Treating Dementia Related Behaviors

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This is arguably one of the greatest challenges in the elderly.  I nearly daily get asked questions about behaviors associated with dementia.  Often these patients can be aggressive, hit, spit, kick, swear, hallucinate, be sexually inappropriate, or have delusions.  I was once asked what the best medication is to treat these behaviors.  I relate that question to what is the best antibiotic to use.  If there was one miracle medication that worked, every patient would be on it.   It really depends upon what you are trying to treat, and often we can do an adequate job of treating these behaviors without medications or at least by thorough assessment of the patient in identifying the root cause of the behavior.

There are many questions to ask when assessing new or abnormal behavioral symptoms.  Here’s just a few to focus on from the start:

1. Identify the specific behaviors and be sure to relay this information to the clinicians/caregivers who are helping in making decisions.

2.  When did these behaviors start and what time(s) of the day do they happen?

3.  Can we correlate the start of new behaviors to anything else? (i.e. fall, medication, stroke, family crisis, infection, change in environmental factors etc.)

If you work with dementia patients, feel free to contribute other ideas/questions that have been helpful for you!

Zoloft (sertraline) and Loose Stools

robin williams picIn light of some recent awareness about mental health issues with the tragic passing of Robin Williams, I’ve decided to give you all a mental health related case study on one of the challenges in treating depression.  57 year old patient diagnosed with depression and was initiated on Zoloft (sertraline) 50 mg daily.  The physician in this case felt the patient was very depressed, and wanted to titrate the dose up fairly quickly.  Zoloft was increased to 100 mg daily after two weeks, and then further to 150 mg two weeks after that.  Remember that patient adherence to medication especially antidepressant therapy can be challenging due to the fact that most patients are not going to experience any relief in their depressive symptoms on a short term basis.  However, the side effects from antidepressant therapy can be apparent immediately upon starting the medication.  A couple days after the increase to 100 mg daily, the patient began experiencing troubling loose stools, multiple times per day.  Patients are usually very perceptive to side effects of medications especially when the timing initiation of the medication and the onset of the side effects correlate.  This patient ended up stopping the Zoloft on their own due to the intolerable side effects and refusing further antidepressant therapy.

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Medication Management and CKD

via Canadian Diabetes Association Clinical Practice Guidelines Expert Committee
via Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

78 year old male on a hefty list of medications.  The major issue to resolve was a rash that had started about 3-4 weeks ago and was spreading nearly all over the body.  I was asked to help out with the case by looking over the meds.  There had already been a couple of meds held to rule out the rash being drug induced.  In medication management, the first place to look when new symptoms happen is the changes that had been made previously to the new symptoms.  In this case, Lasix (furosemide) had been increased and Zoloft (sertraline) had been started within the last few months.  Both had been held for over a week, and it was felt as if the rash was not improving.  At this point, the primary provider did not feel as if it was medication related and was searching for other diagnosis and dermatology involvement.  Not so fast.  What was noted was that this patient had chronic kidney disease (CKD) and the kidney function had been changing over the previous few years labs and that the baseline creatinine had gone from about 1.2-1.5 range and was now consistently above 2.  Estimated GFR had dropped between 20-30 points.  Amongst the massive medication list, a seemingly innocent dose of allopurinol 300 mg daily was hiding.  Remember that allopurinol is cleared by the kidney and with the worsening kidney function, this drug was sure to be at higher concentrations in the body than it was years ago.  The allopurinol was held and a low dose of colchicine 0.3 mg daily was initiated without issue.  (Remember that colchicine needs to be dose adjusted as well).  The rash began to resolve over time and all was well again!

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Antiplatelet Therapy – Med List Review

Tylenol 16

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I’m going to cover a couple points tonight, and let you guys help with anything else you’d be concerned about by looking at the med list!

The morphine dose certainly needs to be clarified, and along with that we might as well ask how frequently it is used for chest pain.  Along with the potential for chest pain and cardiac type medications, it is pretty suspicious that this patient is not on an antiplatelet of any kind?  Maybe bleeding risk history? Frequent falls potentially Parkinson’s with Sinemet Rx?

