Expert: Mary Gordon - 2/11/2010

Question
My farther was put into a senior behavioral unit the Friday before Fathers day.  Before going in he had become agitated and was wondering off, but could care for himself for the most part.  We finally came home the first week in August, a week and half later we were in the hospital with pneumonia, he wasn't aspirating at the time.  Three to five days before he came home the change his medication to 100mgs of Geodon.  When he came home in August he was at a shuffle, but could walk and after he went in the hospital for the pneumonia he has not walked since, became bedridden, wears  diaper, did have his food pureed.  He began to aspirate last week  and though the hospice nurses see no infection , he is now choking every time my mother gives him something and he will not eat.  Any suggestion????  Also I would like to know your opinion of Geodon and the rapid decline, PLEASE!!!!

Answer
Geodon is not a treatment for Alzheimer's - it does not slow down the progress of the illness. Drugs that can be used for that include cholinesterase inhibitors like Aricept, Galantamine and Exelon, or glutamate blockers like memantine. These drugs don't cure Alzheimers - they just can slow it down somewhat in some people, giving them a better quality of life longer into the illness.  

Geodon is considered an atypical antipsychotic and is used to treat psychotic behaviors - usually for schizophrenia and the manic phase of bipolar disorder in adults. It is an "off label use" when prescribed psychotic conditions related to dementia, because it can cause heart failure, sudden death, or pneumonia in older adults with dementia-related conditions. The FDA in the US has issued a special "black box"warning about its use for people with dementia.

Usually, these drugs are only tried if a range of other options have failed, and the person is absolutely being made miserable by their symptoms. Typical problems that might result in the use of something like geodon are problematic delusions, hallucinations, severe psychomotor agitation, and combativeness.

Things that are usually tried with a patient who is very agitated and aggressive include behavioral approaches and changing the environment. Caregivers can watch for what triggers the agitation and try to head it off at the pass, by repeating, reassuring and redirecting. They can tackled stressful activities at a time of day when the person is less easily upset (such as scheduling bathing for the morning when the person is rested and calm, rather than later in the day when they may be stressed). A caregiver can use a predictable routine. The environment of the home might be made simpler, and anything that triggers upset removed or hidden. Certainly, with my mother in law, if you knew her well, you could pick up cues that things were getting to be too much for her and that it was time to back off. Hired assistants didn't always know the signs, and this could result in major meltdowns.

If these approaches aren't enough, there are a range of drug types that can be tried. Everyone is different, so the approach is trial and error with the end goal to make the person feel calmer and more comfortable, at the lowest possible dose with a medication that causes the least bothersome side effects. Options can include anti-agitation mood stabilizing drugs like trazodone, anxiolytics like Ativan and Buspar, antidepressants like zoloft.

Why was he put on it in hospital? I would have thought he'd be pretty whacked out by the pneumonia alone. Also, being in a strange environment is very stressful, and a hospitalization alone would be more than enough to set off a lot of agitation in most people with advancing dementia.

At this point I can't fathom for the life of me why he would be still on such a medication. I can understand why agitation might be a problem if he were wandering, hitting, sleepless, aggressive, screaming - and nothing else was working to help him feel more settled. However, your poor father is currently bedridden. I can't see what you have to lose in talking to the doctors about weaning him off the drug to see what happens. Extreme care must be taken to very gradually wean him off the medication to avoid withdrawal symptoms.

I doubt very much the aspiration is related to the geodon. As many dementias progress the person loses control of their muscles. Their coordination and balance become so impacted they can no longer walk or do things for themselves. The same process affects chewing and swallowing and they start to aspirate - it's called dysphagia. The hospice nurses should be able to call someone (usually a speech therapist) in to assess his swallowing and make some recommendations on how to get more calories into him.

Here are some very general tips to help prevent aspiration:  
Keep him in an upright position (as near 90 degrees as possible) whenever eating or drinking.
Give him small bites -- only 1/2 to 1 teaspoon at a time.
Give him only one food at a time and don't rush him.
Don't encourage him to try to talk while eating.
If one side of the mouth is weak, place food into the stronger side of the mouth. At the end of the meal, check the inside of the cheek for any food that may have been pocketed (this is called chipmunking and it can be very serious!).
Try turning his head down, with his chin tucked to the chest, and bending his body forward when swallowing. This often provides greater swallowing ease and helps prevent food from entering the airway.
Do not mix solid foods and liquids in the same mouthful (i.e. such as crunchy cereal with milk) and do not "wash foods down" with liquids, unless you have been instructed to do so by the therapist.
Make sure he is eating in a relaxed atmosphere, with no distractions.
Following each meal, keep him sitting in an upright position (90 degree angle) for 30 to 45 minutes.
Ask a therapist about thickened liquids.

Hope this helps. I know the progress is shocking, but his condition will not have been helped by having pneumonia. Even a minor illness can really knock them back mentally, and they often never regain the ground they lose during a major one. Ask about getting him off the geodon gradually, and see how he is. You can always explore other options that are less problematic in terms of potential side effects.

Thinking of you.

Mary G.