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Drugs Contraindicated in Dementia

Drugs Contraindicated in Dementia. Joseph H. Flaherty, M.D. Division of Geriatric Medicine Saint Louis University Health Sciences Center St. Louis VA Medical Center GRECC. Downloaded from www.pharmacy123.blogfa.com. Drugs Contraindicated in Dementia: Propensity to Cause Mental Status Change.

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Drugs Contraindicated in Dementia

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  1. Drugs ContraindicatedinDementia Joseph H. Flaherty, M.D. Division of Geriatric Medicine Saint Louis University Health Sciences Center St. Louis VA Medical Center GRECC Downloaded from www.pharmacy123.blogfa.com

  2. Drugs ContraindicatedinDementia:Propensity to Cause Mental Status Change

  3. Drugs Contraindicated in Dementia:Propensity to cause mental status change • Attitude: High index of suspicion • Skills: a. Awareness of “at risk” patients b. Identify subtle mental status changes • Knowledge: specific categories/drugs

  4. Attitude ANY* DRUGcan causeMental Status Change Refs: “Almost any” Lipowski ZJ, NEJM 1989; “Virtually any” Carter GL, Drug Safety 1996

  5. Skills CNS Vulnerability in Medically Ill Persons Alzheimer’s Dementia Cholinergic System* Vascular Dementia Circulation Parkinson’s Dopaminergic & Cholinergic *Noradrenergic & Serotonergic systems may play role here too.

  6. Skills PHARMACOKINETICS (moving the drug through) Medically Ill Persons Postgastrectomy, Malabsorption CHF, Dehydration, Malnutrition Renal or Hepatic Insufficiency

  7. Skills Curve of Life “EAMA student” Functional Capacity Functional Capacity 80 y/o NH resident with dementia Function Dys-Function Age……Disease Process ---->>>>> Age……Disease Process ---->>>>>

  8. Knowledge ANTICHOLINERGICS #1 DELIRIUM

  9. Knowledge The POWER of ANTICHOLINERGICS • 1% scopolamine eye drops • scopolamine transdermal patch Ref: Danielson et al. 1981, MacEwan et al. 1985

  10. Knowledge ACUTE CHANGE IN MS DRUGS THAT CAUSE DELIRIUM

  11. A CIM CHNS U A T N E G E DRUGS THAT CAN CAUSE A CHANGE IN MENTAL STATUS

  12. ACUTE CHANGE IN MS Antiparkinsonian Drugs • Levodopa, Bromocriptine, Amantadine • Up to 20% of pt.s • Most at risk: pt.s with cortical atrophy Refs: Cummings 1991; DeSmet et al. 1982

  13. ACUTE CHANGE IN MS CORTICOSTEROIDS • “Steroid psychosis” • Dose related • Up to 18% if >80 mg/day • Variety of MS changes: depressive/manic, paranoid/hallucinatory, confusion • Withdrawal may precipitate Refs:Ling PH, 1981, Glaser GH, 1953,VonArnim T 1976 (book), Dixon RB, 1980

  14. ACUTE CHANGE IN MS URINARY INCONTINENCE • Action: (-) muscarinic action of acetylcholine on smooth muscle, i.e. ANTICHOLINERGIC • Oxybutinin (DITROPAN*), Flavoxate (URISPAS) Retention=>Delirium Incontinence

  15. ACUTE CHANGE IN MS THEOPHYLLINE • “Theophylline madness” • Hyperactive periods with periods of withdrawal and mutism • May herald onset of seizures • Usually related to toxic levels Refs: Wasser WG 1981, Culberson CG 1979,Paloucek FP 1988

  16. ACUTE CHANGE IN MS EMPTYING DRUGS • Metoclopramide (REGLAN) • Antagonism of peripheral and central dopamine receptors (x-es BBB!) • Restlessness, drowsiness, depression, confusion Refs: Anderson H 1994, Bottner RK 1985, Fishbain DA 1987, Ritchie IH 1997

  17. ACUTE CHANGE IN MS CV DRUGS • Clonidine • Digoxin • Antiarrhythmics (PDQ) • Beta-blockers • Calcium Channel Blockers Refs: Hoffman & Ladogana 1981; Jacobson et al. 1987; Eisendrath & Sweeney 1987; Kuhr 1979; McGahan et al 1984.

