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12 - Central Nervous System Disorders |
367
C 1: D
Setting:
Hospital.
Subjective:
GM is a 74-year-old man who presents with a chief complaint of confusion and incontinence.
His wife says he became confused about 2 days ago. The confusion at first was minor but
worsened until he tried getting into the car and going to work at 5:00 a.m., although he has
been retired for 9 years. Today he was incontinent and she brought him to the hospital, where
he was admitted for evaluation.
Past Medical History:
MCI for 2 years, hypertension, benign prostatic hypertrophy. Medications prior to admission:
lisinopril 10 mg daily, doxazosin 4 mg at bedtime, aspirin 81mg daily.
Social History:
Retired schoolteacher, lives at home with his wife.
Physical Examination:
Well developed, well-nourished older gentleman. Oriented ×2. Otherwise unremarkable except
for pain with palpation at the costo-vertebral angles.
Labs:
BUN 48 mg/dL, serum creatinine 1.8 mg/dL, CBC: WBC 13,000. Urinalysis: positive leukocyte
esterase, positive nitrites; CK-MB WNL; troponins WNL. ECG: no change from previous.
Assessment:
Urinary tract infection and delirium secondary to infection.
Plan:
1.
Start oral levofloxacin dosed per creatinine clearance.
2.
Avoid intravenous lines, urinary catheter, and other tethers.
3.
Nonpharmacologic measures for reduction of delirium, including music, massage,
redirection, and stimulation during the day; quiet at night.
Rationale:
1. Infections and MIs frequently do not present with the same symptoms in elderly patients
as they do in younger adults. Individuals with cognitive impairment from any source may
become delirious as a result of the insult. When a patient presents in delirium, work-up
must include evaluation for the common precipitants. As this patient did not have any
medication changes, a focus on infection or cardiac conditions is appropriate.
2. Levofloxacin is an appropriate antibiotic to choose in a complicated urinary tract infection;
however, it has been associated with causing delirium. Appropriate dosing in renal
insufficiency will help minimize this effect.
3. Avoiding intravenous lines and urinary catheters when not needed will eliminate the
risk of the delirious patient pulling them out, causing more damage. Nonpharmacologic
measures such as music therapy, massage, aromatherapy, and behavior techniques have
been shown to reduce the risk for delirium and may aid in recovery after delirium has
developed. Families or friends may be able to help with these, although some hospitals
have specialized units that include volunteers who can implement such measures. Using
these nonpharmacologic measures early in the hospitalization will help prevent the need
for pharmacologic treatment of delirium and hopefully speed recovery.
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| Fundamentals of Geriatric Pharmacotherapy
C 2: P D
Setting:
Assisted living facility.
Subjective:
PG is an 86-year-old female patient with a past medical history positive for PD for 3 years. Her
PD symptoms have been controlled on levodopa/carbidopa 200/25 mg three times daily for
the past 2 years. However, she is currently experiencing “wearing off” before her next dose of
levodopa/carbidopa is due, as well as problems “getting moving” when she wakes up in the
morning, around 7:00 a.m.
Past Medical History:
PD ×3 years, osteoporosis ×17 years, s/p hip fracture 12 years ago, episodic hypotension, and
glaucoma. Her concurrent medications include calcium/vitamin D3 500 mg/200 international
units three times daily, alendronate 70 mg once weekly, dorzolamide/timolol 1 drop both
eyes twice daily, travoprost 1 drop both eyes at bedtime, aspirin 81 mg once daily, and
acetaminophen 650 mg as needed for headache.
Objective:
Ht 5´0˝, Wt 96 lb; BP 131/89 (sitting), 113/79 (standing); P 79 BPM (sitting), 90 BPM (standing);
T 98.2°F, RR 17.
Physical Examination:
Resting tremor present R>L, shuffling gait, slight stooped posture.
Assessment:
86-year-old PD patient experiencing wearing off and morning bradykinesia.
Plan:
1.
Change dosing interval of levodopa/carbidopa 200/25 mg to four times daily 7:00 a.m.,
1:00 p.m., 7:00 p.m., and 11:00 p.m.
2.
Counsel patient to take levodopa/carbidopa in the morning before rising from bed and to
wait 30 minutes or more for it to take effect.
3.
Review medication regimen for issues with administration.
4.
Return to clinic in 4 weeks to assess improvement in wearing off and possible
dyskinesias.
Rationale:
1. The wearing off PG is experiencing can be attributed to disease progression, and although
there are options other than decreasing the dosing interval, PG appears to be tolerating
the levodopa/carbidopa well. If possible, it is best to stay with the single drug, levodopa/
carbidopa, to avoid additional exposure and risk for adverse effects. Other options are
available should this one not be optimal. A dopamine agonist could be added; however,
PG is of advanced age and may be more prone to the psychiatric adverse effects of this
type of medication. A COMT inhibitor could also be added with each dose of levodopa/
carbidopa; however, these are expensive agents and would add to pill burden (unless the
combination product, also expensive, was used). Another option is addition of selegiline
or rasagiline. Selegiline is the least expensive option, except for the orally-disintegrating
tablet, although it offers an important dosing option for the early morning. Rasagiline has
been shown effective in this situation and is dosed conveniently at once a day but is more
expensive.
