Should antipsychotic medication dosage be reduced?

MsMadge, There are many reasons why antipsychotics are used in the elderly. I can name three. 1 To treat psychotic episodes especially when accompanied by delusions, paranoia, hallucinations (auditory and/or visual). 2 To treat anxiety. Benzodiazepines are a class of drugs (which includes Valium, Xanax, Ativan, Klonopin, etc.). For the most part, benzodiazepines are the first line of drugs to treat anxiety. However, these drugs can make things worse in elderly patients and are usually avoided. 3. To treat delirium.

I realize this response comes a little late. However, since my mom has been and is currently taking antipsychotics, I thought sharing this experience would help. My mom is having a tough time with delirium. First, I should say that not all antipsychotics work the same way and are usually classified as "typical antipsychotics" and "atypical antipsychotics." My mom was first given Haldol (an old but reliable drug) that is referred to as a "typical antipsychotic." However, the doctors discontinued the Haldol due to a common and very uncomfortable side effect known as akathisia. The older, "typical antipsychotics" are notorious for causing akathisia - a feeling of restlessness that makes you want to pace the floor or jump out of the hospital bed. Then, she was placed on Seroquel. Seroquel and Risperdal are newer drugs and are considered as "atypical antipsychotics." Of the newer atypical antipsychotics, Seroquel tends to be more sedating. My mother was on very high doses of Seroquel and it essentially knocked her out. But that was all it did - it just knocked her out. The doctors thought it was working since it put her to sleep. But when she woke up, her delirium did not subside. With my professional background, I was fortunate enough to come up with the idea to put her on Klonopin. After I did much researching and consulting specialists, I asked the neurologist to put her on Klonopin. As I mentioned above, Klonopin is a benzodiazepine and benzodiazepines are usually avoided in the elderly. Because of this, the neurologist would not do it. So there was a bit a friction between the doctor and me. This was not an easy thing for me to go through since my mother's well-being lies in the hands of this doctor. After several days with no success, he decided to try the Klonopin. The following day we noticed some improvement. Eventually, she came out of it.

The take-home message is this. I am not advocating the use of benzodiazepines as a treatment for delirium. But as care-givers, we know our loved ones very well. The difficulty in treating the elderly with some kind of mental dysfunction is that there are a plethora of reasons that can cause it. UTI, pain pills, lack of sleep, you name it. The elderly a particularly susceptible. What I have learned about being a care giver is to acknowledge your instincts. However, this is easier said than done. It can be difficult to confront a doctor as it was in my case. But look at how my mom improved. I could have been wrong, but sometimes it never hurts to try. I don't know how much of what I just wrote helps any. But sometimes information, as little as it may be, can make a difference. I wish you and your mother the best!

I found a Medscape article you may like to read if you haven't seen it already titled "Most Dementia Patients Can Safely Stop Antipsychotics"

www.medscape.com/viewarticle/781903

I should  add Mom is showing slow improvement from the hospitalization for a UTI earlier this month which presented very much like a stroke 

She is still very weak and doesn't seem to be able to move her arms or legs or be able to turn herself in bed  - she is trying to use her left arm more but basically needs to be spoon fed although she is now off oxygen and swallowing better 

Thanks all for the feedback

Mom hasn't been tested with an MRI to determine type of dementia and her neuro didn't seem to think it made much a difference at her age especially since my goal was to keep her anxiety down

The initial drug tried, seroquel, didn't help at all and just knocked her out

Since her move to memory care 18 months ago I've taken her out to her doctor visits and while I may have to switch from her PCP of 25 years now, I'm very reluctant to use the facility visiting psych

Since her move to memory care and more since taking the risperdal, mom has gained some 25+ pounds - side effect or being doled out cookies and ice cream 

Of course, when she doesn't eat, she is really sick which was the case earlier this month - Mom's complete decline from being able to transfer to needing a Hoyer lift over the course of a weekend didn't prompt any notice from the facility staff until my insistence on getting an urinalysis done stat

On Monday I have a follow up care meeting with the facility

I'm also reluctant to move her now as at least she's in her own comfortable full size adjustable bed and staff has been more attentive since her return from the hospital but like everywhere it is often a function of how much family is there to stay atop of things

I recognize that even at 94, one could look up the definition of a berserker Viking and see her picture in the dictionary - of course, that's not her true self

Went to the neuro today -
mom was tired and gurgling quite a bit - she still has weakness on her right side and needs a lot of cues while eating to chew and swallow -
it's slow spoon feeding her and she really needs help
I found her asleep at lunch after my care meeting at the facility -
Not sure how to get more private caregiver coverage for lunch now?