The other point I will mention is that this patient is on a fairly substantial dose of insulin – so we certainly need to pay close attention to blood sugars  and any abnormal symptoms as this patient likely has dementia being on the Namenda.  Hypoglycemia identification can often be a challenge in dementia.

Definitely a couple other things to monitor and point out here…thanks for your help in advance!

Drug Induced Edema

via articles-home.org
via articles-home.org

 

A 64 year old male patient was struggling with blood pressure management, usually running in the 160′s range (systolic).  He was already taking lisinopril 40 mg daily and had failed at implementing lifestyle changes up to this point.  Procardia (nifedipine extended release) 30 mg daily was added to this patient’s regimen.  It had minimal effect and  the patient was slowly titrated up to a dose of 120 mg daily.  This had dropped the blood pressure 10-20 points on average, but the patient refused to continue to take the medication due to bothersome significant edema.  This patient was successfully transitioned to a beta-blocker as well as a low dose thiazide diuretic for blood pressure management.  Calcium channel blockers are effective at lowering blood pressure, but are also one of the more common medication causes of edema especially at higher doses.

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If It’s Not Broke, Don’t Fix It – Defining Polypharmacy

via cancergrace.org
via cancergrace.org

I appreciate all of your comments on the site!  An engaging, interprofessional audience really helps enhance the learning environment.  I recently received this comment on a recent diabetes med list review I posted: via Leo Lawless - “While the comment on the dosing schedule for Actos and Oxybutynin are valid we need keep in mind that manufacturers recommended dosing schedules are not a bible and we are treating people and need look at their individual response to a varied schedule. If its not broken don’t try to fix it,”  The comment is very thoughtful and absolutely true as well, and there is no textbook on how to manage patients’ medications because there a literally hundreds to thousands of variables that can affect medication management.  For me personally, I’m going to lean in and attempt to investigate how and why this patient ended up on twice daily Actos and Ditropan patch once weekly.  If the primary provider has no idea (or can’t remember), and the patient doesn’t know why either, I’m in the camp that is probably going to attempt to take some risk to reduce medication burden by consolidating the Actos (pioglitazone), monitoring blood sugars as well as closely assess the patient’s urinary symptoms and recommend a trial hold of the Ditropan patch to minimize anticholinergic burden going forward.  If the patient is adamant that the medications are working well, well tolerated, and have improved their diabetes, urinary symptoms, and overall well being, of course I wouldn’t suggest any changes.

I wanted to use this comment to demonstrate that it can be challenging to address medication related problems, and even more challenging to address them when everything is going fine with our patients.  I believe the “If It’s Not Broke, Don’t Fix It” philosophy is one of the major culprits that leads to polypharmacy.  At what point does too many medications actually become “too many medications”?  If the patient is on 52 medications is that too many?  If they feel perfectly fine on 52 medications and are doing well should we not reduce or change anything?  If a patient is on two medications that do the same thing, but are doing fine should we leave it alone?  Every patient brings a whole set of new circumstances that has to be considered.  “What is polypharmacy?” depends upon the provider, depends upon the patient, and is a question that each healthcare professional has to find a comfort level with.

For me, I work primarily in geriatrics and when I hear, “if it’s not broke, don’t fix it” – I can feel polypharmacy creeping in.  It’s a mindset that is easy to have, but I do not believe it is the best mindset for the majority of my patients.  – Notice how I said “majority” – not all :)

Healthcare professionals disagree, and I would make that argument that if there is no disagreement, there’s no critical thinking happening.  I have had the unique opportunity to make recommendations to well over 100+ different providers/healthcare professionals and while I feel I do my job in a consistent manner, there are providers that agree with nearly everything I suggest, and there are providers that disagree with many of my recommendations, and I’m ok with that.  What’s your philosophy?

