Alprazolam as an alternative to low-dose haloperidol in older, cognitively impaired nursing facility patients

OBJECTIVES

To determine if alprazolam is equally as effective as low dose haloperidol in managing disruptive behavioral episodes associated with delirium, dementia, and amnesic and other cognitive disorders (formerly called organic mental syndromes).

SETTING

Twenty-five community nursing homes in western Washington.

PARTICIPANTS

Older nursing home residents (N = 48) receiving a low-dose neuroleptic for the treatment of agitation and behavioral disturbances.

INTERVENTION

Randomized, double-blind, crossover trial of alprazolam and low dose haloperidol. Data were gathered at baseline and at the end of 6 and 12 weeks from direct observation and from clinical forms completed routinely by trained nurses.

MEASUREMENTS

Number of behavioral episodes, activities of daily living as measured by the Blessed Dementia Scale, extrapyramidal symptoms as measured by the Abnormal Involuntary Movement Scale (AIMS), and psychopathology as measured by the Clinical Global Impressions (CGI) and the Sandoz Clinical Assessment - Geriatric (SCAG) scales.

RESULTS AND CONCLUSIONS

No significant differences were observed between patients using haloperidol or alprazolam in terms of behavioral episodes per week. Further, with few exceptions, no significant differences were found in other outcome scales. Essentially the same findings were found when analyses were repeated for subgroups of patients with high levels of cognitive impairment and for patients with low and high levels of recorded problematic behavioral episodes. Alprazolam was as effective as low dose haloperidol in this population.

Brachial plexus palsy with the use of haloperidol and a geriatric chair

An 81-year-old white man was admitted to an intermediate care facility because of increased wandering and confusion secondary to dementia. On the first day after admission, the patient tried to leave the facility and was hitting and kicking the employees. Haloperidol 0.5 mg tid was prescribed to help control his behavior. He became more agitated and confused; haloperidol was then increased to 1 mg qid and the patient was confined to a geriatric chair to prevent injuries. Cogwheel movements, rigidity, and marked sedation were documented. A right brachial plexus palsy was diagnosed. This case demonstrated the hazards of two commonly used interventions in a nursing home: antipsychotic agents and the geriatric chair.

Drug abuse? Use and misuse of psychotropic drugs in Alzheimer's care

Although psychotropic drugs are widely used to control symptoms related to dementia, concerns are raised by the potential for adverse effects and misuse. Antidepressants may be useful when depression and dementia coexist in the early stages of Alzheimer's disease. In later stages, anxiety and agitation are often treated with antianxiety or antipsychotic agents. Concerns escalate about the use of antipsychotic agents as chemical restraints. Nursing home reform provisions of OBRA '87 mandate dose reductions of antipsychotics in an effort to discontinue their use. The role of the nurse is to establish and monitor therapeutic goals, to assess the incidence and severity of predictable side effects, and to provide a safe, supportive environment that reduces the need for pharmacological intervention.