Event ID: 2811835 Event Started: 12/15/2015 1:49:38 PM ET

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Let's get started. This is the dementia and antipsychotic long-term care initiative. A partnership between federal local center and queue source. This is our third in a series of six sessions. You can see what is coming up. If you have missed the first two sessions or one of the ones, you can view our website. The recordings from sessions one and 2 are there. You should to the email link pop-up in your chat panel. Britney will be monitoring chat panel which of the at the top or the right-hand side of your screen depending on how you have yours laid out. We have the phone went needed today during the presentation. If you question or comment or anything please send that to break through the chat and will respond.

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Again this is the third in our series of six. Today is psychopharmacology in the nursing home. We have Dr. Warren Taylor with us today. He's director of new disorders program in psychiatry department attended the University. Is a geriatric psychiatrist who specializes in depression in older adults and depression and cognition in older adults. We're lucky to have him with us today. Is a great resource to be thinking of questions for him along the way. And to turn it over to him

Thank you very much. Thank you for coming and for listening. We have a number of objectives we want to touch on. I want to give you a broad overview of how we think about psychotropic drug treatment in older adults. Specifically in nursing homes with some on table and off label uses we will talk about how we need to be aware of these in nursing home or extended care environments. And think about whether appropriate or inappropriate uses. When we get to antipsychotics we will talk about the regulations and what we need to think about is only initiate the use and when we have to have them come off the medications.

In general I was always taught to give punchline first. So I want to give that. Pharmacotherapy -- medication management should not be the first thing you jump to in the case of behavioral disturbances in dementia. Always think about environmental interventions, behavioral interventions. When those are not working or you have a more severe case then think about pharmacologic's. In general when you decide to initiate medications for behavior monotherapy is an ideal. It's unfortunately we don't often achieve it. Poly therapy polypharmacy is more common. We really need to carefully think about what we're doing. We think about combinations we can crease risk of bad side events those side effects or adverse events. People can refuse medicine or dose is being messed. And what bothers me is when I see people on multiple of the same medicine. Why would you want to give people three antidepressants? It doesn't make sense. We need to think rationally about what we're doing and if we initiate a second or third medicine, why is it and what we hope to gain versus incident adding a third, taking one often putting a new one on? We have to think carefully about what we're doing in these cases.

The reason this matters is psychiatric systems are common in the older population particularly those with dementia which is the orange bar. As you look you can see we have a number of psychotic symptoms are common depression and anxiety. Other things like irritability or eating problems. When you look at all of it, 80% of people with dementia have some neuropsychiatric symptoms. These things are really common. When you think about pharmacotherapy I'm struck by one of the lessons I learned when I was in training. When it comes to behavioral disturbances and training with medication, on the medications work sometimes. Which means that not nearly as often as we want. It becomes a real problem all of us deal with.

When you think about how select behavioral problems might be most responsive, think about behaviors that are continuous and that you've tried interventions that didn't work. This might be nonaggressive agitation or persistent anxiety. Or some depression. Think about behaviors that occur in response to a stressor. People become agitated during bathing or certain activities. Think about using a medication on a time schedule before the activity to help make that more tolerable. Or think about behavior that are similar to other psychiatric disorders like psychotic symptoms and dementia. Let's dive right in. That start in a place medical don't think acetylcholinesterase inhibitors. These are approved for the treatment of memory disorders. We have Aricept and others. And all we may use them for the treatment of memory that is good data to show they can improve a number of other behavioral problems like apathy or anxiety and decreased frequency of hallucinations. They don't necessarily make these disappear but if they come over the severity or the frequency, that can still be a huge benefit. The showed the drug effect there's a study that was done if you stop the medicine down the road if you're not sure it's helpful, assistance those symptoms can get worse. This is showing graphs and studies. This is one wanted to highlight. The yellow bar is Aricept. A comment used inhibitor. When you look at NPI or the narrow psychiatric inventory which is a range of disturbances, people on the drug over the course of 24 weeks did far better than people who got a placebo or no medicine at all. When these investigators looked at what domains of behavioral the most affected as I said depression anxiety and apathy. It looks like to provide some good benefits. This is a subsequent study. When you see that everyone had the first 12 weeks and with the Aeros pointing down the either randomized on the drug or a placebo and the people with placebo their behavior got worse. It makes a good argument that when you can use these medicines with people with behavioral disturbances they could have sporadic disturbances and scratch your head and say is this helping? The answer is often yes it's. If there's a good way to stop the medicine that is fine but we should not those who -- monitor how the person is doing and see if the disruptive pay period scores. Was a medicine working?

