From the Guidelines
For a 96-year-old with profound dementia being transferred to memory care against her will, low-dose haloperidol 0.5-1 mg orally at night and every 2 hours when required, as recommended by the most recent guidelines 1, may be considered for short-term use (1-2 days) during transition. These medications can help reduce agitation and anxiety during this stressful period. Alternatively, lorazepam 0.25-0.5mg could be used, but with caution due to fall risks in elderly patients. Non-pharmacological approaches should be tried first, including:
- Having familiar objects
- Maintaining routine
- Having a trusted person accompany her during transfer Any medication should be prescribed by her physician who knows her medical history, as elderly patients with dementia are sensitive to medications and at higher risk for side effects. The goal is minimal effective dosing for the shortest duration possible, with close monitoring for adverse effects like sedation, confusion, or cardiovascular issues, as suggested by the American Psychiatric Association practice guideline 1. Once settled, medication should be tapered as the patient adjusts to her new environment. It's also important to consider the patient's quality of life and mortality risk when making treatment decisions, as antipsychotic medications are associated with clinically significant adverse effects, including mortality 1. The use of antipsychotic medications should be balanced with the potential benefits and harms of a particular intervention, as compared to other therapeutic options for the individual patient 1. In addition to medication, non-pharmacologic interventions such as providing a predictable routine, allowing the patient to dress in their own clothing, and keeping possessions, as recommended by guidelines for managing Alzheimer's disease 1, can help reduce behavioral disturbances. Overall, the treatment plan should prioritize the patient's safety, comfort, and quality of life, while minimizing the risk of adverse effects.
From the Research
Medication Options for Calming a 96-Year-Old with Profound Dementia
- Risperidone has been shown to be effective in managing behavioral and psychological symptoms of dementia, including agitation and aggression, with a relatively favorable safety profile in elderly patients 2, 3.
- The recommended dosage of risperidone for elderly patients with dementia is 1 mg/day, which has been found to be effective in reducing symptoms with minimal adverse effects 3.
- Compared to other medications, such as escitalopram, risperidone has been found to have a faster onset of action in reducing psychotic symptoms and agitation in patients with Alzheimer's disease 4.
- Risperidone has also been found to have minimal effects on cognitive functions in healthy elderly volunteers, with no significant impairment on speed of reaction, vigilance, and sustained attention 5.
Considerations for Medication Use
- The use of antipsychotic medications, including risperidone, should be carefully considered in elderly patients with dementia, as they can be associated with increased risk of adverse effects, such as extrapyramidal symptoms and cognitive impairment 2, 3.
- The decision to use medication should be based on a thorough assessment of the patient's symptoms and medical history, as well as careful monitoring of potential adverse effects 2, 3.
- It is also important to consider the patient's advance care planning and do-not-resuscitate orders, as these can impact the intensity of end-of-life care 6.