Title: Psychotropic Medications
1Psychotropic Medications
- Broad term encompassing any medication used to
influence mood, mental status or behavior - CMS guidelines break them into four categories
- Anti-psychotics
- Anti-anxiety agents
- Hypnotics
- Antidepressants
- Additional important categories
- Cognitive enhancers
- Mood stabilizers
2QI Domains And Psychoactive Medications
Skin Care
Accidents
Quality of Life
Behavioral/Emotional Problems
QI Domains
Psychotropic Drug Use
Clinical Management
Physical/ Functioning
Cognitive Patterns
Elimination/ Incontinence
Nutrition/Eating
Infection Control
3Paradigm for Comprehensive Assessment
- Dementia
- Frontal lobe impairment
- Delirium
- Medical illness
- Psychotic disorder
- Affective disorder
- Anxiety disorder
- Personality disorder
- Environment/stressors
Cognitive enhancers
Mood Stabilizers
Antipsychotics
Antidepressants
Anxiolytics
4Acetylcholinesterase Inhibitors (AChI)
- Aricept (donepezil)
- Start 5 mg qhs x 4 6 wks, then Increase to 10
mg qhs - Exelon (rivastigmine)
- Start 1.5 mg bid w/ meals x 2 - 4 wks
- Target dose 6 mg bid, titrate 1.5 mg q 2 - 4
weeks - Reminyl (galantamine)
- Start 4 mg bid
- Target dose is 24 mg qd
- Titrate by 4 mg bid increase q 4 weeks
Treatment goal is to titrate to the highest dose
tolerated
5ACHI Treatment Effects
- Initial improvement may be seen _at_ 2 - 4 weeks
- At 26 wks Approximately 20 of mild/mod pts will
have significant cognitive improvement - Approximately 80 will remain above baseline for
function for 6-10 months - Cost vs benefit analysis ongoing
- Watch for significant sudden decline when stopped
- Initial data indicates delay in NH placement gt20
months in those with 4 years of donepezil use
6Memantine
- Marketed in Germany since 1982 for Organic Brain
Syndrome and spasticity - Approved as Namenda in October 2003 for moderate
to severe Alzheimers Disease - No significant food interaction, i.e., can be
administered without regard to meals - Interactions with highly protein-bound drugs
unlikely - No interactions with acetylcholinesterase
inhibitors
Slide courtesy of Schneider L. Geriatrics.
2003(Aug)Suppl
7Memantine Study Results
- Memantine treatment was associated with less
decline vs. placebo on - Global, CIBIC-plus
- Cognition, Severe Impairment Battery
- Function, ADCS-ADL outcome measures
- Patients switched from placebo to Memantine
showed significant improvement relative to
projected decline - Memantine treatment resulted in reductions in
caregiver time, institutionalisation rate and
total costs compared to the placebo group - Memantine was well-tolerated with dropout rates
and side effects rates similar or lower than
placebo
8Paradigm for Comprehensive Assessment
- Dementia
- Frontal lobe impairment
- Delirium
- Medical illness
- Psychotic disorder
- Affective disorder
- Anxiety disorder
- Personality disorder
- Environment/stressors
Cognitive enhancers
Mood Stabilizers
Antipsychotics
Antidepressants
Anxiolytics
9Frontal Lobe Impairment Pharmacologic Management
- Antipsychotics
- Conventionals
- Atypicals
- Risperidone
- Olanzapine
- Quetiapine
- Ziprasidone
- Aripiprazole
- Mood stabilizers
- Carbamazepine
- Divalproex sodium
- Lithium
- Topiramate
- Gabepentin
- Benzodiazepines
10Mood Stabilizers
- These pathways transmit gamma-aminobutyric acid
(GABA). - Lower levels of GABA associated with aggressive
animal behavior. - NH study of 56 agitated elderly patients given
Carbamazepine had significant improvement in
agitation and decreased staff time needed. - Newer anticonvulsants advantageous due to
improved side effect profile but have few good
clinical studies
11Mood Stabilizers
carbamazepine (Tegretol) divalproex sodium
(Depakote)gabapentin (Neurontin)lithium (Lith
ium)topiramate (Topimax)
12Mood Stabilizers
- Their role is uncertain at present
- No need to monitor serum/blood levels for
Lamictal or Topimax - Behavior effects can be seen at low serum levels
- The role of multiple mood stabilizers
concurrently remains uncertain - Documentation on the working diagnosis and
monitoring of benefits and side effects remains
important
13Divalproex Study in Dementia
- Randomized, double-blind, placebo-controlled
trial1 - N172 NH residents met criteria for secondary
mania - Target dose 20 mg/kg/day in 10 days
- N100 completers
- Statistically significant improvement on CMAI
score - Consistent with antiagitation, not antimanic
effects - Study suspended due to side effects (sedation)
- Follow-up indicated with lower doses/slower
titration
1. Tariot et al, 2000
14Divalproex in Elderly Mania / Dementia
Cohen-Mansfield Agitation Inventory (Total Scores)
Mean Change from Baseline
(SE2.72)
(SE2.65)
0
7
14
21
28
35
42
Days
plt0.05 for group differences
Tariot et al, 2001
15Valproate Summary
- Clinical effects similar to Carbamazepine
- risk of drug interaction
- SE profile
- More definitive controlled trial underway
- Current clinically recommendations
- Initial dose 125-250 mg bid with 125-250 q 5d
