A DOCS Education member writes:
This female patient is 67 years old. She is being treated for anxiety, cardio protection, hypertension, depression, ulcers and cholesterol levels. I believe she would be categorized as ASA II.
Her meds are: alprazolam, aspirin, atenolol+chlorthalidone, citalopram, omeprazole, pravastatin, and calcium carbonate with Vitamin D, Vitamin E, Fish Oil, Flaxseed Oil and Vitamin C. All meds are classified B or C interaction per LexicompÂâ„¢ with DOCS Education protocol drugs. The patient has an allergy to Sulfa meds.
She wishes to be sedated for a single crown appointment which could last approximately two hours. I am planning on prescribing the appropriate depressant level of dosing for the elderly/debilitated on CNS depressants using Protocol 1.
When patients are on medications for anxiety and depression, I think twice about adding additional medcations due to increased respiratory depression. I think, "dose low and slow.†I see that you instruct that patients may "hyporespond" and need more sedation meds. Could you explain further on this topic? I know you may not be able to generalize, but should these situations cause any red flag other than the reduced dosage protocol?
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
We approach patients on multiple CNS depressants cautiously due to the potential for additive CNS depression, but also with the practical reality that they almost always need higher total doses and longer time to become sedated due to tolerance they have developed.
We accomplish this by reducing their out-of-the-office doses and dosing low and slow to effect while in the office. (If using a single dose protocol we dose according to assessment).
In this patient I would cut the normal night before dose in half (2.5 mg diazepam), or eliminate it altogether if the patient is taking her anti-anxiety medication at bedtime. The loading dose on the day of the appointment would also be cut in half (eg. 0.125 mg triazolam). The initial assessment dose would be based on assessment of the patient at time of arrival.
A DOCS Education member writes:
If the medication is taken in the morning normally, do I also consider skipping the diazepam, keep the 0.125 triazolam and reassess?
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
Diazepam the night before is skipped only if the patient is taking three or more CNS depressants during a 24-hour period; the patient is taking other medication at bedtime to sleep; or if they work/drive the morning of an afternoon appointment.
