Note To Attending Physician/Prescriber
Personal Consult
Physician: Physician, Unassigned
This review is based on the information provided.

Patient with dementia and behaviors and now non-responsive, will not talk, does not interact per family.
Recent psych admission d/t behaviors likely related to her dementia.
On Exelon Patch, Ativan prn, Seroquel prn, Trazadone, Namenda as concerns psych meds. She is on other
meds that can also affect her condition as described above such as Digoxin, Vicodin prn, Coreg.

Exelon patch treats mild and moderate dementia. Unsure what stage her dementia is from the data.
Ativan should be avoided in elderly with dementia since this group of drugs (benzodiazepines) can cause
confusion, sedation and fall. Unsure what the level of use is of this drug from the data.
Seroquel (and all antipsychotics) should be avoided in elderly with dementia per 2005 FDA notice that these
drugs can cause cardiovascular events, cerebrovascular events and death in this population. The use of these
drugs on a prn basis (atypicals) is questionable since they do not have the pharmacokinetics to provide the
required onset for prn use.
TRazadone is know not only as an antidepressant but can also be useful as an anti-anxiety agent and
Namenda is useful in moderate to severe dementia but depends on renal function to be excreted from the
body. If excretion cannot be achieved then the levels of this drug build and side effect occur.
Digoxin can cause psych effects and some other effects such as drowsiness depending on the level. None
provided with the information.
Vicodin can be problematic since it is a narcotic analgesic and the related effects can be psych or sedation
Beta blockers (Coreg) can have a Valium-like effect in some patients although it is not as common with the
newer agents which as Coreg.
Zoloft is being used for depression but can also be helpful with anxiety
1. Change Exelon Patch to Aricept 10mg hs x 3 months then 23mg hs. Aricept has much better data for
dementia and is effective for all levels of dementia from mild to very severe. It is also now available generically
at much less cost the Exelon patches and if a patient can take other oral meds, it may be beneficial to use this
drug in pill form.
2. The use of prn Ativan should be very limited and if use increases then adjustments to other medications that
can affect anxiety should be attempted or other medications added for the anxiety.
3. Seroquel prn should be DC'd as this is not an efficacious use of this class of drug and has no indication for
4. Trazadone dose noted at 100mg hs which may be excessive at this point. Perhaps a change to a dose such
Copyright Managed Health Care Associates, Inc. (MHA) 2011.
Note To Attending Physician/Prescriber
Personal Consult
Physician: Physician, Unassigned
as 25mg bid could be used and behaviors monitored from that point. Slight increments can then be made
depending on the escalation of behaviors such as 25mg am and 50mg pm, etc.
5. A check of serum creatinine with calculation of creatinine clearance is required to dose Namenda. If the
calculation shows a clearance < 30ml/min then the Namenda dose should be 5mg bid.
6. A dig level was not provided but a check of this would be warranted to rule out dig toxicity as a possible
cause of her mental status change.
7. The use of Vicodin should be minimized as it will have an impact on her mentation the more it is used.
Perhaps Tylenol 1000mg dose could be employed at no > 4000mg/day if this has not already been
attempted.Ultram is also a useful alternative to narcotics and could be tried if the Tylenol fails.
8. Even though the Coreg could have an effect, I think it unlikely and would leave this drug as is.
9. Would review the dose of Zoloft at 150mg/day. It also can cause some sedation, etc. and if no
depression/anxiety currently a problem, then perhaps a dose reduction to 100mg/day could be attempted.
10. This is all in an attempt to get some of the drugs out of her system and essentially start over based on
what her behaviors are once she is weaned somewhat.
11. If behaviors ensue, than an increase of the Trazadone and Zoloft would be the first line of treatment since
these drugs are already on board and need not achieve levels at this point. Would avoid use of antipsychotics
and benzodiazepines. Depakote is a very useful alternative in the elderly with dementia and behaviors and has
a greater success rate than the antipsychotics for treating such behaviors. This could be a potential alternative
to an antipsychotic if her behaviors warrant escalating her treatment over the TRazadone and Zoloft. A change
to aricept will be helpful because there is good data showing it can also help reduce behaviors in dementia.
Basically, this approach looks at avoiding the drugs that would have the greatest negative impact on her
dementia which may be the likely cause of the behaviors now being treated. We would also like to minimize
use of agents that may cause her significant sedation and confusion. We also need to look at other issues that
may impact her condition such as pain, dig toxicity, narcotics, renal function.
Use of drugs for her behaviors that avoid conflict with the dementia and yet do not overly sedate her would be
beneficial. It may just be that she needs less doses of the TRazadone and Zoloft and that would be sufficient
to make her more alert. It will be a balancing act to get the right dose to avoid the sedation yet treat the
behaviors to the point at which she is not harmful to herself or others and others can help with her care issues.
Depakote is more useful in these patients than the antipsychotics (especially since the FDA black box warning
referenced above) and could be a useful alternative or addition at low dose. It could essentially replace the
Trazadone and/or the Zoloft in this scenario. There are special dosing parameters for DEpakote when used for
this condition. Should you decide to pursue this avenue, please contact me again concerning this and I will be
happy to provide that information. No need for that info now unless a decision is made at some point to move
forward in that area.
Copyright Managed Health Care Associates, Inc. (MHA) 2011.
Note To Attending Physician/Prescriber
Personal Consult
Physician: Physician, Unassigned
Thank you very much for the opportunity to provide a different professional approach to the treatment of this patient to you for your consideration.
Bill Schlachter RPh, CGP, Board Certified Geriatric PharmacistConsultant Pharmacist Physician/Prescriber Response
Copyright Managed Health Care Associates, Inc. (MHA) 2011.


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Dialogues in Cardiovascular Medicine - Vol 16 . No. 2 . 2011 Alexander Lyon, MA, BM, BCh, MRCP, PhD Walport Clinical Lecturer in Cardiology - Department of Cardiac Medicine National Heart and Lung Institute - Imperial College - Flowers Building 4th floor - London SW7 2AZ - UK (e-mail: / Dialogues Cardiovasc Med. 2011;

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