- Usual range 500 - 1,250 mg/d
- Usual level 40-90 µg/ml
- Clinical response more important than serum level
16Paradigm for Comprehensive Assessment
- Dementia
- Frontal lobe impairment
- Delirium
- Medical illness
- Psychotic disorder
- Affective disorder
- Anxiety disorder
- Personality disorder
- Environment/stressors
Cognitive enhancers
Mood Stabilizers
Antipsychotics
Antidepressants
Anxiolytics
17OBRA Guidelines Antipsychotics
- Use only if patients exhibit symptoms that impair
functioning or cause danger to themselves or
others, and/or interfere with provision of care - Agitated behavior is an insufficient reason to
use an antipsychotic medication (i.e. must be
psychotic or aggressive) - Considered unnecessary if initiated as treatment
in the absence of documentation of the approved
indications - Use requires approved diagnosis and symptoms
Stoudemire A. Gen Hosp Psych. 19961877-94 The
Long Term Care Survey.ACHA
18Accepted Diagnosis for Antipsychotic Use in LTC
- Schizophrenia
- Schizo-affective Disorder
- Delusional Disorder
- Psychotic Mood Disorder
- Acute Psychotic Episodes
- Brief Reactive Psychosis
- Schizophreniform Disorder
- Atypical Psychosis
- Tourettes Disorder
- Huntingtons Disease
- 11. Organic Mental Syndromes IF certain criteria
are met
19Treatment with Antipsychotics Requires
- Quantitative and Objective Documentation that
- The behavior requires intervention
- You determined if the behavior is permanent or
transitory - The behavior has been evaluated for possible
social or situational causes - Environmental causes have been ruled out
- Medical causes have been ruled out
- The symptoms are persistant
- Not caused by preventable reasons
20Treatment with Antipsychotics Requires
- Organic Mental Syndromes with associated
psychotic and/or agitated behaviors defined by - Specific Behaviors (biting, kicking, extreme
fear, etc) that have been quantified AND present
a danger to themselves or others (including
staff) - Continuous crying out, screaming or pacing if
quantified and cause a functional impairment or
actually interfere with the staffs ability to
provide care - Psychotic symptoms (AH, VH, PI, delusions) that
are not dangerous but cause distress or an
impairment in functional capacity
21Antipsychotics Should NOT be used if
- the following symptoms are the ONLY criteria
- Wandering
- Poor self-care
- Anxiety/Restlessness
- Impaired memory
- Uncomplicated Depression
- Unsociability
- Fidgeting
- Nervousness
- Uncooperativeness
- Agitation without any danger to resident or others
22Antipsychotic Medication Guidelines
- F-tag 330 Use only as necessary to treat a
specific condition as diagnosed documented in
the clinical record - F-tag 331 Gradual dose reductions behavioral
interventions, unless clinically contraindicated,
are required in an effort to discontinue these
drugs - Currently, only IM Zyprexa is approved by the FDA
for the treatment of acute agitation in dementia - Usually reserved for dangerous or very distressed
psychotic symptoms such as aggression, delusions
or hallucinations
23Antipsychotic Medication Guidelines
- The cause of the psychosis indicates the
treatment duration - For psychosis as a symptom of dementia,
stabilizing behavior may take as long as 12 weeks
and may require treatment for at least several
months and up to a year - For Schizophrenia, antipsychotic treatment is
lifelong although the dose may decrease with age - For Bipolar illness, antipsychotics are used
during acute mania or long term to prevent
relapse - For psychotic depression, antipsychotics are
typically needed for a few months in addition to
a longer term antidepressant - For delirium, antipsychotics are needed for a few
days to a few weeks (even after medical problem
is cleared)
24Antipsychotics
- Typicals
- Haldol (haloperidol )
- Thorazine (chlorpromazine)
- Many others
- Atypicals
- Clozaril (clozapine)
- Risperdal (risperidone)
- Zyprexa/Zydis (olanzapine)
- Seroquel (quetiapine)
- Geodon (ziprasidone)
- Abilify (aripiprazole)
25Atypical Antipsychotics and Increased Stroke Risk
- Data from four International studies revealed
increased incidence of CVA TIA in Risperidone
treated pts 1 - In 2003, the FDA changed the Risperdal label
warning that the use of Risperidone dementia
patients has an increased risk of stroke - Currently a similar label is pending for Zyprexa
- Perhaps increased stroke risk is a class effect
- Stroke risk should be included in the
risk/benefit assessment
1. Web site address http//www.hc-sc.gc.ca/hpb-dg
ps/therapeut/zfiles/english/advisory/industry/risp
erdal
26Antipsychotics Summary
- Atypicals are effective in the management of
psychosis in the elderly - In elders, atypicals offer improved safety and
tolerability compared with conventional agents - Differences in tolerability/side effect profiles
between atypicals impact treatment selection - It is critical to evaluate for Parkinsons
symptoms before choosing the atypical to avoid
worsening motor symptoms.