The polling question is if this drug helps memory and cognition but they don't have -- help with behavioral disturbances. True or false?

Make sure you hit the submit button you select your answer. -- After you select your answer.

Come on no answers. We can do better. The reason I put this question in is because I want to emphasize these medicines can have the benefit. They are not going to be used for someone whose acutely agitated. This is not for someone having a problem right this minute any control. But in the long-term, it can reduce the severity and frequency of some of these behaviors and can be quite helpful.

There are many points to make but the indications we think about for antipsychotics are psychotic symptoms, hallucinations, they see something or hear something that is not there. Delusion which they believe something that's not real. But also progression. We can occasionally see people have severe anxiety or treatment resistant depression. When we use this for behavioral disturbances, the experience of many of us is the efficacy is modest rather than striking. The sun won't come out and have in your click your. A modest reduction in what happened. In some cases this can worsen behavior. I want uses as an example. This was a case I think about for my own training. A gentleman was brought to the ER for increasing levels of education and aggression. As the story goes as was he was put on haloperidol and old antipsychotic. Given somewhat aggressive and agitated so they put him on a little bit of medicine. One of the side effects of the medicine is [ Indiscernible ] which makes you feel very restless. You cannot sit still. You have a strange uncomfortable words to move around. And that's what happened to him. He started pacing more and getting more educated and of course what did the nursing home do? They give him more helpful. And she got worse. Now he cannot lay down. Pig on several days without sleeping and he would round up in the ER. We stopped the medicine and he got better. Keep in mind medicines can have strange effects you don't anticipate. Other events we see extrapyramidal systems. They get very stiff or slow down. It can also cause sedation or confusion or have cardiovascular effects with like everything or other heart problems. And the release an increased risk of death.

I will spend a lot of time talking about this complicated table. Other than the first column under the blue. All cause mortality. If you look about the different drugs in blue these are a range of commonly used antipsychotic medications. The take-home message is that all of them when we compared to people without these medications all of them have higher rates of death in the first 180 days after starting the medication. The first six months after starting this the risk of death goes up. What I want to emphasize is that for haloperidol has a much higher rate than we see the some of the newer medications. We can feel more confident that our newer medications are safer and that is true. But it's not that they have no risk at all. These medications do have dangers.

These medications for a long time or used as chemical restraints. For better or worse. We now have federal regulations about a week can do and how we should use them. By and large we should only use these medications if they exhibit symptoms of impaired functioning or put them causing danger or risk of danger to themselves or others or they somehow interfere with the vision of care. Simply being agitated is not a sufficient reason to use them. There needs to be something else. Are they aggressive? Is there a threat? Does interfere with their care? Are they psychotic or hallucinating? And the key thing is documenting. It's considered if you're not using them for the approved for and to document everything. And document everything else you've tried it if they are be aggressive agitated document the other things you've tried first now will only help your case if you get audited. And use requires an approved diagnosis and approved symptoms.

