MHM Magazine

Issue 3 | 2021 | MENTALHEALTHMATTERS | 37 MHM that phlegm and sputum build-up is more evident in elderly patients therefore agents like olanzapine can make swallowing as well as night coughing an issue. EXAMPLE OF A NEUROLEPTIC REGIMEN Combination Risperidone (Risperdal) 0.25 – 0.5 mg twice daily Increase the dose for daytime control 0.75, 1.0 and 1.5 mg twice daily Together with: Quetiaine (Seroquel) 25 mg at night Increase the dose for nocturnal control 50, 75 and 100 mg at night Always wait a day or two between increases Single Medication Olanzapine (Zyprexa) 2.5 – 10 mg at 17:00 MAXIMUM DAILY DOSING Risperidone (Risperdal) 4 mg Clozapine (Leponex) 300 mg Quetiapine (Seroquel) 400 mg Olanzapine (Zyprexa) 10 mg Amisulpiride (Solian) 300 mg Aripiprazole (Abilify) 10 mg Ziprasidone (Geodon) 20 mg Haloperidol (Serenace) 10 mg Chlorpromazine (Largactil) 200 mg MOOD STABILISERS / ANTICONVULSANTS Unless the patient is a long-term Bipolar patient who is over 60, don’t introduce mood stabilisers or anticonvulsants into their treatment regime. (Maintenance levels of lithium should be between 0.4 to 0.6 mmol/L). There is no convincing evidence that advocates the routine use of these medications in non- long-term Bipolar patients. Patients in their late 50s who show signs of hypomania, severe psychosis and other key Bipolar symptoms, who have no history at all of Bipolar Disorder may have so- called ‘Frontal Release Syndrome’. This is often misdiagnosed as a psychiatric issue or as Alzheimer's Disease and is almost always a sign of Vascular Dementia. These patients do not benefit from anticonvulsants and require treatment with neuroleptics. It’s very important to educate and prepare caregivers and family for a diagnosis of Vascular Dementia which will generally be obvious once the medication has taken effect. EFFICACY OF COGNITIVE ENHANCERS AND EARLY TREATMENT Cognitive enhancers work for Mild Cognitive Impairment (MCI) and the earlier you begin treatment the better. Overseas, cognitive enhancers are registered for use in Vascular Dementia, Alzheimer’s Disease, Lewy Body Dementia and Parkinson’s Disease. In terms of the MMSE, as soon as a dementing illness is suspected, start treatment. On average, the MMSE score of a person with Alzheimer's declines about two to four points each year. When a patient reaches 8 or below on the 30 point scale, cognitive enhancers are no longer effective. The patient needs to be weaned off these medications over at least six months to prevent severe rebound effects. Evidence shows that while cognitive enhancers don’t extend life, they do improve functioning. Without these, patients need full nursing care three to four years earlier (at a starting cost of R14 000). Caregivers also report far more social and cognitive involvement. Only supplement when it’s indicated and always test and treat early. INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL) Functional decline and restriction of instrumental activities of daily living are critical to diagnose MCI and predict dementia. Most patients you see early on won’t show any decline in MMSE score. There are subtle changes in IADLs over the 10 years preceding the clinical diagnosis of dementia and research has shown that patients who later developed dementia performed worse in complex activities of daily living. Problems with Communication (Telephoning): Issues with communication start 10 years before dementia is diagnosed. Driving: This is heavily weighted as a pre-onset indicator. Be very aware of a patient’s driving history – have they had repeated small incidents like reversing into walls or driving into gates, is there a history of accidents or near accidents? Medication: Correctly taking medication is also an issue. Do patients need a pill dispenser to remember their medication regime, does a caregiver need to administer medication, does the patient consistently take the correct dosages?