27Paradigm for Comprehensive Assessment
- Dementia
- Frontal lobe impairment
- Delirium
- Medical illness
- Psychotic disorder
- Affective disorder
- Anxiety disorder
- Personality disorder
- Environment/stressors
Cognitive enhancers
Mood Stabilizers
Antipsychotics
Antidepressants
Anxiolytics
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29Treatment of Major Depression
- There is no good reason for depression to ever
go untreated - Start low, go slow, but go!
- Strive for maximum recovery/function
- Compare GDS or Cornell
- Treat the sleep disturbance initially then change
to a prn after 2-3 wks - The dose that gets them well, keeps them well
- Continue for 6-12 months or perhaps even
lifelong?
30Common Antidepressants
- SSRIs
- Fluoxetine (Prozac)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
- Citalopram (Celexa)
- Escitalopram (Lexipro)
- SNRIs
- Bupropion (Wellbutrin)
- Mirtazapine (Remeron)
- Venlafaxine (Effexor)
- Trazodone (Desyrel)
- too sedating to treat depression
31Depression Therapy
- TCAs vs. SSRIs vs. SNRIs
- Select the drug based on target symptoms and the
side effects wanted, for example - Dep. anorexia mirtazapine
- Dep. lethargy activating antidepressant
- Dep. constipation sertraline
- Dep. psychosis - cymbiax
Insomnia can be effectively treated with the
addition of Trazodone, Ambien, or Sonata
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33Paradigm for Comprehensive Assessment
- Dementia
- Frontal lobe impairment
- Delirium
- Medical illness
- Psychotic disorder
- Affective disorder
- Anxiety disorder
- Personality disorder
- Environment/stressors
Cognitive enhancers
Mood Stabilizers
Antipsychotics
Antidepressants
Anxiolytics
34Anxiolytic Therapy Guidelines
- F-tag 329 Guidance to Surveyors
- Short-acting maximum doses indicated
- Behavioral monitoring charts needed
- Does not indicate how to monitor
- Gradual dose reduction al least twice within one
year before can conclude dose reduction is
clinically contraindicated per regulations
35Anxiolytic Therapy Guidelines
- Indications for use
- - other reasons for the distress have been
considered eliminated - - use results in maintenance/improvement of
residents functional status - - reduction must be attempted by 4 months
- - specific diagnoses (anxiety disorder, organic
mental syndromes, panic disorder, anxiety in
concert with another psychiatric disorders)
36lorazepam (Ativan) 0.25 2.0 mg /d
alprazolam (Xanax) 0.25 1.5 mg / d oxazepam
(Serax) 7.5 30 mg / d buspirone (BuSpar) 10
45 mg / d temazepam (Serax)klonzepam (Klonopi
n) 0.25 -3.0 mg / d
Anxiolytic
37Benzodiazepines
- Minimal efficacy data
- Sedating
- Further inhibit learning and memory
- Ataxic gait is episodic - difficult to assess
- Associated with falls
- Paradoxical disinhibition possible
- Avoid long acting benzodiazepines in the elderly
38Anxiety Disorder Treatment
- Short-acting benzodiazepines
- sedating, inhibit learning, increases fall risk
- Trazodone
- check orthostatic BP and Pulse
- Buspirone?
- If paranoid or psychotic component, consider
Atypicals - Consider antidepressants, may need empiric trial
39Insomnia - Hypnotics
- F-tag 329 Unnecessary drugs GTS
- Address sleep hygiene issues
- Daily dose 10 or more continuous days requires
documentation of necessity for maintenance or
improvement of functional status. - Maximum hypnotic dosages
- Dose reduction attempts at least 3 times within 6
mo. before declaring further reductions are
contraindicated.
40Insomnia Hypnotics - 2
- Trazodone 25-200 mg _at_hs
- Mirtazepine (Remeron) 7.5-45 mg _at_hs
- Short-acting benzodiazepine
- Zolpidem (Ambien) 5-10 mg _at_hs
- Zalepion (Sonata) 5-10 mg _at_hs
- Melatonin 3 mg _at_ 6 pm
41Remember, Psychotherapy Can Also Help Some
Residents
42Summary
- Distressed behaviors are only symptoms
- Unless urgent, a complete assessment to
determine/develop a working diagnoses should
guide the long term treatment approach. - Consider nonpharmacologic management in every
case. - Monitor treatment benefits MMSE, GDS, FAST,
Cornell dementia in depression scale, Behave AD,
Cohen Mansfield Agitation Inventory - Optimal care requires teamwork, education, and
respect.