Managing Geriatric Aggression

Question 1

The brain connects billions of neurons in a healthy individual. Electrical and chemical signals transmit information between neurons, muscles, and organs.

How are the neurons affected in dementia and Alzheimer’s disease?

Answer 1

Neurons stop functioning, lose connections with other neurons, and die.

Brain communication is disrupted, leading to cognitive and functional impairment.

Question 2

What is the amyloid hypothesis in Alzheimer’s disease?

Answer 2

This hypothesis states that the “accumulation and deposition of oligomeric or fibrillar amyloid B (AB) peptide is the primary cause of Alzheimer’s disease.”

Research is shifting away from the amyloid hypothesis to the tau hypothesis.

Question 3

What is the tau hypothesis in Alzheimer’s disease?

Answer 3

Research suggests that the brains of patients with Alzheimer’s disease contain tau proteins that are misfolded and abnormally shaped.

Question 4

In a brain with Alzheimer’s, abnormal levels of a naturally occurring protein clump together to form plaques that collect between neurons and disrupt cell function. What is the band of the brain plaques?

Answer 4

Amyloid plaques.

Question 5

In the early stages of memory decline in Alzheimer’s disease, cholinergic innervation is lost, but cholinergic post synaptic targets remain.
How can we use this knowledge to improve the patient’s symptoms?

Answer 5

Stimulating post synaptic cholinergic receptors by increasing ACh levels (through acetylcholinesterase inhibition) can restore some of the lost function of degenerated cholinergic neurons.

Later in the disease there is a progressive loss of the neurons (through cell death) and increasing ACh levels will no longer help.

Question 6

Donepezil

Answer 6

Reversible, long-acting AChE inhibitor in pre and post synaptic cholinergic neurons as well as in other parts of the CNS.

Also inhibited AChE in the periphery (GI tract) so most side effects are GI related and mostly transient.

Question 7

Rivastigmine

Answer 7

Pseudoirreversible (it reverses itself over hours), intermediate-acting, AChE and BuChE inhibitor.

Has more GI side effects than donepezil when taken orally, but it is now available in a transdermal formulation that greatly decreases peripheral side effects.

Question 8

Galantamine

Answer 8

Dual mechanism of action: AChE inhibitor as well as positive allosteric modulation of nicotinic cholinergic receptors.

Question 9

Memantine

Answer 9

Uncompetitive open- channel NMDA receptor antagonist with low to moderate affinity, reduces abnormal activation of glutamate neurotransmission and thus interferes with the pathophysiology of Alzheimer’s disease, improving cognitive function, and slowing the rate of decline over time.

If dose is too high it would interfere with learning, memory, neuroplasticity, and could induce a schizophrenia-like state.

Question 10

Acetylcholinesterase (AChE) inhibitors inhibit the cholinesterase enzyme from breaking down ACh, increasing both the level and duration of the neurotransmitter action. Which two groups can AChE inhibitors be divided into according to the mode of action?

Answer 10

Reversible and irreversible.

Question 11

What is the recommended starting dose of the anticholinesterase inhibitor donepezil?

Answer 11

5mg once a day.

Start small until tolerability can be established.

Question 12

What is the recommended starting dose for Memantine immediate release?

Answer 12

5mg daily.

Max of 20mg daily for immediate release.

Question 13

T or F: The maximum recommended dose for Memantine immediate-release (IR) form is 20mg daily.

Answer 13

True.

Half-life of Memantine IR is 60-80 hours.

Question 14

What is the recommended dementia antipsychotic approved by the FDA?

Answer 14

Aducanumab (Aduhelm).

Half-life is 24.8 days.

Question 15

What are the contraindications for prescribing benzodiazepines to the geriatric population, if any.

Answer 15

Evidence supports a correlation with dementia.

(But this does not mean causation.)

Question 16

Buspirone appears to be effective in treating behavioral disturbances in dementia. What is the mean dose?

Answer 16

The mean dose of buspirone is 25.7mg +/- 12.50.

Question 17

Which mood stabilizer is contraindicated with patients experiencing dementia and diagnosed with a renal disorder?

Answer 17

Lithium.

Question 18

A patient living in an assisted living center has experienced an increased number of falls. Which medication has the lowest risk of falls?

Answer 18

Lamotrigine (Lamictal).

No fall risk found associated with geriatric patients.

Question 19

Which drug class is recommended for patients experiencing dementia?
1. Monoamine oxidase inhibitors (MAOIs)
2. Tricyclic antidepressants (TCAs)
3. Selective serotonin reuptake inhibitors (SSRIs)

Answer 19

SSRIs

Question 20

What is the recommended intervention for patients with Alzheimer’s disease who are experiencing aggression or behavioral problems?