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After a C. Diff. Infection

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78 year old male living in a long term care facility was recently treated with a couple of different courses of antibiotics to treat recurrent respiratory infections.  Treatment was eventually successful, but a few days following the final treatment with antibiotics, diarrhea started to develop.  It started out fairly mild but was progressing to several loose stools per day.  The physician was notified of the diarrhea and nurses had wondered if Imodium would help resolve the issues.  Imodium 2 mg twice daily was prescribed, with additional doses after each loose stool (up to a max of 16 mg/day).  Even with Imodium, the loose stools did not completely resolve.  C. Diff. testing was performed and it was indeed positive.  The resident was treated with metronidazole which was successful.  Diarrhea was 100% resolved and the resident was without any lingering symptoms.  In the effort and justified concern with treating the C. Diff infection, what was forgotten about was that the resident was still on the Imodium months after the C. Diff. has been treated.  The lesson here is to remember avoid long term medication use for an obvious short term problem that resolved with treatment.

Certain factors to Consider when choosing Analgesics In Elderly patients with Heart Failure

Another Guest Post via Amanuel T. B.Sc., Pharm.D. – Clinical Pharmacist: View his profile on Linked In

Have a passion for medication education?  Would you like to give back to healthcare students?  Would you like to be an expert on a particular topic and increase the size of your professional network?  Please be a guest contributor and donate a medication related case that all healthcare professionals can learn from!

Thanks again to Amanuel for his dedication to medication education and donating his time and talents!

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A 76 year old woman with a history of heart failure and s/p mitral valve repair asked to get a medication for her back pain. She specifically requested to be on Ibuprofen (NSAID) 600mg, a regimen she claimed (and documented on her chart) was getting as an outpatient with good results.
A pharmacist was consulted for advise on whether or not it’s appropriate for patient to be on this analgesic drug.
Upon review of her medical chart it was revealed that patient was on antiplateletes: Clopidegrel 75mg and Aspirin 81mg for heart failure and lisinopril 5mg. Lab review showed a remarkable decrease in platelet count from 207k to 143k in a 36 hour period. Heparin Induced Thrombocytopenia (HIT) was ruled out for patient was not receiving heparins or any other parenteral anticoagulants that are associated with HIT during her admission.
Patient was experiencing fluid retention associated with the heart failure and complained of swelling of her upper extremety.
Ibuprofen is a NonSteroidal Antiinflammatory Agent that’s widely used as an analgesic and in treating various types of inflammations including rheumatiod arthritis and osteoarthritis. However, there are several factors which preclude this patient from having this drug as part of her regimen: Ibuprofen inhibits platelet aggregation ; thus adding another antiplatlet agent to the regimen she is already on will certainly put her at increased risk for bleeding. This is specially true given that patient’s platelet count has dropped significantly in a short period of time. Fuid retention and peripheral edema have been reported with a chronic use of Ibuprofen and should be avoided, if at all possible. Also note that the patient is on Lisinopril-an ACE Inhibitor- for hypertension. There is a documented risk for renal toxicity and injury when Ibuprofen and ACE Inhibitors are used concomitantly. Ibuprofen has also been associated with decreased renal blood flow via inhibition of prostaglandin.
Given the patient’s medical and medication history and the drug-drug interactions with other drugs, use of Ibuporfen should be totally avoided.
There are a number of other analgesics that could be recommended as an alternative to Ibuprofen. Tramadol HCL in a smaller dose has been shown to be as effective as and with less adverse effects when compared with Ibuprofen , especially in patients with heart failure. Naroctic analgesics such as oxycodone or oxycodone/acetaminophen, in small doses and short term, could be considered if patient has no response to or is intolerant to Tramadol. Risk of fall, respiratory depression are common occurrences associated with narcotic analgesics and as such should not be used routingly.
The Pharmacist, after reviewing patient’s med history, made his recommendation to discontinue Ibuprofen and place her on Tramadol 50mg given q6-8 hours prn pain.

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Double Dose, Double Trouble – Dilantin Toxicity

98 y/o female had a long history of seizures was treated with Dilantin (phenytoin) 100 mg twice daily.  The Dilantin level was routinely drawn every 6 months and had been in the 6-10 range for quite sometime (normal total level is 10-20, but there are multiple variables that can make the value less than accurate).  The most recent level was 5 and the primary provider was concerned it was too low and increased the dose from 100 mg BID to 200 mg BID.  Keep in mind this patient had not had a seizure for years.  This patient’s albumin was lower as well, which actually increases the corrected Dilantin value as well.  An increase in a maintenance dose like this with Dilantin should scare you.  I have seen toxicity result several times due to inappropriate increases.