When should you not use them? There are many times people used use of the you should not. Wondering is a common one. Antipsychotics make people city but will not stop them from wondering. Looking at poor self-care or anxiety depression when it uncomplicated, fidgeting or nervousness, agitation when there is no danger. These are not sufficient causes according to the regulations. Allowable diagnoses are focused on cases where there is a psychotic symptom. Again the hallucinations or delusions. You see the schizophrenia and associated symptoms. Is the other psychotic episodes. It's allowable and Huntington's and practice order for specific neurologic instances where they might be helpful. And organic syndromes meeting dementia is a certain criteria are met. Will talk about those in a moment. I want to touch briefly on the antipsychotics are. The more common ones we see you start risperidone and others. The take-home message is to be aware of in providing care for people is that they are not those antipsychotic medications are not your friend. They caused some degree of weight gain. [ Indiscernible ] is one of the worst culprits for weight gain. They all cause sedation to some degree. [ Indiscernible ] is the common culprit for that. And other medication such as aripiprazole that are less sedating and have less weight gain. [ Indiscernible ] has less data and clozapine is a older agent and more effective antipsychotic medications behalf. It's particularly useful for people who have neurologic illnesses where they cannot tolerate other antipsychotics such as Parkinson's disease. They could worsen their Parkinson's symptoms. One key to show with that is it it's a complicated Nelson in his serious effects on our immune function. So when you start you have to monitor weekly to make sure their immune system is not shutting down. Once they've been on it for several weeks then you go to every other week. But involves a lot of monitoring.

If you have someone who is on these medications for a good cause -- city has schizophrenia or bipolar disorder. Or the dementia with aggression or with psychosis. We do have rules we have to have a gradual dose reduction every six months. The intent of the regulations is that you don't want someone to be put on these medicines and left on it forever when the might not need to be on it forever. We know that in dementia symptoms can fluctuate. Some of the very aggressive today but six months from now that might not be the case or not the case for everyone. Katie is that every six months you want to have a gradual reduction to see can they tolerate a lower dose or off the medicine? If you cannot you document it and go back to where you were before. That is a good rationale to continue on the medicine. You have to do this every six months unless the patient has one of the 10 approved conditions. Schizophrenia, dementia with psychosis or something in that range. If the diagnosis of organic medicine drum which is a broad diagnosis plus you try to do it in the past. They have diagnoses and we've done this a couple times and it's not gone well. We feel they need to continue on this indefinitely. In this case document document. Diagnosis, symptoms your targeting, the other diagnoses you considered and is there will for other risk benefits? If someone becomes very aggressive or highly psychotic when they are of the medicine, clearly the risk of staying on that is counterbalanced by the fact that when in the acute Allstate you cannot take good care of them or their behavior if there are the things you need to do for their safety or good treatment. That will work but documenting his key. That will only be your friend. The next point to make is that these medicines even when you think I don't want to the people of them. Why do we go through this? The reality is many people come off medicines anyway. A study was a number of years ago and this was done in schizophrenia. But they another arm of the study and people with Alzheimer's have had psychotic symptoms. The gist of the study was they were looking to say do any of the antipsychotic medicines we use help improve psychotic symptoms in this population in a large group let's and as you see be used a lot of medicines we been talking about. And a have a placebo so people did not get medicine. The short version is the study did not show any drug effect on any of the drugs. No drug was better than placebo. We were all surprised by this. But then if you stop and think we've seen plenty people we treat the have Alzheimer's or psychotic symptoms and are given these medicines and they don't response. So maybe we should not have been surprised.

This is looking at how you treat people and see what happens. When people come off the medications. This is up for up to 10 weeks at a time and you see people and their caregivers do they want to do after about 16 weeks, over 70% of people have stopped the medication. Why is that? A number of them stopped because it was not working. Yellow is a placebo arm. Unsurprisingly they stopped the medicine faster. The other antipsychotics -- over 40-50% stopped the medicines after 60 makes after they felt it was not helping. If a look at tolerability not many people stop the medicine because they had problems. But clearly 20%-30% stopped because they had side effects. We at these numbers up and people stop these medicines at high rates because they cannot tolerate them because it doesn't work. To me this captures the challenge in treating these behavioral disturbances in this population. It's not an easy job.

