Demented Patient with Psychosis

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.
It is not useful for long term treatment because of the incidence of EPS and its short half-life.
Risperdal is a better alternative.

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.
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.

Resources:
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
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.

Updated: 01/03/2009