Dilantin is metabolized by a few different enzymes, and when those enzymes get saturated, the amount of Dilantin in the body can skyrocket quickly.  Think of a hockey stick type curve.  So clinically what this means is that when you start to hit the upward slope of that curve, small increases in dose is the usual practice.  MODERATE TO LARGE INCREASES IN DILANTIN CAN LEAD TO HUGE JUMPS IN LEVELS!  Pharmacokinetics is an ugly word for some, but not knowing the kinetics of Dilantin can harm patients.

Within a week or two, this patient began displaying signs of Dilantin toxicity – GI symptoms, difficulty with walking, lethargy, and confusion.  She was hospitalized and was diagnosed with Dilantin toxicity with a total level of 28.

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Serotonin Reuptake Inhibitors(SSRI) and Monamine Oxidase Inhibitors(MAOI): Major Drug Interaction That should not be left ignored

Wonderful Guest Post via Amanuel T. B.Sc., Pharm.D. – Clinical Pharmacist: View his profile on Linked In

Have a passion for medication education?  Would you like to give back to healthcare students?  Would you like to be an expert on a particular topic and increase the size of your professional network?  Please be a guest contributor and donate a medication related case that all healthcare professionals can learn from!

Thanks again to Amanuel for donating!

If you haven’t subscribed yet for future updates and access to more free clinical medication content, please Click Here to do so!

Case Study:

A 24 year old male patient with cystic fibrosis was admitted due to CF exacerbation and flare up. He’s known to have chronic sinusitis, colonized with MRSA and mucoid pseudomonas. New culture from this admission grew out MRSA and Pseudomonas.
Allergy : vancomycin (Redman’ syndrome) & Amoxicillin
Patient’s vital signs were unremarkable with a temp of 35.5c, blood pressure (sbp/dbp) of 105/57 mmhg respectively, heart rate of 89bpm and respiratory rate of 18br/min
His laboratory parameters include a serume creatinine = 0.57 mg/dl and wbc = 9.7 x10 3.
patiet’s home regimen which were documented on his chart are of multitude nature and include: Sertraline 50mg, pancrelipase , omeprazole 20mg, vitamin E and Albuterol inhaler among others.
Upon admission, patient was started on broad spectrum antibiotics which included: linezolid 600mg (vancomycin was discontinued 24hrs after initiated), colistimethate 80mg, ceftazidime 2 gram in accordance to the hospital protocol.

CLINICAL SIGNIFICANCE:

During verification process the pharmacist noted a major drug-drug interaction that occur between two of the patient’s regimen which could cause potentially serious harm. The drugs in question are sertraline, a serotonin reuptake inhibitor widely used in the treatment of depression, and linezolid, an antimicrobial agent used as an alternative to vancomycin to treat MRSA infection.
There’s a well-established medical data that “coadministration of linezolid (MAOI) with serotonergic agents may potentiated the risk of serotonin syndrome, a rare but serious and potentially fatal condition…” Symptomes of serotonin syndrome may include mental status changes such as irritability, altered consciousness, hallucination and coma; autonomic dysfunction such as tachycardia, hyperthermia, diaphoresis, shivering and mydriasis; and neuromuscular abnormalities such as hyperreflexia, tremor and rigidity.

RESOLUTION:
The Medical Resident who initiated the order was contacted and alternatives were given to avoid the harmful effects which may ensue from such interaction without delaying therapy. One option was discontinuation of Sertraline temporarily until patient’s infection is adequately treated using appropriate clinical parameters. Initiation of another antidepressant agent from a different group would be another option to look into. Unfortunately, most antidepressants on the market. including the tricyclic antidepressants (TCAs) posses serotonergic activities to a certain degree and have been shown to interact with MAOIs significantly.
After reviewing and weighing in the pros and cons in using serotonergic agent along with a monamine oxidase inhibtor; assessing patient’s clinical condition for which he was readmitted and given that vancomycin, the one and best alternative to linezolid in treament of MRSA, could not be used due to intolerance, the discontinuation of sertraline until patient’s overall clinical conditions imporve was deemed the best option.

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Interprofessional Medication Education