Let's go to the polling question. Antipsychotic medications are required to have a dose reduction and withdrawal plan in place. True or false?

Check your answer and make sure you hit submit.

We should have Jeopardy music.

More participants. Great. 60% of you said true which is correct. One of you said falls which is incorrect. And previous to do not answer. Let's see if we can get 100% participation by the end. The answer is true. When you start the medication they need to be done thoughtfully. We need to have a plan to say one those we're going to try to get the resident patient at the lowest possible dose or off of the medicine within a reasonable timeframe. I think you need to go with the this with open eyes. For some people that will work and they will be off the medicine other times it will not any to go back on but at least you had a plan and to answer the question do they need to continue on the medicine ask in that case the answer might be yes. But for others the answer is no and it's great to get them off of medicines that can have serious side effects and increased risk of mortality.

Let's talk about antidepressants and dementia. I would start with and on one. Most of us we use trazodone I think about with sleep. I use this in my younger adults and older adults. It's not a great antidepressant but a fantastic sleep aid it does not create dependence. No one ever got addicted. And it does a nice job. There's also a role for it in the treatment of behavioral disturbances. If you have anxiety related agitation or episodes every -- aggression or sleep disturbances or vocalizations they can be helpful. Trazodone has a large therapeutic range. When I use this with my younger patients I use 50-150 mg. In older adults particularly those of many -- memory impairments what start now. 25 mg is a good place to start. And you can use the PRN. This is an as needed medicine right before you know a time when they might get upset. So they get upset when it's time to assist with bathing give it to them beforehand and its moons that process out. It's a short half-life and does not stay in the system for long. And you can combine with other medicines including antipsychotic or other antidepressants. It's a medicine that is well tolerated with one exception people with serious part disease. If they have a lot of arrhythmia or heart disease this one a special higher doses can cause problems.

That is one medicine. There are many others. This is a commonly prescribed drug in many residential living facilities. As a whole they are effective in the treatment of depression and can be effective for anxiety. It can also be used for a host of other disturbances. Irritability is the most common one. Hostility, anxiety, and in some cases can help with vocalizations. Depression -- you know as well as I depression is a prominent problem in assisted care living facilities. And sometimes it doesn't do as good a job as we want. We can use it with an combination of antipsychotics and other cognitive enhancers. Antipsychotics there's been a change in the clinical practice over the last few years. Some of the newer atypical antipsychotics within talking about appear to have significant efficacy to help improve depression in people that don't do well with the usual antidepressants we start with. Start them on site telegram or [ Indiscernible ]. And they might get better but they aren't doing well. There is some hope for sleep medicines and aripiprazole is one approved by the FDA for treatment in depression. There is a role for this in many environments. There is new data they are safe and effective in older adults. But again be cautious and how you document it and why you're using and what the target is an you are using it for FDA improved -- approved indication. Documentation is critical. There is a role to say even when it does well is can they come off the medicine down the road and still do well? Often we think about antidepressant medicine they stay on long-term. In many cases they have to but there are some people that may improve on something like aripiprazole and maybe it makes sense to trail off the medicine like you would for any other indication. If depression returns you be on firm ground to say we did our best in return. Or start the medicine again for the indication. And I think would be on firm ground for use in those ways.

Antidepressants have risks. And this is something I want all of us to think about more. Recently serotonin medicines like fluoxetine [ Indiscernible ] were part of the beers criteria which is a list of medicines that should be avoided if possible in older adults. This was controversy oh in the psychiatry realm. It's really concerned about use of the serotonin drug but they associate with higher risk of falls or fractures. At the same time there some data showing that people older adults on antidepressants commensurately higher risk of stroke. These were both serious side effects. But the way I think about this is being acutely depressed is also serious. And they are not engaging in physical therapy or other activities or eating that will be too bad outcomes as well. Number to the criticism of the studies is they are comparing people on antidepressants to people off of antidepressants. Depression has a higher risk of stroke and if you are depressed does it lead to higher risk of falls and fractures? I don't have the answer to that. But what is related to the medicine is related to the underlying illness is the main question. The way I'm pragmatic about this. When I gives to my patients we talked about this being a risk. We also emphasized you are depressed and this is why we need this. And again I think these are risks we have to accept and be aware of. If we're in a residential setting if you are adding a new antidepressant be more vigilant and are they looking more risk of falls or pay more attention to that.

