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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 21 of 21. This is the beginning of the thread.
Posted by zonked on April 20, 2014, at 9:18:47
My mom occasionally has episodes of delirium/dementia where she feels she is not "at home"... last night she got in her shoes, packed a bag and started walking and I bolted after her. In short, we got in a taxi and she wanted to go to her childhood home 40 miles away.
Talked her out of it. Went to see my brother instead, and had the taxi take us "home" (which she accepted as being her home)... the home hospice nurse came because I called and gave her Ativan on top of her usual night meds. It worked.
But we have Haldol in the emergency meds bag just in case she continued to stay up late worrying about the conspiracy where some unknown entity transports her between her house, and a house that looks identical but is not "home". (This is in her head, of course.)
I've read that risperdal is safer if say, she became out of control. The doses I believe they said they use (don't have the bottle handy) I believe were 0.25-1mg.
I've since read that Haldol has neurotoxic metabolites and risperdal is safer for dementia.
If she took a dose of Haldol would she feel "ok" the next morning? Should I ask hospice about Risperdal instead for emergencies, since there is research to support that it's safer? Also, this is Wikipedia I'm sourcing but apparently Haldol has neurotoxic/parkinsogenic metabolites.
I never thought I'd find myself in a position where I'd rubber-stamp giving her an old AP, but if she didn't calm down last night I would have endorsed it.
My poor Mom. No amount of showing her GPS, logic etc will take the delusion away when it's active. When it's passive, she knows she's at home but her memory of the "transports" seem real to her, in other words, she still thinks she's been transported in the past. I don't care about that, it's not dangerous.
I am going to develop a draft plan for when she wants to leave. It seems that if we get her in a taxi, and go SOMEWHERE and stop for a bit, then go "home" she feels at home again. Going all the way to her hometown wouldn't be good, she'd want to go to her childhood home, where people we do not know live, likely a family, and this was after 9pm at night. Plus the expense would be unfathomable, even though she can afford it.
Thanks all,
-zOh, her other meds: Keppra b.i.d., gabapentin t.i.d., namenda XR 21mg qam, xanax 1-2mg/day prn anxiety (we match there!), zoloft 100mg qhs, temazepam 30mg qhs.
"Emergency" meds include Ativan 0.5 and a bottle of Haldol I didn't get a look at, and meds for severe pain which thankfully, she has not had.
I am so glad home hospice is 24/7. The nurse was a lifesaver last night. If she had encountered a policeman or someone else or gone to an ER, she would CERTAINLY would have been detained and transported to a psych facility under California 5150 law.
Still trying out how to help her with this delusion - logic does NOT work, nor does GPS, nor does changing the subject. She wants an "investigation" started and I don't know what to do. Will speak with her providers Monday.
-z
Posted by Phillipa on April 20, 2014, at 9:51:19
In reply to For my mom: Haldol for out of control delirium?, posted by zonked on April 20, 2014, at 9:18:47
Zonked what a tough situation. I don't have the answers. Can you have a talk with the hospice RN and see how common this is? Why would she be detained since it's a medical condition? Phillipa
Posted by ed_uk2010 on April 20, 2014, at 10:00:24
In reply to For my mom: Haldol for out of control delirium?, posted by zonked on April 20, 2014, at 9:18:47
Antipsychotics are generally not effective at getting rid of delusions which occur in the setting of dementia, but they can sometimes temporarily reduce agitation and aggression (as occur in dementia, delirium and psychosis associated with dementia). Sadly, dementia is always a progressive condition but psychiatric symptoms can fluctuate a great deal from day to day and week to week. In time, this delusion may disappear, but may be replaced by something else.
I think you handled the situation very well. If you can handle these problems without additional medication that's great but occasionally the PRNs will be appropriate. Your mum already takes a lot of benzos for someone with dementia. Benzos worsen cognitive function and memory, increase confusion and increase the risk of falls. If she's been taking regular benzos for many years, they may be very difficult to taper but I would be cautious not to use too many PRN doses unless it's absolutely unavoidable.
Haloperidol 0.5mg or risperidone 0.25mg-0.5mg may be tried if something is necessary to reduce agitation, but they probably won't get rid of the delusion. Haloperidol is more like to cause movement disorders, risperidone is more likely to cause a BP drop or dizziness. When used regularly in people with dementia, both drugs increase the risk of death, stroke and pneumonia. Risperidone is approved for use for a maximum of 6 weeks in dementia pts in the UK; it is not approved for this use in the US. The initial dose is 0.25mg up to twice a day, increasing to 0.5mg twice a day if necessary. The drug should be tapered off as soon as possible. Repeated courses can be used for exacerbations of symptoms. For haloperidol, the usual dose is 0.5mg up to twice a day (as necessary). In some cases, distraction techniques may reduce agitation and improvement in lighting/surroundings may reduce confusion. Of course, it's often not enough...
