How would you help Mrs. S adjust to her new surroundings? How would your treatment plan differ from that of the internist?Table 2
ANTIPSYCHOTICS: SIDE-EFFECT PROFILES
| Haloperidol 0.75-2 mg/d | Clozapine 25-100 mg/d | Risperidone 0.5-2 mg/d | Olanzapine 5-15 mg/d | Quetiapine 25-700 mg/d* | Ziprasidone 40-160 mg/d* | |
|---|---|---|---|---|---|---|
| Anticholinergic effects | +/- | ++ | - | - | - | - |
| Sedation | ++ | ++++ | + | + | ++ | + |
| Extrapyramidal symptoms | ++++ | - | + | - | - | - |
| Tardive dyskinesia | ++ | - | - | - | ? | ? |
| Hypotension | + | +++ | ++ | - | + | - |
| QTc prolongation | + | ? | - | - | - | + |
| Weight gain | + | +++ | + | ++ | + | +/- |
| Diabetes mellitus | + | + | + | + | + | ? |
| * Side effects are probably more severe at higher dosages, but the data are not clear. | ||||||
Dr. Verma’s observations
The decision to transfer a loved one to a nursing home is difficult for all concerned. I have often seen caregiver “burnout” play a major role in the family’s decision.
After 40 years in her own home, Mrs. S is not likely to adjust readily to living in a “regimented” environment, no matter how comfortable and elegant it may seem. The phenomenon is often called “transfer trauma” and manifests as a sharp decline in function upon moving to a new environment. Most individuals do adapt with time; involving Mrs. S. in a socialization program and insisting on her presence during meals and at other facility events would have hastened her adjustment. Above all, clinicians should be supportive and avoid resorting to medication too soon.
Because Mrs. S’ functional decline was so sharp, however, trying a nondrug therapy would have been easier said than done. Indeed, the internist resorted too quickly to medication, prescribing a short-acting benzodiazepine at first and, when this was perceived as ineffective, adding a neuroleptic antipsychotic.
Psychotropics are a double-edged sword. Used appropriately, they can reduce distressing symptoms and enhance function. Drugs, however, are increasingly replacing human contact. As we see here, medication side effects in nursing homes can be deleterious. Federal regulations enforced under the Omnibus Budget Reconciliation Act of 1987 have helped reduce the inappropriate use of psychotropics as “chemical restraints.” Still, the emotional distress for patient and caretaker during transitions often leads to inappropriate reliance on psychotropics for predictable adjustment symptoms.
Benzodiazepines have been found to cause sedation, falls, and cognitive clouding and thus should be avoided in older patients. Haloperidol has long been used in psychosis, but its use in older patients is contraindicated because of its side-effect profile. Extrapyramidal symptoms (EPS) are a common side effect of neuroleptics in older persons and are associated with a high incidence of tardive dyskinesia, gait disturbance, akathisia, and cognitive impairment.
Atypical antipsychotics have a more benign side-effect profile (Table 2) and should constitute first-line treatment—but only after human contact, stimulation, and care have been attempted.
Continued treatment: Another setback
A week after starting on haloperidol, Mrs. S fell and fractured her hip. She was transferred to the general hospital, where a surgical repair was performed. Her recovery was slow and difficult. She would not participate in physical therapy and required much coaxing to walk or stand up, often insisting that she could no longer do either. She developed urinary incontinence and became increasingly unable to care for herself. She remained in the hospital for 1 week, then was transferred to a rehabilitation facility.
Dr. Verma’s observations
A causal relationship between Mrs. S’ fall and the haloperidol/oxazepam combination is more than likely. Older persons have diminished pro-prioception, walk on a wider base, and struggle with postural sway. EPS combined with sedation can therefore have disastrous consequences, as this case clearly illustrates. Benzodiazepines, anticholinergics, antihistamines, and the typical neuroleptics are known to impair mobility. Many antidepressants, especially tertiary tricyclics such as amitriptyline and imipramine, may lead to falls by causing orthostatic hypotension secondary to alpha-adrenergic receptor blockade.
Check for pre-treatment orthostatic changes in blood pressure before prescribing psychotropics to older patients. An ECG can also help rule out rhythm abnormalities and assess baseline QTc interval. Agents with the most benign side-effect profiles—atypical antipsychotics, SSRIs, and newer antidepressants such as bupropion and venlafaxine—are recommended for older patients. For Mrs. S, a low dosage of a novel antipsychotic instead of haloperidol and oxazepam would have preserved her physical function and might have greatly reduced her chances of falling.
Follow-up ‘:Not helping’
Mrs. S has been in the nursing home for about 3 1/2 weeks. Staff members consistently report that she “is not helping herself,” is “always weepy,” and “feels her family (has) abandoned her.” She is now taking oxazepam, 15 mg bid, haloperidol, 0.5 mg bid and 1.0 mg at bedtime, and diphenhydramine, 50 mg at bedtime, to help her sleep.
Staff members also report that Mrs. S is “confused and very forgetful … (she) may have Alzheimer’s disease.” Urinary and bowel incontinence are an increasing problem, and she has lost about 15 pounds since she entered the facility. Laboratory readings are normal, but oral intake is poor.