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Pharmacological Management of Behavioral Problems

Pharmacological Management of Behavioral Problems. Should I give a medication…. Or just take one myself?. Dr. Gordon Thomas Geriatric Psychiatrist Royal Ottawa Mental Health Centre. Psychotropic drugs Part of the overall approach. Psychotropic:

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Pharmacological Management of Behavioral Problems

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  1. Pharmacological Management of Behavioral Problems Should I give a medication… Or just take one myself? Dr. Gordon Thomas Geriatric Psychiatrist Royal Ottawa Mental Health Centre

  2. Psychotropic drugs Part of the overall approach • Psychotropic: • Any drug capable of affecting the mind, emotions, and behavior • Examples • Antidepressants • Antipsychotics • Anxiolytics/Sedatives • Mood stabilizers • Cognitive stabilizers

  3. Psychotropic drugs Part of the overall approach Behaviors that Do Not respond to Medication: • Wandering / pacing • Exit-seeking • Sundowning • Hoarding • Rummaging • Resistance to care • Sexual disinhibition • Inappropriate dressing/disrobing • Inappropriate voiding/defecation • Swearing • Screaming/repetitive vocalizations • Spitting

  4. Psychotropic drugs Part of the overall approach Causes of behaviors that May respond to Medication: • Anxiety • Depression • Mania • Psychosis • Sleep disruption • Aggression • Frontal disinhibition • General medical illness • Infections • Medication side effects • Delirium • Pain • Agitation

  5. How the body handles drugs: Pharmacokinetics

  6. Psychotropic drugs Use in the Elderly • Changes in how the body handles drugs • Absorption • Distribution • Metabolism • Elimination

  7. Psychotropic drugs Use in the Elderly • Absorption • Slower in elderly patients • Decreased motility and gastric pH • No clinical significance without overt disease • Can be delayed by other medications • Antacids • Aluminum containing cathartics • Calcium/Magnesium • Fibre

  8. Psychotropic drugs Use in the Elderly • Distribution (fat / water / protein bound) • Higher fat:muscle and fat:water ratios • Lipid soluble medications stored and take longer to clear • Most psychotropics are lipid soluble • Lower protein (albumin) levels • Not clinically significant by itself • Multiple medications bind protein and may compete

  9. Psychotropic drugs Use in the Elderly • Metabolism • Phase I: oxidation before entering circulation • Decreased in elderly = more active drug in system • Phase II: conjugation/glucuronidation • Relatively unaffected • Other changes decrease this process • Reduced liver blood flow (40-45%) • Reduced liver mass • Some activate or deactivate the process • Decrease or increase levels of active drug

  10. Psychotropic drugs Use in the Elderly • Elimination • Decreased renal function with age • GFR decreases yearly from age 20 • Calculated CrCl needed (eGFR is inaccurate) • Decreased response to volume changes • More likely to have abnormal electrolytes (SIADH)

  11. Psychotropic drugs Use in the Elderly • Illnesses alter handling of drugs • Gastric surgery • Heart failure • Liver disease • Renal disease • Malnutrition

  12. How the drugs affect the body: Pharmacodynamics

  13. Psychotropic drugs Use in the Elderly • Changes in how drugs affect the body • Increased sensitivity • Changes in receptor density • Decreased responsiveness of regulatory systems • Direct sensitivities (stroke, Parkinson’s, dementia)

  14. Psychotropic drugs Use in the Elderly • Different approach to using medications • “Start low and go slow” • Overall therapeutic dose often unchanged • Longer time to get a clinical response • Can be toxic at “therapeutic levels” • More vulnerable to some side effects

  15. The happy pill… Antidepressants

  16. Psychotropic drugs Antidepressants • Antidepressant usage • Depression treatment/prevention • Anxiety • Sleep disruption • Agitation • Frontal symptoms / Behaviors • Pain control