  18. ACUTE CHANGE IN MS H2 BLOCKERS • Widely Prescribed => Increases Chances • Anticholinergic? • Physostigmine can reverse cimetidine induced delirium • Older persons with Renal Insuf. Refs: Jenike & Levy 1983, Schentag et al. 1979

  19. ACUTE CHANGE IN MS ANTIMICROBIALS • Mostly case reports • Ciprofloxacin, Sulfamethoxazole, Cephalosporins, Procaine PCN, Clarithromycin, Gent, Tobra, Strepto • Isoniazid • Acyclovir • Chloroquine, Quinacrine

  20. ACUTE CHANGE IN MS NARCOTICS • Acute users > Chronic users • e.g. hospitalized pt • Meperidine (DEMEROL) - metabolite normeperidine has anticholinergic effects • Tramadol (ULTRAM) - centrally acting pain med

  21. ACUTE CHANGE IN MS GEROPSYCHIATRY DRUGS • Act centrally >> risk • Mechanisms are not “pure” • TCAs vs SSRI’s • Anticholinergic vs hyponatremia, serotonin syndrome, interactions • BDZ’s

  22. ACUTE CHANGE IN MS ENT • Antivertigo medications • Meclizine (ANTIVERT), dimenhydrinate (DRAMAMINE) • AntihistaminIC action: STRONG • Anticholinergic action: WEAK, but present

  23. ACUTE CHANGE IN MS ENT • Cold/Sinus medications: ANY • Antihistamine “DANGER” • chlorpheniramine, astemizole • Decongestant “DANGER” • sympathomimetics: pseudoephedrine • Expectorant & Antitussive- probably okay • guaifenesin & dextromethorphan • COMBINATIONS “DANGER”

  24. ACUTE CHANGE IN MS INSOMNIA DRUGS • OTC may be worse than RX Antihistamine (Diphenhydramine) • “Anything”-PM • Withdrawal Insomnia (and daytime anxiety)

  25. ACUTE CHANGE IN MS NSAIDS • ANY • Most Risky: Protein Bound • Indomethacin: Don’t use in older persons

  26. ACUTE CHANGE IN MS MUSCLE RELAXANTS • Action: Centrally Acting Does not directly relax tense skeletal muscles. Through sedation => relaxes muscles Methacarbamol (ROBAXIN) Carisoprodol (SOMA) Chlorzoxazone (PARAFON FORTE)

  27. ACUTE CHANGE IN MS SEIZURE DRUGS • Related to serum levels • Protein bound? • Usually drowsiness, occasional agitation, depression, psychosis

  28. Drugs Contraindicated in Dementia:THoM • Attitude: High index of suspicion-> Almost ANY drug can cause MS changes • Skills: Curve of Life & awareness of subtle mental status changes • Knowledge: ACUTE CHANGE IN MS

  29. ANTIPARKINSON CV DRUGSINSOMNIAMUSCLE RELAX. CORTICOSTER. H2 BLOCKERSNSAIDS SEIZURE URIN INCONT ANTIBIOTICS THEOPHLLYINE NARCOTICS EMPTYING DRUGS GERO-PSYCH ENT DRUGS THAT CAN CAUSE A CHANGE IN MENTAL STATUS

  30. Why Older Persons So Susceptible to Psychiatric Side Effects Pharmacodynamics CNS Vulnerability Pharmacokinetics How the body Absorbs Distributes Metabolizes Excretes

  31. 2. How is it going to MOVE THROUGH my patient ? 1. How is it going to ACT on my patient ? Starting a New Drug

  32. ANXIETY • Caffeine • Inc. Sensitivity; May be in OTC’s • Sympathomimetics • i.e. most Cold/Sinus meds • e.g. SUDAFED, ENTEX, NEO-SYNEPHRINE • Withdrawal from: • Alcohol, Narcotics, Sedative-Hypnotics

