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Psychotropic Medications

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Title: Managing The Why & When Author: Albert Riddle Last modified by: Jeann Jackson-Siegale Created Date: 2/9/2002 12:17:58 PM Document presentation format – PowerPoint PPT presentation

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Title: Psychotropic Medications


1
Psychotropic 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

2
QI 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
3
Paradigm 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
4
Acetylcholinesterase 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
5
ACHI 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

6
Memantine
  • 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
7
Memantine 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

8
Paradigm 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
9
Frontal Lobe Impairment Pharmacologic Management
  • Antipsychotics
  • Conventionals
  • Atypicals
  • Risperidone
  • Olanzapine
  • Quetiapine
  • Ziprasidone
  • Aripiprazole
  • Mood stabilizers
  • Carbamazepine
  • Divalproex sodium
  • Lithium
  • Topiramate
  • Gabepentin
  • Benzodiazepines

10
Mood 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

11
Mood Stabilizers
carbamazepine (Tegretol) divalproex sodium
(Depakote)gabapentin (Neurontin)lithium (Lith
ium)topiramate (Topimax)
12
Mood 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

13
Divalproex 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
14
Divalproex 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
15
Valproate 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

16
Paradigm 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
17
OBRA 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
18
Accepted 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

19
Treatment 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

20
Treatment 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

21
Antipsychotics 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

22
Antipsychotic 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

23
Antipsychotic 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)

24
Antipsychotics
  • Typicals
  • Haldol (haloperidol )
  • Thorazine (chlorpromazine)
  • Many others
  • Atypicals
  • Clozaril (clozapine)
  • Risperdal (risperidone)
  • Zyprexa/Zydis (olanzapine)
  • Seroquel (quetiapine)
  • Geodon (ziprasidone)
  • Abilify (aripiprazole)

25
Atypical 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
26
Antipsychotics 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.

27
Paradigm 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
28
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29
Treatment 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?

30
Common 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

31
Depression 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
32
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33
Paradigm 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
34
Anxiolytic 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

35
Anxiolytic 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)

36
lorazepam (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
37
Benzodiazepines
  • 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

38
Anxiety 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

39
Insomnia - 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.

40
Insomnia 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

41
Remember, Psychotherapy Can Also Help Some
Residents
42
Summary
  • 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.
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