Nurse practioner didn't think we should lower the risperdal and risk having mom get more anxious when so much else is going on with her

While the ct scan in the ER didn't show a stroke I guess that's not always conclusive but I'm not going to try and put her through a MRI so we'll try to get a new urinalysis to make sure the UTI is gone and another chest X-ray and do a swallowing test

Sad that mom couldn't say when her birthday is today and she's always known that - she'll be 94 in two weeks
She cried the whole time in the van - it was a bit of a mr toads wild ride

God bless my Viking

@ohmeowzer, Don't feel hurt when your mother calls you names. My mother did the same thing. I know my mother loves more than anything in the world. So I knew when she called me and my siblings bad names, it was because of her mental status. My mother went through a time when she actually bit a therapist. My mom is the sweetest person I know. I just looked at it as if she were sleep walking, that is, she appears to be awake, but she is unaware of her actions. At firsts, it's hard to hear your mother call you names. My sister took it very hard. When my mom began saying nasty things to my sister, the nurse pulled my sister out of my mom's room and said this is not uncommon.

As far as being alone, I am in the same boat. The situation with my mom has put us siblings on edge. I was the sibling who was my mom's caregiver. Trying to make ends meet and tending to my mother's needs is a lot to bear. So, when my siblings made comments as if I was doing nothing, it sent me over the edge. Unfortunately, things boiled over and some unpleasant words were exchanged. Now I feel very isolated and depressed.

When I hear you mention that you are tired, I became concerned. Maybe I am interpreting this the wrong way, but when I get to the point where I keep saying to myself that I am too tired, it usually means my depression is getting the best of me. You need to look after yourself as well. But I will be the first to admit that I don't always take my own advice. Sometimes I get into a state of mind where everything seems meaningless. It's not easy being a careGIVEr because we GIVE so much of our lives. And that's something you should be proud of! Many people are not as generous. But even with that said, there are times where I still find myself feeling low and hopeless. And in those times, my perspective of reality changes to the point where I begin contemplating to put a swift end these feelings. It's easy to feel overwhelmed, and feeling overwhelmed is something everyone experiences. But it is the constant feeling of being overwhelmed that gets the best of us. I am struggling with this as well and I wish I had a solution. But, for some reason, it helps to know that you are not alone with this. So, for this reason, I wrote this reply. Take care!

Dear MsMadge, Wow, I'm sorry to hear of this recent decline in your Mom!

My FIL isn't on any Antipyschotics, but his recent hospitalization sure zapped him of any strength whatsoever! Is it the post Sepsis, the Lung cancer, or generally just being in bed for well over weeks 3 week now that is doing it? I just do not know! 

I am trying to force him to to some simple bed exercises, and also making him hold a fork when possible and his cup or mug, and now have sippy cups, so no spills! Also now that he is bedbound, when turning him, getting him to hold the rail, but that is about as much as he can still do, and Only when I force him as he is unable to turn himself in bed. Otherwise he would be perfectly happy letting me do Everything for him! It's use it or lose it type situation now!

It sounds like things are really rough for you and your Mom, I'm so sorry to hear that!

It seems we are both coming to the end now with our folks, and perhaps it's time. I cannot see how people do this for years on end, no way!

Please know that I am thinking of you! I hope your Mom gets better!

Ms. Madge, no answers, just ((((hugs))))))

(((((madge))))) It does sound like what happened to mother. From November to December she went from using a walker, albeit with obvious effort needed to walk/shuffle, to being in bed or a wheelchair and sleeping a fair amount during the daytime. Mother also gained a lot of weight in a short period of time. For a while I could hardly keep up with buying her new clothing that fit. Since then she has not changed much. The advantage of knowing what type of dementia someone has is knowing the pattern of progression of the disease. Mother is still "mother", she has the same personality though it has been improved by the risperdal and the antidepressant she is on. However her communication skills have decreased and she has some cognitive impairment. She answers in a few words and sometimes doesn't understand. Vascular dementia usually has a step like decline not a gradual one. Mother never had a stroke Her vascular dementia is due to narrowing of the small blood vessels deep inside the brain -small vessel disease. I am wondering what the next step down will bring.

I sure understand your reluctance to move her and gather her personality has changed. Tough times...

I'm sorry for your mom's decline ,,I know your pain ...my mom was on xanax and the dr changed her buspar but it is doing nothing .. I think she's withdrawing from the xanax too and the dr shouldn't of cut her off cold turkey ...the buspar is just not helping esp with the withdrawal ..I'm a RN and worry about mom ..she is declining anyway and her memory is worse .l.it seems her eyesight is worse too....she maybe mean and call me vile names I would never in my life think,mom would come to this ...I'm not sure what to do anymore ,.i just take it as it comes ..most days are difficult and hard and I have no family that will help..after my sister died everyone was helping ,,now no one will help ..not even contact me anymore ..I work 12 hour shifts at the hospital, mom has a caregiver for 12 hours when I'm at work, I'm 55 and sick myself ..i will pray for you and your mom ..I love everyone 's advice because I'm so tired all,the time I'm short on advice ...I just make it through everyday ,,,but I,love you all