  33. ANXIETY • Thyroxine • Antiparkinsonian (L-Dopa, Bromocriptine) • 10-15% will develop anxiety • Theophylline Ref: Cummings 1991

  34. DEPRESSION Reserpine Propranolol Methyldopa “...the rest of the story.” (Paul Harvey)

  35. DEPRESSION • Reserpine • Catecholamine depleting antihypertensive • 20% of pt.s • Generally resolves with discontinuation Ref: Goodwin & Bunney 1971

  36. DEPRESSION • Methyldopa • Antihypertensive, effective and inexpensive • metabolite a-methyl norepinephrine => potent a2-adrenergic agonist 3.6% (Only 1.1% warranted d/c of drug) Ref: Paykel et al. 1982. Reviewed 65 clinical trials, n=2,320 patients.

  37. DEPRESSION • Propranolol • B-adrenoreceptor antihypertensive • Lipophilic => crosses BBB • Atenolol • Less lipophilic => probably <1% 1.1% Ref: Paykel et al. 1982. Reviewed 65 clinical trials, n=2,320 patients.

  38. DEPRESSION 1.5% Clonidine Centrally acting a-agonist antihypertensive Ref: Paykel et al. 1982. Reviewed 65 clinical trials, n=2,320 patients.

  39. DEPRESSION • Digoxin • Even at therapeutic levels • Watch it: undernourished, dehydrated, or renally impaired older persons • H2 Blockers • Not just Cimetidine • Corticosteroids Refs: Pascualy & Veith 1989, Billings & Stein 1986, Billings et al. 1981

  40. C (Dig, PDQ) I (Dir. & Indir.) M (Frail Elderly) H (Usu. other MS) N (Indomethacin) S (Frail Elderly) A (Definitely: Dopa & Antichol) N (Possible) G (Of course) E (Dir. & Indir.) HALLUCINATIONS

  41. Risk Factors for Psychiatric Side Effects of Drugs • Age • More MEDs, more ADE’s • OTC users • Brain Dysfunction • Medical Illnesses

  42. Recommendations • Identify those at RISK • Remember: ANY drug can do it • Don’t add ‘til you TAKE AWAY • Don’t be afraid to TAKE AWAY

  43. GUIDELINES for Medication Reduction • JUST DO IT • Caution: Taper • Clonidine, B-blockers, Reserpine, Narcotics, BDZ’s, Corticosteroids, Barbituates • Careful but DO IT (esp if pt in hosp!) • Cardiac drugs (digitalis, antiarrhythmics) • Close follow-up! • Home care, social worker

  44. Drugs OTC >>> Rx 300,000* 65,000 *Includes different package sizes, dose strengths, and forms. Ref: 1995 PDR for Nonprescription Drugs

  45. OTC’s(Over the Counter Drugs) $13 Billion/Year in America Increases 8-10%/year Ref:1995 PDR for Nonprescription Drugs Note: Total Health Care Expenditures = $750 Billion in 1991

  46. Self-Medication with OTC’s Frequency % of Consumers Frequently 76% Occasionally 17% Rarely 4% Never 1% No Response 2% Ref: Gannon 1990.

  47. How People Treat Common Health Complaints with OTC’s Treatment 1982 1992 Treated with OTC 35% 38% Not treated 37% 30% Treated-Home remedy 14% 16% Treated-Previous Rx 11% 13% Sought Prof. help 9% 17% Ref: Heller Research Group. 1992. n=1500; average person suffered 6 probs/2 wk

  48. “ADE’s”ADVERSE DRUG EVENTS 2-3 x More Likely to Happen in Older Persons Ref:Vestal & Cusak 1990

  49. Hospital Admissions for “ADE’s” % Ref.s: Beard 1992, Col 1990, Nelson & O’Malley 1988. All Hosp. Age >65 Psych Adm’s Adm’s

  50. DELIRIUM: INSOMNIA DRUGS • OTC may be worse than RX Antihistamine (Diphenhydramine) • “Anything”-PM • Withdrawal Insomnia (and daytime anxiety)

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