When we think about using it for agitation we talk about trazodone. And again the SSRI for irritability or vocalizations start using low-dose. Lower than you would expect. 12.550 Miller -- milligram dose for trazodone. The serotonin drugs which is a good one to start despite what I just told you. We start at one quarter-half the dose and go slow. Don't be afraid to go to higher doses. But definitely go slowly. Polling question. Antipsychotics should never be used to treat depression in the elderly. Two or false? -- True or false?

15 more seconds. Select your answer and hit submit.

Let's get 100%.

40% say true and 20% say falls. And 40% said no answer. Not as good as last time. Spoke the answer is true. But I think this is an area that is a moving target. The FDA indicated those indication for aripiprazole is in the grand scheme of things fairly new and is certainly newer than the guidelines for how we use antipsychotic medications. I think it's a reasonable thing to do with appropriate documentation. But certainly is not the first thing out of the gate to try. Try more conventional antidepressants and use those if they work then great. If they don't then you are on firm ground to lose something like aripiprazole according to the indication.

Let's talk about some other medicines and shift into some other issues that may complicate. Anticonvulsants. These are medicines that have been long used for treatment of bipolar disorder or manic-depressive illness. We talk about things like Depakote or [ Indiscernible ]. Lithium although is not anticonvulsants. And honestly the data of how we can use these medicines for behavioral disturbances that they just are not very good. Anecdotally when you talk to many of us would seem to put them beautifully on his medicines. The data support it. Some small trial supported efficacy and larger trials wasn't so sure. Anecdotally I've seen people who have done well on this medicine and benefit from it. Is not an antipsychotic to free yourself from the regulations. The dose you start at a low-dose twice a day. If someone is not compliant the liquid formulation and there are sprinkles to make it easier to take. This is a medicine you can measure blood levels in. If you're worried someone is not doing well check the blood level. Does look very low? Don't increase the dose because the blood level is low but go by how they are behaving and the symptoms you are targeting. But on the other hand if you say the medicine is not done much for them so far everything need a higher dose.

Here we use the this used for agitation and those resident or patients it seem like there always moving around or agitated or have higher low energy. Sleep might be an issue. Things you would expect to see in someone who is managed. Talking excessively or not sleep is much. We're trying to reduce symptoms and dementia patient that might nor will we see in someone with bipolar disorder in that case it might be reasonable to try.

This is controversy oh. Many of us hate [ Indiscernible ] but every so often we need to use them. It can be useful for short-term management when you see high anxiety or if you need rapid control of education. The media risk issue are escalating any something to help calm them down quickly. Use short acting agents like less of them or 1/4-1/2 dose. As best you can don't do this regularly. Regular use of this is problematic. Sedation being the most common side effect but it can also disinhibit people. You can make the problems worse. The easy way to think about this medicines is think about having a beer or two beers. Most of us if you had a beer and you're feeling tense are anxious you to better. Your anxiety lessons and you start smiling and feel better. You feel more relaxed. But then if you have two or three beers then you start doing things you later regret. And benzodiazepine are similar. A little dose might go a long way make you tired and sleepy. If you give them more and they are disinhibited and of a what don't want to go to bed. They want to stay up and do things. Be aware that a little bit goes a long way. It also has many risks. Think about what the Spirit do? Or any alcohol slows and reaction times and makes you stumble. Increases your risk of falling. Makes you more confused. It does all these things. And it if you fall as you know falls are bad. Hip fractures can be a death warrant for many patients.