  17. Psychotropic drugs Antidepressants • SSRI (Selective Serotonin Reuptake Inhibitor) • Celexa (citalopram): few drug interactions • Cipralex (escitalopram): few drug interactions • Zoloft (sertraline): minor interactions • Luvox (fluvoxamine): more interactions, sedating • Effective and well tolerated • Depression/anxiety, agitation, behaviors • Prozac (fluoxetine): half-life too long • Paxil (paroxetine): too anticholinergic

  18. Psychotropic drugs Antidepressants • SNRI (Serotonin Noradrenaline Reuptake Inhibitor) • Effexor (venlafaxine) • Cymbalta (duloxetine) • Effective and well tolerated • Depression/anxiety, (behaviors) • Neuropathic pain • Nociceptive pain (new indication)

  19. Psychotropic drugs Antidepressants • NaSSA (Noradrenergic and Selective Serotinergic Antidepressant) • Remeron (mirtazapine) • Effective and well tolerated • Depression/anxiety, sleep disturbance, appetite • (behavior), (pain)

  20. Psychotropic drugs Antidepressants • NDRI (Norepinephrine-Dopamine Reuptake Inhibitor) • Wellbutrin (bupropion) • Effective and well tolerated • Depression • May worsen anxiety

  21. Psychotropic drugs Antidepressants • TCA (Tri-Cyclic Antidepressant) • Nortriptyline, Desipramine • Amitriptyline, Imipramine • Effective but poorly tolerated • Cardiac effects (hypotension, tachycardia) • Increased fall risk • Anticholinergic effects • Dry mouth, confusion, constipation, confusion, urinary retention, confusion, blurred vision, confusion

  22. Psychotropic drugs Antidepressants • MAOI (MonoAmine Oxidase Inhibitor) • Parnate, Nardil • Poorly tolerated due to need for diet (yuck!) • Mannerix (Moclobemide) • No need for diet • Less effective and poorly studied in elderly

  23. Psychotropic drugs Antidepressants • Trazodone • Not used for depression (need high doses) • Used at low doses • Sleep initiation • Anxiety • Agitation • Frontal symptoms

  24. Psychotropic drugs Antidepressants

  25. Psychotropic drugs Antidepressants

  26. Psychotropic drugs Antidepressants • Common questions • When should the dose increase? • When should the drug stop? • How long does it take to work? • What if it doesn’t work? • What other options are there? • What about ECT?

  27. Psychotropic drugs Antidepressants • Common Uses • Depression and Anxiety • Pain (Effexor & Cymbalta) • Sleep (Remeron & Trazodone) • Frontal Disinhibition • Smoking Cessation (Wellbutrin)

  28. The crazy pill… Antipsychotics

  29. Psychotropic drugs Antipsychotics • Antipsychotic usage • Schizophrenia / Delusional disorders • Psychotic depression • Delirium • Dementia with behavioral problems These are not first choice medications

  30. Psychotropic drugs Antipsychotics • Atypicals (newer medications) • Risperidone (Risperdal) • Olanzapine (Zyprexa) • Seroquel (Quetiapine) • Zeldox (Ziprazidone) • Abilify (Aripiprazole) • Fewer side effects than older medications • Still need to be used cautiously • Sedation, weight gain, risk of falls, risk of stroke • Small increase in mortality

  31. Psychotropic drugs Antipsychotics • Typicals (older drugs) • Haldol, Perphenazine, Nozinan, Loxapine, Chlorpromazine, others… • More side effects, higher risks • Parkinsonian symptoms • Tremor, rigidity, bradykinesia, restlessness, falls • Cognitive blunting • Tardive dyskinesia • Increased mortality

  32. Psychotropic drugs Antipsychotics

  33. Psychotropic drugs Antipsychotics • Common questions • When should the dose increase? • When should the drug stop? • How long does it take to work? • What if it doesn’t work? • What other options are there? • When should they not be used?

