represents a sudden change from the person’s previous course of dementia. Unlike the subtle decline of Alzheimer’s disease, the confusion of delirium fluctuates over the day, at times dramatically. Thinking becomes more disorganized, and maintaining a coherent conversation may not be possible. Alertness may vary from a “hyperalert” or easily startled state to drowsiness and lethargy. The hallmark separating delirium from underlying dementia is inattention. The individual simply cannot focus on one idea or task.

What if you suspect delirium?
First, tell your doctor. Delirium may be the first and perhaps only clue of medical illness or adverse medication reaction in the Alzheimer’s individual. Be prepared to list all medications, and mention any that were recently stopped. Report such “clues” as a change in bowel or bladder habits, ankle swelling, respiratory symptoms, pain or fever. Secondly, create a safe and soothing environment to help improve the course of delirium: keep the room softly lit at night, turn off the television and remove other sources of excess noise and stimulation. The reassuring presence of a family member, friend, or a professional often prevents the need to medicate. And lastly, tread lightly with medications. Sedatives, sleeping medications and other minor tranquilizers play a very limited role in delirium management unless a patient is experiencing drug withdrawals. When severe delirium poses an immediate threat to health or safety, specific antipsychotic medication such as haloperidol (Haldol) seems to offer benefit. “But be careful,” advises Elizabeth Landsverk. M.D., director of ElderConsult in Burlingame, California. “Haldol can be problematic in some folks, especially with Parkinson’s disease.”  Dr. Landsverk recommends seeking consultation with a Geriatrician or Geriatric Psychiatrist if possible, because they often know what medications to keep and what to remove, what interventions help and which will cause more agitation in older adults.

Prevention of Delirium
* Avoid illness through smoking cessation, a balanced diet, regular exercise, adequate hydration and vaccinations to prevent influenza and pneumonia.
* Avoid alcohol in any amount.
* Exercise caution with medication, especially sleep aids, and periodically ask the physician for a “medication review.”
* Eliminate or reduce the use of the following medications:
Antihistamines (e.g., diphenhydramine)
Bladder relaxants
Intestinal antispasmodic
Centrally-acting blood pressure medicines (e.g., clonidine, methyldopa)
Muscle relaxants
Anticholinergics (drugs with atropine-like effects)
Opioids (e.g., codeine, hydrocodone, morphine)
Anti-nausea medication
Benzodiazepine type sedatives

The following interventions appear to reduce the risk of delirium during hospitalization:
* Early mobilization after surgery (e.g., walking, getting up in a chair)
* Assisting the individual with eating
* Round-the-clock acetaminophen for surgical pain (may lessen the need for stronger drugs)
* Minimizing bladder catheter use
* Avoiding physical restraints
* Avoiding multiple new medications
* Hydration – encourage and assist with fluids
* Normalizing the environment (e.g., pictures from home, familiar objects, cognitively stimulating activities and reminders, visits from family members)
* Providing sensory devices if needed (glasses, hearing and visual aides from home)

Causes of Delirium
* An acute medical illness, such as a urinary tract infection or influenza
* A “brain event,” such as stroke or bleeding from an unrecognized head injury
* An adverse reaction to a medication, mix of medications or to alcohol
* Withdrawal from abruptly stopping a medication, alcohol or nicotine

Factors That Increase Susceptibility for Delirium
* Normal brain aging
* Prior stroke or brain injury
* Hearing/vision impairment
* Alzheimer’s disease or a related dementia
* Multiple medications
* Alcohol use
* Malnutrition
* Dehydration
* Indwelling bladder catheter
* Electrolyte (blood salt) imbalance
* Use of certain medications
(see Prevention sidebar)