Long-term use it use it chronically there's a longer-term risk of cognitive decline and you have to get them off of it. And so diazepam withdrawal is a serious medical issue. People are admitted to the hospital to wean them off of it. They can have withdrawal symptoms. It's a very serious thing to come off of.

We move from there into sleep aids. That's a slightly different message. Sleep aids by and large with the exception of trazodone have some of the same risks. Many of the sleep aids like Ambien that people have heard about work similarly to the benzodiazepine. We have concerned about risk of falls with this class of medicine. What interesting the sleep specialist have highlighted insomnia itself is associated with falling. And so I don't want to get into the gory details but looking at the number of people at variables related to falling over a lot of people and if you have insomnia in a supervised facility your risk of having a fall goes up. And actually using hypnotic or sedative it goes up as well but independent of insomnia. It seems to me and the sleep specialist will tell you that it's not so much taking a sleep aid as it is risk is being not sleeping. If you are not sleeping the risk goes up and what's that is if you're not sleeping and taking a sleep aid. That is a one-to punch. When this makes darn sure they stay asleep. Insomnia is not your friend and it makes sense. Lights are low things are dark. People are in baggy pajamas. We are less staffed at those times. Environment variables may play a role in contributing falls. Even without a sleep aid.

Medical issues. In control. Just because we develop memory does not mean we don't feel pain. Pain medicine have a negative effect on cognitive performance and memory. In many cases but also untreated pain can be a big issue in exacerbating behavioral disturbances. If any of us are hurting are we going to be a pleasant person? Now that. Would be more irritable and short tempered. People with dementia are no different. It can produce irritability or agitation. A study cannot that routine prophylactic Tylenol use which I don't know if I would recommend but it can result in improved social interaction. And if you think about people might not have a good history of chronic pain and the undertreated it makes sense to try increasing their pain regimen to say does his improved behavior? This was a study done a few years back looking at a stepwise more complicated payment protocol management and showing clearly that people who have their pain control their agitation levels go down. Again it's not getting to zero. The education does not all go away but it makes progress. And now rather treat that then put them onto antipsychotic and leave the pain untreated.

Constipation. This is only one of my favorite topics as I teach many people. It's amazing again this is not fun. It can cause pain and if you don't pay attention to it or lose track of it and people are the two psychiatric facilities for agitation or aggression and is and is they have a bowel movement to become the sweetest person in the world. Unfortunately we cause this. Many of the medicines we give can cause constipation. I encourage you I hate is a count the bowel movements but monitor and. If people go a few days without something in the they need to have something to help move things along. You might solve problems that way.

Finally let's touch briefly about delirium. To explain the brief definition is this is a change in people's mental status that can show up in their memory or behavior or anything as related to some medical problems somewhere else. Someone gets a urinary tract infection and becomes more confused. Or more agitated. It has an ammonia coming on and becomes more agitated or confused. Maybe their sleeping 20 hours a day rather than eight hours a day like they were. These can be hard to distinguish from dementia. I want to highlight a couple of key things. Dementia of course is a slow change. They don't just wake up one day and have poor memory. They don't wake up and are trying to beat up everyone they see. That is a delirium. A sudden acute change or acute onset. Another thing is how do the symptoms look? With delirium it fluctuates. You might see the dayshift says Mr. Jones looks great he's been hitting wonderfully. The night shift says it's a disaster. Is aggressive and confused. Again when you hear different shifts say we're seeing different things think about delirium. A dementia is going to be far more consistent. Confused in the morning and confused in the afternoon and evening.

Delirium has marked psychomotor changes. They become very agitated and moving around more. Can be hypoactive. There's all can be the confused with depression. They don't get out of bed. They don't interact with you a lot. A depression won't have quite such an acute onset. With dementia it's for solid you think about changes over months and not days. Again there are consciousness is altered. Consciousness is not affected in dementia. They are alert and maybe memory is just not as good as it was.

