The Wild, Wild West of Medication

Dementia and medications really are a wild, wild west for so many patients. The issue is that far too many patients are peppered with medications like birdshot, often prescribed by multiple different doctors. A hurried doctor who only sees his or her patients infrequently and briefly will tend to prescribe based on the latest symptoms, not the whole picture, with all the effectiveness of a cowboy shooting from the hip. 

I write this because I recently started working with an 84-year-old woman who has diabetes and has suffered from some strokes. She took blood pressure medications, diabetes medications, and constipation medications. She was on Prozac for “anxiety,” on Sanctura for “sleep,” and Zyprexa for ”agitation.” She had been in the hospital several times recently for small strokes, a bladder infection, and agitation. When I met her, she could smile and wave but not speak. She would nod to my questions, and I was able to determine her level of comprehension.

So what can we do for someone who cannot speak and yet seems agitated? 

First, we look for pain. It could be coming from a bladder infection, pneumonia, a pressure ulcer, or arthritis. Despite a history of arthritis, she is unable to ask for pain medication due to her recent strokes. Is she getting the Tylenol that she would need 2-3 times a day to manage her pain? Probably not.

Next, we reduce agitating medications. In this case, she had those in spades. 

  • Prozac may reduce anxiety, but causes other side effects. It is long acting, energizing, and will likely decrease appetite, lead to poor sleep, and may even cause more agitation. This is not a good choice for most elders (an occasional individual will do well on a low dose, but I leave that to psychiatrists).
  • Sanctura is a bladder anti-spasm pill, is very anticholinergic (although billed as better than Detrol/Ditropan), and similar to Tylenol PM or Benadryl, which are also very anticholinergic and should be avoided for elders. It is not an appropriate medication for use as a sleeping pill. In general, sleeping pills are problematic, and I avoid them with my patients.
  • Zyprexa/Olanzapine is an anti-psychotic that was developed to decrease delusions and paranoia. It is unclear whether this woman ever had any paranoia, or whether her agitation symptoms were misdiagnosed as paranoia. Remember, this woman cannot even speak. If she did have paranoia, it could have been caused by her Prozac and Sanctura. I have seen many patients been treated for side effects of one drug by adding yet another drug to their chart. Zyprexa is not FDA approved for use in dementia, and increases glucose, which is not good for a woman with Diabetes.

What to do?

I would stop all three medications and watch the patient closely. If she does not have any infection, I would treat with Tylenol long acting 2-3 times a day, since she cannot tell us directly if she is in pain, though her behavior indicates it. I would not let her sleep more than a 1 hour nap in the afternoon and then have her go to bed at 9 pm or later, not at 7 pm as I have seen in some facilities.

We need to be careful and use only the medications and interventions needed for comfort and to keep health as stable as possible.

Please join us for our Living In the Moment Conference, this Saturday Feb 20, 2016 in Belmont, CA. I will be speaking on this issue of medications and dementia. Information or Register Here and please go to our website for a Community chat where you can comment or ask questions, or on our Facebook page. We welcome your comments and questions.

Elizabeth Landsverk, MD Geriatric Specialist