A few words about medications and violence

[Guest guest]

(I'm updating Geri Hall's post so that I can keep saving them in the

links w/out having her expired contact info on the post)

" I am not trying to be sanctimonious here but wanted to comment about

some of the things said this week:

1. Medications.

Everything we know about mood controlling medications is changing

dramatically in the past few weeks. In the recent past we had four

atypical antipsychotics that we could use because the were " relatively

safe " from Parkinsonain side-effects and neurleptic malignant

syndrome. In the last few months [disclaimer = original post from

2003] we know that they produce many of the same side-effects as the

typical antipsychotics...although perhaps some not as frequently.

Thus the recent claims by Janssen that Risperdal has never been shown

to be safe or effective with psychosis in the aged (although

those of us who have been using it forever HAVE found it to be

relatively safe and effective). So, to date we now have Seroquel --

which has very mixed results with LBD -- and Zyprexa -- which tends

to zombify and change blood sugar. We have Geodon but that may cause

some cardiac side-effects. And we have Clonazepam which tends to

increase the patient's white blood cell count and blood should be

drawn every week (or at very minimum every two weeks) for six months.

This leaves us with a problem. There really are no " safe " drugs.

The person with LBD tends to be extra sensitive to any medications

that can have central nervous system (brain) side-effects. This may

be due to the " most vulnerable system theory " of aging, whereby

whenever a person is ill their most vulnerable system (the brain in

LBD) takes the biggest hit in terms of symptoms. Most of these drugs

affect not only the limbic system (where memory, perception, etc is

found), but also the pyramidal tract (which means the person develops

an associated movement disorder).

NONE of these medications has been designed for or tested in people

with LBD (or even AD -- except Ripseral which is now identified as

too dangerous to use). So what the professional does is work VERY

closely with the family and psychiatrists to develop a regimen that

is least restrictive in terms of somnolence/chemical restraint, but

helps the patient to be comfortable, not frightened, and safe to be

around. So, with DLB patients who are very psychotic we usually see

odd regimens, including a cholinergic, an atypical antipsychotic, a

short-acting benzodiazapine, and or an SSRI antidepressant. And even

then the control is not too good.

One of the biggest issues is that once we get a medication regimen

that is sort of working (after a lot of fine tuning) the minute

someone from a nursing home tries to decrease it, all bets are off.

We rarely see the same regimen in the rechallenge because the

patient's response to it changes.

Second is the issue of how long it takes the medications to work. The

antipsychotics are tricky in that what you see for the first one to

two weeks are the side-effects. It can take three to six weeks before

you see the true effects of the drug. So for the first 48 hours the

patient may be sleepy...but the med was given because the patient was

up for days agitated and is actually physically exhausted. So the

side-effect of drowsiness hits hard. The patient seems zombified, but

does wake up in a few days. Our problem is getting families through

that period without stopping the medication.

2. Violence/aggression

LBD compared to most other dementias has the unique quality of

producing a patient who has a high vulnerability to

violent/aggressive behavior. Over the years I have had one caregiver

killed and many many wounded. It is not unusual to be called by a

caregiver who has locked themself in a closet with the phone to keep

from being killed. The aggression in LBD is VERY dangerous. It should

always be considered a medical emergency. I make sure my caregivers

wear lifeline panic buttons at all times (I had one caregiver

bludgeoned almost to death as she lay sleeping in a separate room

from her spouse. The weapon? An alarm clock. My caregiver who was

killed was stabbed by his wife with a steak knife.

Placement is no cure for aggression. Placement only transfers the

danger to other people. The patient who is aggressive towards other

people poses significant risks to other residents and visitors. The

risk to the staff is huge, making nursing home employment one of the

most dangerous jobs in America. Most aids take the job because they

want to help people but end up being bitten, slapped, pinched, hair

pulled, and beaten. This places the patient at very high risk for

abuse from staff. Then once facilities have a problem, all too often

they try to discharge the patient, thus transferring the problem to

other facilities. Moreover, nurses and families tend to want to blame

the aide saying things like " Well, the aides weren't trained

properly! " or " If you just know how to approach her, this

wouldn't happen. "

My point here are as follows:

1. Violence in any setting is unacceptable. it is a medical emergency

and needs to be treated as such. Untreated aggression/violence only

escalates. (I've had a lot of caregivers and professionals tell me

that they won't treat because they think it's gonna pass -- two weeks

later they call with a dire situation) It needs to be treated by a

geriatric psychiatrist (if you have one available). And it needs to

be followed carefully and closely.

2. When an antipsychotic is prescribed, it has to be given a few

weeks to work. While we often " fiddle " with the dose, we try not to

stop things until we see the true effect.

3. We have no right to expect nursing home staff to be beaten,

bitten, or otherwise injured as a routine part of their job

4. If is the family's responsibility to " team " with the professionals

to manage the behavior. If you are admitting a LO with LBD to a care

center, you need to show the staff how to approach him/her to

minimize potential for violence. You need to tell the staff is

violence is a problem so they can prepare to manage it. If they

choose not to manage it, this is a good thing as the facility should

know its limits.

5. Most people with LBD should be off anti-Parkinsonian medications

because they tend to produce psychosis and should be on a cholinergic

(and soon memantine) to facilitate perception.

Please please understand that violence is one the worst problems

encountered with LBD. That and the psychosis are what really

separates the people with LBD from the other dementias. Each dementia

has its own problems and most have some psychosis in the later

stages, but it is not as florid as in LBD. Thus, if aggression begins

to rear its ugly head, treat early and treat often.

Respectfully,

Geri "