What you do with delirium is need to really say as we think about how to manage behavioral those behavior safely in the short term, was a medical issue causing it? And so as much seem to call a psychiatrist to help with delirium, call the Internet store other medicine provider to say we think there's something going on. We don't know what is causing the delirium and they might need a workup. To wrap this up and have a summary we have various classes of medicine and what they could be used for. Antidepressants for irritability or anxiety. Low nude. Antipsychotics for psychotic symptoms. Anticonvulsant maybe for some hyperactivity. And some things like irritability and aggression with a nice overlap. Keep in mind can be helpful for anxiety or well-timed use of the medicine for a trigger for the behavioral problem. Think about for analgesics. When do they seem restless? When they seem to be uncomfortable or in pain. And when you have the acetylcholinesterase inhibitors they can help memory and behavior as well. So think about if you're using multiple medicines was be rational about how we do it. Again to come back to the point I started with, these behavioral problems are the biggest problem we deal with in dementia. Start with the environment. What medical issues are going on? Is there something in the environment that's contributing? What can we do to change the behavior? Example I always use is as you all have seen people go back and forth from the hospital. God help you if you have a vision impairment or hearing impairments. What happens? They go from home to hospital or hospital to assisted care and go back to the hospital. If they have glasses or hearing aid they are gone. They can be lost.'s night have someone if you facility that cannot see well or cannot hear well and is think about a trigger that may trigger that behavior you can imagine if you cannot see well and all of a sudden your sleep uncomfortable and someone rushes in and turned on the light and gets you out of bed to eat or give you a bath. I don't know about you but I would be aggressive myself. And so it's worth thinking about can we even into what ever we need to help them with? Or are they though she did her glasses get lost? Is the battery dead in her hearing aid? Think about these things that could play a role if the behavior is changing. Once you put all that out then think about a pharmacologic intervention.

These medicines all have risks. Medicines have a role but we need to reevaluate their need. If people have been doing well for a while think about coming off. Reducing dosage is always important particularly with antipsychotics. And that's open up for other questions and a reminder is my colleague Dr. Newhouse will be giving this same talk tomorrow for anyone who's interested.

If you have questions send them to Britney in the check panel. If you have other people at your facility so you would like to get to this presentation the date and time for tomorrow is 10 AM Eastern time -- 10 AM central time. 11 Eastern time. And give the date for session number four. To spend time today talking about documentation and trying nonpharmacologic approaches first. Next month we will dive into that and have an geriatrician and geriatric nurse practitioner to teach you how to document and try different approaches.

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What are your thoughts on how goal for end-of-life care?

I think haloperidol is an older medicine and it's still for acute aggression. It's one of the standards often used. Often when you see emergency titrate dose psychiatry or out of control aggression, that might be an easy quick medicine to use to calm people down quickly. I think in my opinion many physicians are comfortable with it. It's more affordable than some of the newer medicines but it does have risks. There's a greater risk of even end-of-life talk about this. And we're not worried about the longer-term risk of slowing down at the same time I'm leery of getting medicine that may hasten mortality so to speak. And that is a risk of all the antipsychotics but held all seems to be a worse offender. I have mixed feelings. If it's something where your treating psychotic symptoms or long-standing problems I recommend a new agent that is foreign aggression it really is end-of-life taking it's probably okay but it's not my favorite. I it's not the best answer but it does have a role but the more anchors people to shift to the newer agents because they are better tolerated and the mortality risk is lower.

Thank you.

You're welcome.

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Here is my contact information and Britney contact information as well as our project website address. If you have a question for our presenters after today please don't hesitate to contact us. We're more than happy to answer your questions. If you have no more questions and you have completed your evaluation questions we hope to see you back in session 4 in January. We will have an geriatrician and geriatric. -- Nurse practitioner to delve into the nonpharmacologic approaches and how to document what you have tried and what has worked and what is not working. [ Event Concluded ]