  34. The sleepy pill… Anxiolytic / sedative hypnotics

  35. Psychotropic drugsAnxiolytics • Anxiolytics / Sedative Hypnotic use • Use is controversial in elderly patients • Sleep • Anxiety • Behavioral management • Alcohol withdrawal

  36. Psychotropic drugsAnxiolytics • Benzodiazepines • Alprazolam (Xanax) • Diazepam (Valium) • Flurazepam (Dalmane) • Clonazepam (Rivotril) • Non-benzodiazepines • Zopiclone (Imovane) • Zolpidem (Ambien) • Zaleplon (Starnoc) • Lorazepam (Ativan) • Oxazepam (Serax) • Temazepam (Restoril)

  37. Psychotropic drugsAnxiolytics • Side effects • Drowsiness / fatigue • Memory impairment / confusion • Chronic use can meet criteria for dementia • Weakness • Incoordination / ataxia • Depression • Disinhibition / behavior problems • Paradoxial reactions • Decreased sleep quality and worsened apnea • Tolerance and withdrawal symptoms • Elderly (especially with dementia) are more sensitive

  38. The steady pill… Mood stabilizers

  39. Psychotropic drugs Mood Stabilizers • Mood stabilizer use • Bipolar disorder (mania & depression) • Augmentation of antidepressants

  40. Psychotropic drugs Mood Stabilizers • Lithium • Effective for mania and depression • Effective in lower doses for augmentation • Water soluble and cleared by kidneys • Serum levels must be monitored • 0.4 – 0.7 mmol/L (not 0.8 – 1.5 mmol/L) • Lower levels for augmentation (0.3 - 0.6 mmol/L)

  41. Psychotropic drugs Mood Stabilizers • Lithium side effects • nausea, anorexia, diarrhoea,vomiting • weight gain, sedation • subjective memory loss and slowing • tremor, parkinsonism, ataxia • High serum levels are toxic • Increased side effects, delirium • Hold and check level if losing fluid

  42. Psychotropic drugs Mood Stabilizers • Anticonvulsants • Valproic acid (Epival) • GI upset, somnolence, alopecia, tremor, weakness, increased liver enzymes, gait instability • Lamotragine (Lamictal) • Gabapentin (Neurontin) • Carbamazepine (Tegretol) • some evidence of cognitive impairment caused by these drugs

  43. The memory pill… Cognitive stabilizers

  44. Psychotropic drugs Cognitive Stabilizers • Cognitive Stabilizer use • Stabilizers not Enhancers • Preservation of Abilities • Management of Behaviors • Stabilization of Cognitive function • Decrease caregiver time • Delay Entry into LTC setting

  45. Psychotropic drugs Cognitive Stabilizers • Cholinergic agents • Aricept (donepezil) • Reminyl (galantamine) • Exelon (rivastigmine) • Effective for Mild to Severe dementias • Stabilize cognition for 1-2 years • Still some benefits even when decline resumes

  46. Psychotropic drugs Cognitive Stabilizers • Cholinergic agents • Side Effects (MIND) • Muscle cramps • Insomnia / nightmares • Nausea *** • Diarrhea • Caution with: • COPD, heart block, seizures, ulcers

  47. Psychotropic drugs Cognitive Stabilizers • Glutaminergic agents • Ebixa (memantine) • Effective for Moderate to Severe dementias • Stabilize cognition for 1-2 years • Small number have some improvement • Small number get more confused • Not covered by ODB ($120 per month)

  48. Psychotropic drugs Cognitive Stabilizers • Glutaminergic agents • Side Effects (CHECK) • Confusion • Headache • Equilibrium (dizziness) • Constipation • Kidney function • Dosage depends on CrCl (eGFR is not adequate)

  49. Psychotropic drugs Cognitive Stabilizers • Who might benefit? • Alzheimer’s dementia • Vascular dementia • Mixed Dementia • Lewy-Body Dementia • Other neuropsychiatric disorders • i.e. Parkinsons-related Dementia Fronto-temporal dementia can get worse

  50. Psychotropic drugs Cognitive Stabilizers

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