MDS Alert

The resident's real problem may be easily correctable.

If a resident has Alzheimer's, you might be right that his cognitive decline or psychotic symptoms are dementia-related ... or you might be way off track.

The real culprit might actually be a medication or even depression, cautions William Simonson, PharmD, FASCP, CGP, independent consultant pharmacist in Suffolk, VA.

"Facilities should assess residents for drugs that could cause dementia to be worse than the patient's baseline cognitive impairment - or drugs that might be causing psychotic symptoms or agitation," he advises.

Clinical example: Simonson cared for one patient who became very delusional on amitriptyline prescribed for neuropathic pain, which he says usually doesn't cause cognitive problems in low doses. "But in this case, the physician had titrated the drug to a higher dose," Simonson explains.

When the patient developed delusions, the doctor tapered the dose and switched to another drug to achieve the desired goal of pain management. And the patient's delusional symptoms went away.

Anti-Parkinson's drugs can cause psychosis - most commonly visual hallucinations of people or animals or delusions. Spousal infidelity is a common paranoid delusion, said Ella Hunter, RN, PhD, at the June 2004 National Association of Directors of Nursing Administration in Long Term Care in Orlando.

Residents are at highest risk for developing anti-Parkinson's drug-induced psychotic symptoms at the outset of drug therapy when the physician increases the dosage to find a therapeutic level, Hunter says. Residents are also at risk for psychosis if the clinician increases their anti-Parkinson's medication when it no longer works as effectively as it had previously.

"Depression can affect cognition and also in some cases cause psychotic symptoms," Simonson adds. "A high incidence of depression coexists with dementia and worsens the person's cognition - and even contributes to or causes behavioral/psychotic symptoms," he says.

Sometimes cognitively impaired residents will really blossom when they start an antidepressant, notes Karl Steinberg, MD, CMD, a geriatrician and medical-legal consultant with Stone Mountain Medical Associates Inc. in Oceanside, CA. "Their cognition improves and they turn into a different person."

For that reason, Steinberg advocates prescribing an SSRI antidepressant for cognitively impaired residents who aren't communicative unless they are obviously not depressed - for example, if they are usually cheerful.

"If you don't see any therapeutic effect within six to eight weeks on an SSRI, then you'd stop it," he adds. "But SSRIs are relatively safe drugs so the benefits outweigh the risks in trying the medication on a trial basis for someone with dementia who can't communicate their mood state verbally."

Real-world example: One facility relays how a resident with diagnosed severe dementia turned into a different person on an antidepressant. She became alert, oriented and a leader in the resident community.

Assessment tip: Antipsychotic meds, tricyclic antidepressants or drugs with anticholinergic effects (Benadryl) can cause signs of delirium coded at B5, cautions Jane Belt, MS, RN, CS, a consultant with Plante, Moran Swartz Group in Columbus, OH.