Overall, either risperidone or haloperidol could be used as a PRN, but the doses used should be kept very low, and treatment should be short-term. Unfortunately, it's common for the meds not to help, in which case they should be stopped. I do think either med is more likely to be effective than lorazepam however, because your mum is already taking benzodiazepines. Mutiple benzodiazepines are not generally recommended. Neither antipsychotic can be used if the diagnosis is Lewy Body dementia, but can be used very cautiously in Alzheimer's disease if the benefits seem to outweigh the risks.
It must be so hard for you, and your mum. Hope you find something that helps.
Posted by zonked on April 20, 2014, at 10:00:34
In reply to Re: For my mom: Haldol for out of control delirium? » zonked, posted by Phillipa on April 20, 2014, at 9:51:19
> Zonked what a tough situation. I don't have the answers. Can you have a talk with the hospice RN and see how common this is? Why would she be detained since it's a medical condition? Phillipa
Hypothetical. Like let's say she ran into a police officer and he didn't know it was medical, and I had gone to run errands, and she was fine when I left but the delusion appeared and she was by herself and took off. Or even if he did know it was due to brain cancer and still perceived her as a danger to self, he could take her to the psych unit. I think that the law is worded that people can only be involuntarily detained "because of a mental disorder", but how is a cop to know? Hopefully she'd blurt out brain cancer if GOD FORBID that ever happened.. I will ask home hospice nurses all these questions, and also find out if there's a way to inform the local police AHEAD of time that, just in case, they know she has organic dementia/delirium/delusions (why do all these things start with "d"?) due to brain cancer, and that instead she should be taken to a regular ER on a non-psych hold until hospice and family were informed.
Time for a medical ID bracelet the police could recognize.
Phillipa haven't forgot your babblemail, thank you, will respond when I have a chance.
-z
Posted by ed_uk2010 on April 20, 2014, at 10:09:03
In reply to Re: For my mom: Haldol for out of control delirium? » Phillipa, posted by zonked on April 20, 2014, at 10:00:34
Oh I see she has cancer, how old is she? Most of what I said still applies but the risks of antipsychotics are lower in younger people than in elderly people with Alzheimer's disease.
Posted by zonked on April 20, 2014, at 10:09:59
In reply to Re: For my mom: Haldol for out of control delirium?, posted by ed_uk2010 on April 20, 2014, at 10:00:24
Ed: outstanding information, thank you.
They'd only be used if she continued to want to take taxis all over the area or in some way could NOT be calmed down, was missing sleep, etc.
I'd personally like to see her temazepam replaced with trazodone, which has been discussed, she is probably going to replace her many specialists with home hospice's in-house doctor, who is familiar with, and regularly prescribes, all the meds she takes. Plus, he can come to see her and works for home hospice, so communications would be better.
I do like her neurologist though. I'd keep him.
Anyway ... yes, she takes an average of 1-2mg/day Xanax and has been taking it longer than I have! At this point, no one wants to take that away. She.. how do I say this. She has lived past some doctor's expectations, if you know what I mean, so we don't know how long.
Certainly, her behavior is such that we will avoid using antipsychotics at all unless it is necessary for her safety: physical, financial, legal etc. You can imagine the scenarios with dementia (due to brain cancer that has become inoperable, and her refusing chemo which made her sick as a dog and would only give her another month or two.)
She had the money for the $60 in cab fare we paid yesterday, that is okay. What wouldn't be is driving around all night and a $500 cab bill with no rest, or disturbing people who now live in her childhood home late at night, etc.
I can't wait for my support groups. So many mixed emotions, but I am so glad to be here for her.
Posted by zonked on April 20, 2014, at 10:11:40
In reply to Re: For my mom: Haldol for out of control delirium?, posted by ed_uk2010 on April 20, 2014, at 10:09:03
> Oh I see she has cancer, how old is she? Most of what I said still applies but the risks of antipsychotics are lower in younger people than in elderly people with Alzheimer's disease.
>
>57 as of January. Still physically frail from the chemo, and her body heals slowly. We're in the process of convincing her to get a fall detection device, and now I really want one with GPS as you can imagine. A fall without being able to get up is a real possibility. And I can't be here 24/7/365.... she doesn't have 100% coverage right now. Family is talking.
Posted by ed_uk2010 on April 20, 2014, at 10:17:37
In reply to Re: For my mom: Haldol for out of control delirium? » ed_uk2010, posted by zonked on April 20, 2014, at 10:09:59
>They'd only be used if she continued to want to take taxis all over the area or in some way could NOT be calmed down, was missing sleep, etc.