Answer 20

Nondrug interventions.

(Psychosocial interventions.)

Question 21

What is a common risk factor for aggression in patients with dementia?

Answer 21

Infections.

Infections such as UTIs are among the most common causes of aggression in patients with dementia.

Question 22

What is the first symptom of acute agitation in patients with dementia?

Answer 22

Restlessness.

Restlessness and sleep impairment are often the first signs of acute agitation in patients with dementia.

Question 23

Persistent aggressive behaviors in individuals in long-term facilities are hard to manage. What is a common cause of persistent aggression in these patients?

Answer 23

Untreated pain.

Question 24

A PMHNP decides to start an antipsychotic with an older adult patient because the patient injures another patient, has potential to harm self, and has extreme distress because of psychosis. Which antipsychotic has been shown to have a moderate strength of evidence for use in older adults?

Answer 24

Risperidone (Risperdal).

Question 25

How can you reduce the risk of getting Alzheimer’s disease?

Answer 25

Regular exercise, healthy diet, and diabetes and cardiac disease management.

Question 26

A PMHNP is called by the daughter of an older adult dementia patient. The daughter reports that she had taken her mother to see her PCP for a checkup and was given several medications. The daughter says now that her mother is very blunt, more talkative than usual, and has made embarrassing sexual statements to strangers when out in public. These medications are typically contraindicated in adult dementia patients. Which medication is the most likely cause of these behavior changes? Metformin Lovastatin Alprazolam (Xanax)

Answer 26

Alprazolam (Xanax). Benzodiazepines can cause disinhibition in dementia patients and are contraindicated.

Question 27

A PMHNP receives a call from a long-term care center reporting that an 85-yr-old depressed patient with dementia, usually calm and pleasant, has become irritable and argumentative. What would be the possible cause of these behavior changes? 1. Improved sleep 2. Death of roommate 3. Initiating pet therapy

Answer 27

Death of the roommate.

Question 28

A PMHNP is asked to evaluate an older adult patient living in a long-term care center for aggressive, combative behaviors that developed over several days. The patient accuses the staff of abusing him and poisoning his food. What should the PMHNP do?

Answer 28

Review recent medication changes, order labs, etc. The patient is presenting with delirium, and a full review of medications and labs is needed.

Question 29

The American Psychological Association (APA) recommends that patients with dementia who show an adequate response of symptoms to treatment with an antipsychotic should be weaned down with the intent to withdraw from the antipsychotic. How long is the recommended weaning period for an antipsychotic in this population after initiation?

Answer 29

Four months.

Question 30

An older adult patient with dementia who is exhibiting problem behaviors does not significantly improve after a 4-week trial of an adequate dose of an antipsychotic drug. What does the American Psychological Association recommend for this patient?

Answer 30

The medication should be tapered and withdrawn. Older adult patients are at risk of harm with antipsychotics and drug-drug interactions.

Question 31

What is Caprylidene (Axona)?

Answer 31

Purpose: It is intended to compensate for the brain's impaired ability to metabolize glucose in Alzheimer’s patients, thereby supporting cognitive function, providing an alternative brain energy source. Administration: It is taken orally, typically under medical supervision. Mechanism: When metabolized in the liver, it produces ketone bodies (beta-hydroxybutyrate and acetoacetate) that cross the blood-brain barrier. Efficacy: Studies have indicated it may help stabilize or improve memory and cognitive function. Side Effects: Common side effects include gastrointestinal issues such as diarrhea, flatulence, and dyspepsia.

Question 32

What is Selegiline (Eldepryl)?

Answer 32

Mechanism of Action: It acts as a selective, irreversible inhibitor of monoamine oxidase type B (MAO-B), which is the enzyme responsible for breaking down dopamine in the brain. By blocking this enzyme, it increases the duration and effectiveness of levodopa, reducing "wearing-off" effects between doses. Medical Uses: Parkinson's Disease: Used as an adjunctive treatment with levodopa/carbidopa. Depression: A transdermal patch (Emsam) is used for major depressive disorder. Off-label Uses: Sometimes used for early Parkinson's disease or attention-deficit hyperactivity disorder (ADHD). Dosage Forms: Available as capsules, tablets (including orally disintegrating tablets), and transdermal patches. Common Side Effects: Dizziness, nausea, dry mouth, insomnia, and confusion. Warnings & Precautions: High doses can lose selectivity and inhibit MAO-A, leading to potential dangerous interactions with certain foods (high in tyramine), antidepressants, and cold medicines.