Oct 14, 2020
Sanjay Gupta, MD, conducts a Masterclass on treating geriatric
patients with symptoms of dementia, particularly amid the
restrictions tied to COVID-19.
Gupta is chief medical officer at BryLin Hospital in Buffalo,
N.Y. He is also is a clinical professor in the department of
psychiatry at the State University of New York, Syracuse, and is
affiliated with SUNY at Buffalo. Dr. Gupta attends at 8-10 nursing
He disclosed serving on the speakers’ bureaus of AbbVie, Acadia,
Alkermes, Intra-Cellular Therapies, Janssen, and Otsuka.
- Common neuropsychiatric symptoms in patients with dementia
include agitation, aggression, delusions, insomnia, anxiety, and
depression. One-third of community-dwelling elders and between
60%-80% of nursing facility patients have these neuropsychiatric
- The most common medication class Dr. Gupta uses is
antipsychotics. The use of these medications in individuals with
dementia is off label. The Food and Drug Administration maintains a
black-box warning on the use of antipsychotics for geriatric
patients because of the increased risk of sudden death.
- Risperidone is supported by the most data, then olanzapine,
then aripiprazole, and finally quetiapine. Quetiapine has very
limited data to support its efficacy. Most antipsychotics have
modest efficacy data for their use in this population. The riskiest
adverse effects are cardiovascular adverse events, which are higher
- Dr. Gupta starts risperidone at a low dose of 0.25 mg taken by
mouth b.i.d. and titrates to a maximum dose of 2 mg/24 hours. The
starting dose for olanzapine is 2.5 mg up to a maximum dose of 10
mg. The starting dose of aripiprazole is 1 mg, and maximum dose 5
mg or less.
- Selective serotonin reuptake inhibitors (most commonly
sertraline or citalopram), the atypical antidepressant mirtazapine,
and anticonvulsants (valproic acid) are also used for agitation in
dementia but there is limited evidence for their efficacy.
Melatonin and trazodone have a positive effect on sleep that can
have downstream improvement on aggressive behaviors.
- To choose an effective treatment, it’s essential to obtain a
detailed history of the symptoms from patients and collateral, such
as relatives and staff members from the facility. Staff members can
be educated about what information is most important to the
clinician, or they may provide vague information, such as “the
patient is confused.” Specific symptoms that can be used guide
treatment include the presence of disorganized thoughts, delusions
and paranoia, or visual and/or auditory hallucinations; the timing
of the behavior (day vs. night); and patterns of aggressive
- Dr. Gupta emphasizes that it’s important to rule out delirium
as the cause of agitation by evaluating underlying medical issues
with laboratory evaluations, and when possible, a physical
- Antipsychotics work best in the context of aggression driven by
paranoia and/or delusions of persecution. Antipsychotics seem to
work less well for general agitation that may be driven by triggers
that need to be uncovered through investigation of the history and
environment. Reasons for agitation and aggression might include
sensory or activity deprivation, difficulty emptying bladder or
bowels, or depression and loneliness, both of which are prevalent
during the pandemic.
- Adverse effects of antipsychotics will be greater in older
adults, and include sedation, gait problems that increase the risk
of falls, and extrapyramidal or Parkinsonian symptoms. In a
geriatric patient, tardive dyskinesia can occur with as little as 1
month of exposure to an antipsychotic, compared with 3 months in
- Before starting an antipsychotic, the clinician must obtain
informed consent from the health-care proxy and inform them that
using antipsychotics in a patient with dementia is a
non–FDA-approved treatment with a black-box warning.
- Gradual dose reduction, a Medicare policy about the use of
psychotropic medications within nursing homes, is defined as
“stepwise tapering of a dose to determine if symptoms, conditions,
or risks can be managed by a lower dose or if the dose or
medication can be discontinued.” Dr. Gupta addresses this policy by
assessing which medications are essential and often stopping some
medications once the patient is started on antipsychotics.
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Show notes by Jacqueline Posada, MD, associate producer of the
Psychcast; assistant clinical professor in the department of
psychiatry and behavioral sciences at George Washington University,
Washington; and staff physician at George Washington Medical
Faculty Associates, also in Washington. Dr. Posada has no conflicts
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