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2. Due to the swallowing difficulties and slowed GI transit seen with PD, the alendronate has
the potential to cause ulceration if it gets caught in the esophagus. And the question must
be asked, can she administer her eye drops correctly with possible tremor and rigidity? All
medications require reassessment due to the motor and nonmotor deficits seen with PD.
Case Summary:
Wearing off between levodopa doses and dyskinesias are common occurrences as PD
progresses. Knowing how to manage these occurrences are important concepts. Although
there are little data to support specific interventions in the elderly when these occur, keeping
the tenets of geriatrics at the heart of the plan is key to success. These include making one
intervention at a time in order to best assess efficacy and tolerability, as well as starting low
with doses and going slow in titration. Timely reassessment of interventions and continued
follow-up are similarly important. Interventions may result in symptom improvement but with
concomitant bothersome dyskinesias. And, as the disease process progresses and symptoms
worsen, additional intervention may be required.
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| Fundamentals of Geriatric Pharmacotherapy
C S
One of the most dreaded diseases associated
with aging is dementia, as no preventive treat-
ment has been identified, therapies do not
alter its course substantially, and, over time,
the patient must rely on around-the-clock care
without a clear sense of self. Dementia may have
vascular causes, but the most common etiology
is AD. CIs are the mainstays of therapy, particu-
larly for mild-to-moderate AD, with memantine an
option for those who are intolerant or progress
to severe disease. NP symptoms also remain a
challenge for treatment as medications have little
evidence that efficacy outweighs the risk for side
effects in this population.
Delirium, most common in patients with
neurologic compromise, is a syndrome of the
elderly that complicates therapy of other disease
states and can lead to significant morbidity
and mortality. Preventive measures have been
successful in hospitalized patients. Once a diag-
nosis of delirium is established, nonpharmaco-
logic measures should be instituted, with phar-
macologic therapy reserved for patients who
pose safety problems for themselves or others.
As another progressive neurologic disease
without cure, PD requires timely re-evaluation
of interventions. Levodopa/carbidopa remains
the gold standard of symptomatic treatment,
and rasagiline has some literature supporting
its tolerability in those older than 70. Dopamine
agonists are likely not the best first choice in an
elderly patient, and, if used, should be titrated
slowly and monitored closely for adverse effects.
In patients experiencing wearing off or dyskine-
sias, one must keep the tenets of geriatrics at
the center of the plan, avoiding anticholinergics
as much as possible due to their myriad side
effects.
Seizures, the final neurologic condition
covered in this chapter, are common in the
elderly, especially among those with a history
of stroke, tumors, trauma, and dementia. There
is a lack of good-quality trials of AEDs specifi-
cally in the elderly population, which makes
the choice of an AED even more confusing.
Lamotrigine, carbamazepine, topiramate, oxcar-
bazepine, and levetiracetam have been studied
specifically in the elderly population for safety,
efficacy, and tolerability, with lamotrigine having
the most data in this population. However, given
Clinical Pearls
• The appropriate duration of therapy with CIs or memantine has not been fully investigated.
Patients who experience adverse effects, perceive little benefit, have rapid worsening,
or are concerned about medication costs may elect to discontinue treatment based
on risk-benefit assessment. In some studies, rapid deterioration occurred when the
CIs were discontinued, and some patients never regained this loss. However, patients
should be evaluated annually, on entry into long-term care or when the patient becomes
bedbound with advanced disease, to determine continued need for CI or memantine
therapy.
•
Switching AEDs, especially when one is intolerable or because of patient preference,
should be done slowly with the dose of the new agent maximized prior to the older
agent being titrated off. Once the new agent is at the minimally effective dose, a 20%
reduction in dose of the older agent should occur every 1–2 weeks until discontinued.
The new agent can have further increases in dose as needed for seizure control and as
tolerated.
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371
the quality of these trials, additional research
is urgently needed to help clinicians make an
evidence-based decision.
S-A Q
1. Why are serum vitamin B12 concentrations
measured in the work-up of dementia?
2.
What are the important counseling points for
a patient who is started on a CI?
3.
When would antipsychotics be appropriate
in treating a patient with dementia?
4.
What are the risk factors for developing
delirium?
5.
What nonpharmacologic treatments for
delirium are useful?
6.
What are the pros and cons of starting
levodopa/carbidopa versus a dopamine
agonist in an elderly patient newly diag-
nosed with PD?
7.
What are the options available to treat the
patient who is experiencing wearing off?
8.
How do dyskinesias contrast with wearing
off?
9.
How do the nonmotor complications of PD
impact the quality of life in a community-
dwelling senior?
10. Which AEDs should have the free concen-
tration measured when conducting thera-
peutic drug monitoring? Why?
11.
Which AEDs should be renally dose-
adjusted in an elderly person?
12.
What precautions should be undertaken
when adding lamotrigine to a valproate-
based regimen?
13. What are the advantages and disadvan-
tages of using the newer AEDs for the treat-
ment of partial seizures in the elderly?
14. Why might the diagnosis of a seizure
disorder in an elderly person be difficult?
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