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Antipsychotics in Alzheimers Treatment Could Cause Falls

Persons with Alzheimer’s disease (AD) or other forms of dementia often exhibit behavioral symptoms—irritability, anxiety, depression, sleep disturbances, agitation, delusions and hallucinations—that can result in falling.
Antipsychotic medications (such as risperidone and haloperidol) are often used to control behavioral symptoms.
 
However, new warnings from the National Institute of Mental Health caution that when antipsychotics are overused they can lead to harmful effects, placing individuals with dementia at a higher risk of falls. Some of the most common include.
  • Loss of energy: Slowing down of movements. A person may appear lethargic or inactive; feeling ‘slowed down’.
  • Feeling restless or jittery; restlessness or inability to sit still. Repeated trembling or shaking movement of the person’s muscles.
  • Need to move around and pace; causes people to pace repeatedly, get up and down from a chair or have fidgety leg movements.
  • Increased daytime drowsiness/sleeping too much.
  • Trouble getting to sleep or staying asleep.
  • Blurry vision.
  • Poor memory and concentration.

Antipsychotics are prescribed by doctors to help address aggressive behavior and mood changes that accompany dementias, such as Alzheimer’s disease. But, at the same time, the side effects from the medication can result in falling. So, what’s the best way out of this catch-22?

Not all individuals with AD or other dementias are alike and they should not be treated the same. Individuals need to be properly evaluated to determine the type of care that would provide them with the highest quality of life.

In most cases, one has to balance medication management and behavioral treatments, keeping in mind the risks of treatment as well as risks of not using medication. For example, agitation itself can lead to falls and injuries. In some individuals, agitation can be handled without resorting to antipsychotics, but in others, medication may be needed to avoid falling. The proper use of medication and/or behavior management can be crucial in avoiding behavioral outbursts and the risk of falling.  

Because of the possible dangerous side effects, individuals should only receive appropriate dose of antipsychotics for the minimum amount of time. As well, medication should be reviewed frequently to see if individuals can take a lower dose or come off the drug gradually.

First Step

Anytime individuals with dementia have a sudden change in their mental state and/or have frequent behavioral outbursts, the first step should be to visit their family doctor for an evaluation. There are numerous health conditions that make dementia worse, and if treated, can help avoid behavioral problems and the use of antipsychotics.
  • Drug side effects; change in medication
  • Depression (also side effects from anti-depression medications)
  • Metabolic (high/low blood sodium; high/low blood sugar; dehydration)
  • Endocrine (high/low thyroid disorders)
  • Nutrition (low vitamin B12, folic acid deficiency)
  • Trauma (subdural hematoma caused by a blow to the head, such as from a fall)
  • Infection (such as urinary or pulmonary infections)
Causes of Behavior Problems

Many behavior problems (agitation, anger, pacing/wandering, aggression, hallucinations, etc.) are made worse by a number of factors. By learning how to deal with behavioral problems, the use of medications, and the frequency of falling can decrease. 

Inability to Communicate

Dementia reduces verbal communication skills. As a result, an individual’s words and expressions may make little or no sense. In turn, the person may have trouble deciphering your words. The resulting misunderstandings makes communication difficult. Ways to facilitate communication include:
  • Speak clearly, in a straightforward manner.
  • Avoid distractions. Communication is difficult against a background of competing sights and sounds.
  • Keep it simple. Use short sentences and plain words.
  • Don't interrupt. It may take a long time for the person to respond. Avoid criticizing, hurrying and correcting the person.
  • Don't argue. Reasoning and judgment decline over time; to spare anger, don't argue with the person and stay calm.
Physical Discomfort

Potential causes of discomfort or pain are the same for people with dementia as they are for everyone else. Except that the person with dementia will express their pain through restlessness, crying or distress. Common causes of discomfort and pain include:
  • Dehydration
  • Constipation and urinary tract infections
  • Sitting or lying in one position for too long
  • Pressure sores
  • Arthritis; back problems
  • Undetected or untreated injuries
  • Headache or migraine
An evaluation by the family doctor may be needed to determine the cause of pain.

Difficulty with Tasks

As it becomes more difficult for the person with dementia to do everyday tasks, it becomes more important to simplify tasks or activities based on the functioning level of the person. For example, if the person is having difficulty dressing or choosing an appropriate outfit, arranging items in sequence can be helpful in reducing confusion and anxiety. While the person cannot learn new skills, some individuals can remember simple tasks or facts with enough repetition.

Environmental Surroundings

Keep the environment simple and uncluttered. This helps to make the home safe from falling and less confusing and frustrating for the individual.

Modify the environment to reduce potential stressors that can create agitation and disorientation. These include:
  • Change in lighting conditions (e.g., glare, shadows, poor lighting).
  • Overly noisy environment or strange sudden noises.
  • Too much stimulation (such as, too many people or overly demanding tasks).
  • Change in environment (unfamiliar place or event).
  • Change in caregiver/routine.
Ways to Identify the Causes of Problem Behaviors

Try to put yourself in the person's situation. Look at the person’s body language and imagine what he or she might be feeling and what they might be feeling or trying to express. Ask:
  • What happened just before the problem behavior started? Did something trigger the behavior? Try a different approach to see if that changes the reaction.
  • Are the person’s needs being met? Are they hungry, thirsty, or in pain?
  • Does changing the environment or the atmosphere help to comfort the person?
  • How did you react to the problem behavior? Did your reaction help to soothe the person or did it make the behavior worse?
In managing behavioral problems, the first line approach should always be to look and see if there are non-pharmacological approaches that may work better.


Guest post by Dr. Rein, this post originally appeard in E-CareDiary.com

Rein Tideiksaar Ph.D., PA-C is the president of FallPrevent, LLC, Blackwood, NJ, a consulting company that provides educational, legal and marketing services related to fall prevention in the elderly. Dr Tideiksaar is a gerontologist (health care professional who specializes in working with elderly patients) and a geriatric physician's assistant. He has been active in the area of fall prevention for over 30 years, and has directed numerous research projects on falls and has developed fall prevention programs in the community, assisted living, home care, acute care hospital, and nursing facility setting.

To learn more about fall prevention and the use of antipsychotic medication in dementia care, take a look at some of the online continuing nurse education courses presented by our authors and experts.

Antipsychotic Medications in Dementia Care
Caring for People with Fall Risks
Facts About Falls
Preventing Falls
The Fall Prevention Care Process
Vitamin D Prevents Falls in Older Adults

Posted: 3/21/2016 9:46:24 PM
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