I think either haloperidol or risperidone could be useful in that situation, probably 0.5mg of either. If haloperidol didn't work you could try risperidone (for a future episode, not the same one). If neither med worked I would look at something else rather than trying more antipsychotics.
>I'd personally like to see her temazepam replaced with trazodone, which has been discussed...
Has the temazepam been started recently? Temazepam is a low potency benzo compared with Xanax, so may not be very effective for sleep in someone who has taken Xanax long term. Trazodone can be effective for sleep but does sometimes cause dizziness. There is a risk of falls when adding additional sedative medication.
Posted by ed_uk2010 on April 20, 2014, at 10:22:59
In reply to Re: For my mom: Haldol for out of control delirium? » ed_uk2010, posted by zonked on April 20, 2014, at 10:11:40
>57 as of January. Still physically frail from the chemo, and her body heals slowly.
She is likely to tolerate antipsychotics better than an elderly person with Alzheimer's, and they will probably be safer for her. Unfortunately, it's still the case that they are unreliable for actually getting rid of delusions in dementia. If she was going through a bad period and you found an antipsychotic to be helpful for agitation, you could continue it for a few days or weeks and then attempt withdrawal. Personally, I do think risperidone is slightly more likely to be helpful and tolerable than haloperidol.
Posted by zonked on April 20, 2014, at 10:25:31
In reply to Re: For my mom: Haldol for out of control delirium?, posted by ed_uk2010 on April 20, 2014, at 10:17:37
> I think either haloperidol or risperidone could be useful in that situation, probably 0.5mg of either. If haloperidol didn't work you could try risperidone (for a future episode, not the same one). If neither med worked I would look at something else rather than trying more antipsychotics.I found the bottle: Haloperidol LAC 2mg/ml for IM.
Over the phone, hospice recommended (if I had to which I didn't) "the full 2mg". A nurse also
did an assessment in person and must have decided
Ativan was enough and it was. They have used it on her before I moved back here, I can tell because the bottle is only 1/4 full. I'll be asking for chart dates and doses.There are other sedatives available, like Ativan IM, or sublingual Ativan, they are aware she already takes Xanax orally. I trust them, they know what they're doing... I think it's good to have an antipsychotic on hand ONLY in an emergency.
Will discuss risperdal also, a pill or a short-acting IM form (if available). Oh, god forbid. She has excellent insurance, so anything (brand or generic) should be covered.
> Has the temazepam been started recently? Temazepam is a low potency benzo compared with Xanax, so may not be very effective for sleep in someone who has taken Xanax long term. Trazodone can be effective for sleep but does sometimes cause dizziness. There is a risk of falls when adding additional sedative medication.
>
>She's been on Zoloft, gabapentin, xanax, and temazepam for 6 years for depression and anxiety. Doses haven't changed, except the Xanax dose which crept up a bit over the years. She never abuses it.
Posted by zonked on April 20, 2014, at 10:29:19
In reply to Re: For my mom: Haldol for out of control delirium?, posted by ed_uk2010 on April 20, 2014, at 10:22:59
Ed,
Thanks for all the help! I agree. Risperdal from my own research, and your posts, seems a safer bet.
I've also read Zyprexa is safer (and is available in an orally instantly disintegrating tablet). Normally, I'd worry about metabolic issues but it would be used infrequently. This is twice in two months we've had an episode like this.
I look forward to meeting her new doctor. I have to tone down pharma talk with doctors, they get very weird if I start talking like I do here :-)
Thanks again,
-z
Posted by ed_uk2010 on April 20, 2014, at 10:38:11
In reply to Re: For my mom: Haldol for out of control delirium? » ed_uk2010, posted by zonked on April 20, 2014, at 10:25:31
>"the full 2mg".
You could use 2mg yes. Haloperidol doses are variable, but are much lower in dementia and delirium than in chronic schizophrenia.
>Will discuss risperdal also, a pill or a short-acting IM form (if available).
The only risperidone injection is a long-acting injection used for maintenance treatment in schizophrenia. Haloperidol has long been the most widely used antipsychotic in palliative care but risperidone can be a good choice in certain circumstances. It's available as standard tablets, an oral liquid and melt in the mouth tablets.
Posted by ed_uk2010 on April 20, 2014, at 10:45:08
In reply to Re: For my mom: Haldol for out of control delirium? » ed_uk2010, posted by zonked on April 20, 2014, at 10:29:19
>I've also read Zyprexa is safer (and is available in an orally instantly disintegrating tablet). Normally, I'd worry about metabolic issues but it would be used infrequently. This is twice in two months we've had an episode like this.
Overall, Zyprexa is less well tolerated in Alzheimer's dementia than low dose Risperdal because it has a tendency to aggravate confusion in some pts. Of course, that wouldn't necessarily be the case for your mum since she has a different type of dementia. So, Zyprexa is worth considering, but personally I'd look at Risperdal first.
