Could Mrs. S’ functional decline have been avoided? How would you improve her function at this point?
Dr. Verma’s observations
A well-intentioned but ill-conceived drug regimen has compounded problems caused by the prior intervention. As Mrs. S becomes increasingly unable to function—and the staff becomes more frustrated with her deterioration and lack of initiative—more drugs are added. The three agents she is taking all carry a significant risk for sedation, and the anticholinergic effects of both haloperidol and diphenhydramine compound Mrs S’ difficulties by causing delirium and cognitive difficulties.
If this regimen is not modified, Mrs. S likely will stay bed-bound, her cognition will remain impaired or worsen, and her incontinence will continue unchecked. She will require more and more nursing time as her condition deteriorates further. Decubiti, sepsis, and even premature death are all likely sequelae.
In retrospect, an initial intervention with an antidepressant and/or an acetylcholinesterase inhibitor might have prevented such a precipitous decline. It is conceivable that Mrs. S could even have avoided institutional placement. At this point, I would gradually wean her off haloperidol and oxazepam, then aggressively treat her depression, resorting to electroconvulsive therapy if necessary.
In today’s atmosphere of cost containment, care decisions are too often dictated by shortsighted formulary lists, not sound clinical reasoning. In this case, the use of more cost-effective drugs with well-documented higher toxicity ultimately led to excess disability, which in turn required increased effort (and cost) by the treatment team.
Psychosocial interventions can be time-consuming, but they might have prevented Mrs. S’ rapid decline and saved substantial staff time. A higher-functioning patient uses far fewer staff resources, and the added expense of treating a hip fracture exceeds any savings from the use of a lessexpensive medication.
Related resources
- Salzman C. Psychiatric medications for older adults–the concise guide. New York: Guilford Press, 2001
- Jacobson SA, Pies RW, Greenblatt DJ. Handbook of geriatric psychopharmacology. Washington DC: American Psychiatric Publishing, 2002.
Drug brand names
- Amitriptyline • Elavil
- Bupropion • Wellbutrin
- Clozapine • Clozaril
- Donepezil • Aricept
- Galantamine • Reminyl
- Haloperidol • Haldol
- Imipramine • Tofranil
- Olanzapine • Zyprexa
- Oxazepam • Serax
- Quetiapine • Seroquel
- Risperidone • Risperdal
- Rivastigmine • Exelon
- Venlafaxine • Effexor
- Ziprasidone • Geodon
Disclosure
Dr. Verma reports that he is on the speakers bureau of Eli Lilly and Co. and Abbott Laboratories, serves as a consultant to Eli Lilly and Co., and receives grant support from Eli Lilly and Co. and GlaxoSmithKline.