Risperidone and Alzheimer's

[ShetlandTony]

Hi all

My dad has advanced Alzheimers and recently has become increasingly violent towards my mum who is his primary carer. He's also tried to hit me and my husband. He can't speak or really understand much so it is a struggle to calm him down and reasoning with him is impossible sadly.The local mental health team prescribed him risperidone which is apparently good for these situations. Unfortunately my dad refuses to take the pills sometimes. If he doesn't take his medication there is a real danger he will have to go into care when neither he or my mum want this.

So to my question - I have read that there is a long lasting (weeks) injectable form of risperidone licensed for use in schizophreniacs. Does anyone have any experience of this being given to dementia patients? I feel that if he could be given one does every couple of weeks it might help him and my mum do better if the aggression were less of a problem.

All advice appreciated.
XXX

My MIL has vascular dementia and due to worsening aggressive behaviour is under DOLS in a dementia care home. They were going to prescribe risperidone which is an anti-psychotic drug I believe however she has potential heart problems - they have to do an ECG before they prescribe it so she has not been put on it. Her behaviour is increasingly unstable so they are trying to get her meds right.

I’m a MH nurse. Yes, you’re technically correct that antipsychotics come in an injectable format; this is known as a depot. However, the use of depots in adults with dementia is not normally recommended for several reasons. Firstly, the use of antipsychotics in general in dementia is associated with an increased risk of stroke and kidney/heart failure, with the chance of death of individuals with dementia being about twice as likely when prescribed antipsychotics as when not, and this risk increases further when injected. Secondly, once a drug is inside someone you can’t take it out and antipsychotics aren’t compatible with some medications that might be given in an emergency situation. Thirdly, you underestimate the lack of dignity and pain associated with injected antipsychotics. The drugs are thick and sticky and have to be injected into a muscle. This means that the needle used is long and thick and it can take a good minute or two to go in. This hurts, even with good injection technique, and, to top it all off, the muscle normally used is the buttock, especially in someone frail, as you need a large muscle for it to go into.
Honestly, if you have any other option it’s not a good idea. I do understood your worry and frustration though. Have you tried covert medication? Risperidone comes in a liquid format that can be mixed with yogurt or the pills can be crushed if need be. It’s not ideal, but better than a depot.

I would suggest that a specialist dementia care home might be the best solution

He may need to be sectioned to a dementia psychiatric ward. It sounds drastic but for a family friend in the same situation it was the best option. And the nhs covers the "continuing care" costs, ie no arguments about care home fees.

They can make a best interest decision to administer medication covertly, but I only know of this happening in nursing homes.

Medication can be given covertly in the home as long as this is in the care plan, post capacity assessment and best interests meeting. A dementia care home or sectioning (!) should only happen if really necessary and not due to medication alone.

www.nice.org.uk/guidance/NG67/chapter/Recommendations#giving-medicines-to-people-without-their-knowledge-covert-administration

The dose used in dementia is a fraction of that used for schizophrenia so the depot injection will be way way too high a dose. Not a go-er I'm afraid

As someone already said the usual solution in this situation is covert medication by putting the liquid version in a drink. Or ye olde risperidone laced Jaffa Cake is a good one. Put the tablet inside the jam bit and the taste is strong enough to conceal it and they usually eat it because who doesn't like a Jaffa Cake.

You should talk to the medication prescriber before doing any of this though to check they think it is OK to do as obviously it would be unethical to do this to someone with capacity so it would need to be agreed he lacked capacity and covert meds are in his best interests

Not necessarily true I'm afraid

If someone is detained under S3 (6 month detention) then their aftercare costs will indeed be covered under S117 MHA BUT this is a very rare scenario

Very few people with dementia meet criteria for detention under MHA at all and those who do will be under S2 MHA (28 days) initially which does not come with an after care entitlement. Only if they were still in hospital and still meeting criteria for MHA after a month would S3 be considered.

NHS continuing care is a separate funding stream that is always assessed for when someone goes into care but is very rarely awarded outside of a palliative care situation

On top of that, while we try our best, dementia psychiatric wards are often not nice places. They're designed to keep people safe and, by necessity, the people looked after there are very poorly so they can be institutional, loud and are really not very homelike.
@ThePure just for interest, if someone is tolerating 1mg a day of oral risperidone they should be able to tolerate a 25mg risperdal consta depot. If they're on less than that, you can give 12.5mg. It's just not usually recommended for the above reasons.

I thought 2-4mg was the oral equivalent of 25mg Risperdal Consta whereas 1mg would be the max dementia dose and I did not think you could give 12.5mg of Consta? It would be very wasteful and inaccurate as you'd have to discard half and it's not a licensed dose.

Academic really. I have never heard of someone with dementia being given a depot (unless maybe they were already having it for a psychotic illness). I always assumed the main reason would be that they would lack capacity to consent and it would distressing and hard to justify restraint for this legally under MCA.

Thanks everyone for your comments. I hadn't realised it would involve a massive needle in the bum.

My mum has tried covert dosing to an extent but nowdays he just grazes on food and drink and rarely finishes anything so that can be a problem. We've not tried Jaffa cakes though!

It's an awful situation and I'm sorry for anyone else also going through this.

@ShetlandTony Yes, it is horrible and I’m so sorry you’re going through it. Have you tried the liquid format? You can get it in 1mg/ml dosages so they only have to consume 1ml of liquid to get the full dose. Mix it into a bit of squash and it should go in.

@ThePure We do at my work sometimes, but generally only under the MHA. The dosage thing is a bit complicated. The manufacturer says that people tolerating less than 3mg a day oral can be given 25mg IM every 2 weeks. In general, 1mg a day well tolerated is fine but you do get issues with over sedation. The manufacturer also recommends the 12.5mg dose and they do also make 12.5 mg vials of risperdal but they’re a bit of a pain to get hold of, otherwise it’s 1ml of solution made up- which as you said is expensive and wasteful. It’s also not fully licensed but risperidone is only licensed for BPSD for 6 weeks so most risperidone scripts for dementia are off license. It is largely academic, you’re right. I only really advocate for it in the most extreme of situations.