Risperdal is absorbed more quickly than Zyprexa, so could be more suitable as a PRN. (Zyprexa oro-dispersible tablets are absorbed at the same rate as standard Zyprexa tablets).
For ease of administration, Risperdal is also available as orally disintegrating tablets.
Posted by phidippus on April 21, 2014, at 12:25:25
In reply to For my mom: Haldol for out of control delirium?, posted by zonked on April 20, 2014, at 9:18:47
Antipsychotics are not recommended for elderly patients with Dementia. The risk of death increases.
Eric
Posted by 10derheart on April 21, 2014, at 13:54:06
In reply to Re: For my mom: Haldol for out of control delirium? » zonked, posted by phidippus on April 21, 2014, at 12:25:25
http://www.dr-bob.org/babble/20140419/msgs/1064523.html
57 not usually classified as elderly. Check out other posts on thread...sounds like OP is saying the dementia is due to brain cancer...different situation...
Posted by zonked on April 21, 2014, at 17:56:26
In reply to Re: For my mom: Haldol for out of control delirium? » phidippus, posted by 10derheart on April 21, 2014, at 13:54:06
> http://www.dr-bob.org/babble/20140419/msgs/1064523.html
>
> 57 not usually classified as elderly. Check out other posts on thread...sounds like OP is saying the dementia is due to brain cancer...different situation...
>
>
Thanks, all. Let me clarify: It's due to brain cancer that has become untreatable. Another operation would be a severe risk of losing her sight AND mobility. Chemo alone will not extend her life much. So she's been off chemo for a year.Of course, the thing is growing, and there are no more MRIs per hospice policy as long as she doesn't agree to surgery. It makes sense, the treatments wouldn't change (just keep seizures/dementia under control) and another MRI would just cause everyone anxiety anyway.
Posted by jono_in_adelaide on April 21, 2014, at 18:27:29
In reply to For my mom: Haldol for out of control delirium?, posted by zonked on April 20, 2014, at 9:18:47
Zonked, I think risperidone would be safer, but perhaps there is somthing that makes haloperidol best in this situation that I'm not aware of.
Ask your mothers doctor if anything else can be done.
Because the atypicals have fewer side effects than Haldol, perhaps she could take say 1mg risperidone every night to keep the delusions under control?
Posted by zonked on April 21, 2014, at 19:15:19
In reply to Re: For my mom: Haldol for out of control delirium?, posted by jono_in_adelaide on April 21, 2014, at 18:27:29
> Because the atypicals have fewer side effects than Haldol, perhaps she could take say 1mg risperidone every night to keep the delusions under control?They like to use Haldol because it can be dosed very precisely in IM form and also is useful if there's severe nausea. I will go along with it for now. Unfortunately, I've been told that unlike (what I believe) happens with schizophrenia and other "mental health" psychosis, with her dementia-based delusions antipsychotics don't actually remove or soften the delusion, they would simply put her to sleep if say, she wanted to go out in taxis all night or started calling the police demanding an investigation--in other words, she started doing something that was dangerous to her safety and health: physical, mental, financial or other health and safety dangers.
She is not combative at all by nature and never has been physically dangerous to others, but I am preparing myself for disease progression. My paternal grandmother died of Alzheimers and at one point was throwing things and biting people. I hope it never comes to that.
This is not an easy job, but it's the most important one I've ever had.
Thanks for everyone's help and suggestions...
-z
Posted by Phillipa on April 21, 2014, at 20:44:50
In reply to Re: For my mom: Haldol for out of control delirium? » jono_in_adelaide, posted by zonked on April 21, 2014, at 19:15:19
So very important and so very loving. Phillipa
Posted by ed_uk2010 on April 22, 2014, at 13:49:26
In reply to Re: For my mom: Haldol for out of control delirium? » jono_in_adelaide, posted by zonked on April 21, 2014, at 19:15:19
>They like to use Haldol because it can be dosed very precisely in IM form and also is useful if there's severe nausea.
The doctor could prescribe both ie. haloperidol for use only if an injection is necessary... and risperidone for use if oral treatment is possible. That's definitely an option.
>with her dementia-based delusions antipsychotics don't actually remove or soften the delusion, they would simply put her to sleep
That's a fair statement. They don't usually remove delusions in dementia, but it is possible that they might. Haloperidol or risperidone won't necessarily induce sleep but they might produce some drowsiness.
Posted by jono_in_adelaide on April 22, 2014, at 18:27:47
In reply to Re: For my mom: Haldol for out of control delirium? » zonked, posted by ed_uk2010 on April 22, 2014, at 13:49:26
You're doing an amazing job - you should be very proud
This is the end of the thread.
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