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Psychotropic Drugs in the Elderly Treatment Considerations

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Psychotropic Drugs in the Elderly Treatment Considerations Psychotropic Drugs in the Elderly Treatment Considerations Sept 2011 Original May 2001, Updated October 2005 The RxFiles Academic Detailing Program Saskatoon City Hospital 701 Queen Street, Saskatoon, SK S7K 0M7 www.RxFiles.ca Saskatchewan residents over 65 years of age (16% of population) ANTIDEPRESSANTS: consume 47% of all prescription medications. The elderly are Caution: TCAs with high anticholinergic, sedative & hypotensive especially susceptible to drug-induced cognitive impairment effects (i.e. amitriptyline, imipramine, doxepin, trimipramine); if partly due to polypharmacy and renal/hepatic dysfunction. Pre- low doses of these TCAs used (for pain/sleep) monitor for existing cognitive problems make it difficult to detect the role of delirium, urinary retention, etc. drugs in causing new symptoms or making old ones worse.1 Nortriptyline or desipramine are suggested TCA options, with ♦See also additional RxFiles Psychotropic Comparison Charts! less anticholinergic effects (e.g. for pain/migraine control) Fewer drug interactions with citalopram & venlafaxine Common Reactions Agents & Comparisons ↓Sexual dysfunction with bupropion & moclobemide Anticholinergics Benztropine, chlorpheniramine, Discourage combinations of antidepressants & antipsychotics confusion, delirium, dicyclomine, diphenhydramine, ANTIPSYCHOTICS: memory impairment, hyoscine, oxybutynin, propantheline, obtundation, dry scopolamine, solifenacin, tolterodine, Caution: Antipsychotics with high anticholinergic effects (i.e. mouth & constipation trihexyphenidyl, trospium chlorpromazine at doses >30mg/day) Low-dose antipsychotics such as risperidone 0.25-2mg/day, Mood Stabilizers / ↓ Cognition possible; ↑ drug interactions; quetiapine 12.5-150mg/day, olanzapine 1.25-10mg/day & Antiepileptics (in general, aim for lower levels in elderly); haloperidol 0.25-2mg/day, may be reasonable choices for those delirium, confusion, Lithium poorly tolerated in some elderly; elderly in whom an antipsychotic is indicated. (Most weight gain, ↓ cognition & amnesia divalproex reasonably well tolerated ↑ glucose & ↑ lipid profile was with olanzapine CATIE 2005) 1. Anticholinergic highest activity with Antipsychotics BENZODIAZEPINES: delirium, confusion, chlorpromazine & clozapine; Minimize long-acting benzodiazepines (clorazepate, diazepam, neuroleptic malignant lowest with risperidone & quetiapine syndrome, 2. Sedation highest with clozapine*, flurazepam, chlordiazepoxide) due to ↑ fall risk & accumulation, anticholinergic effects, olanzapine, chlorpromazine & leading to over-sedation, cognitive impairment & confusion sedation, hypotension, methotrimeprazine; lowest with Avoid triazolam (Halcion) due to amnesic effects weight gain, diabetes, haloperidol & risperidone Minimize use of short-acting benzodiazepines for longer than 2-4 ↑ lipids, EPS 3. EPS side effects highest with haloperidol; weeks (temazepam, lorazepam & oxazepam) (extrapyramidal side lowest with clozapine* & quetiapine Consider mirtazapine, SSRI & venlafaxine rather than chronic effects) especially 4. Hypotension highest with benzodiazepines in treating elderly patients with anxiety parkinsonian & chlorpromazine & clozapine*; lowest When discontinuing, convert to a long-acting benzodiazepine tardive dyskinesia with haloperidol & olanzapine dose (i.e. diazepam or clonazepam (consider if benzo for anxiety) in equivalent 10-25%/wk, esp. slow last 25% Benzodiazepines doses), and then gradually taper over weeks or Clonazepam, Diazepam over several months cognitive impairment, Long-acting & high doses amnesia, excessive increase risk of toxicity OTHER TREATMENTS FOR INSOMNIA: sedation, lack of Lorazepam, Oxazepam Promote non-pharmacological sleep hygiene measures & rule coordination → falls, Short-acting increase risk out other contributing factors depression, pain; medications- steroids, of withdrawal but less accumulation in the acetylcholinesterase inhibitors, SSRI etc. disinhibition, elderly withdrawal syndrome Avoid antihistamine sedatives (i.e. diphenhydramine & with delirium, doxylamine), and barbiturates for treating insomnia hallucinations, caution Ultra short acting Triazolam can ↑ amnesia & if respiratory dysfx behavioural disturbances Some low-dose TCA's useful for sleep but tolerance in weeks May consider low-dose trazodone 25-50mg HS for elderly SSRI antidepressants SSRI: Fewer cognitive / anticholinergic patients with chronic “sundowning” or night-time agitated & venlafaxine side effects than with TCA's; dementia, to avoid anticholinergic side effects/dependence; falls, ↓ concentration, (weight loss may also be a particular problem ↓ tolerance & with fluoxetine in the elderly; potential also for zopiclone 3.75-5mg HS may be an additional option confusion, SIADH & withdrawal however dependency still a concern rarely EPS sexual dysfunction with any SSRI) Limited duration of sedative therapy recommended no more than 3-4wks TCA antidepressants 1 Anticholinergic & Sedation: most with delirium, confusion, amitriptyline, doxepin, imipramine; ANALGESICS: memory impairment least with desipramine, nortriptyline Avoid certain NSAIDs (indomethacin, ketorolac, mefenamic acid, 2 Hypotension with antidepressants: most piroxicam), meperidine, propoxyphene & pentazocine which are more likely to with trazodone; least with nortriptyline cause CNS related adverse effects DISCLAIMER: The content of this newsletter represents the research, experience and opinions of the authors and not those of the *note clozapine requires weekly CBC monitoring initially due to neutropenia; Board or Administration of Saskatoon Health Region (SHR). Neither the authors nor Saskatoon District Health nor any other party who has been involved in the preparation or publication of this work warrants or represents that the information contained herein is also associated with hypersalivation & high cost; seldom indicated in elderly accurate or complete, and they are not responsible for any errors or omissions or for the result obtained from the use of such information. Any use of the newsletter will imply acknowledgment of this disclaimer and release any responsibility of SHR, it employees, servants or agents. Readers are encouraged to confirm the information contained herein with other sources. 2011 1 Management of Behavioural & Psychological Symptoms of DEMENTIA (BPSD) Sep/11 75 Background: very common ≤90% in dementia; a major cause of distress to pts/families/caregivers; harm to self & others; huge cost e.g. institutionalization. -not just agitation but non-agitated Sx (apathy, withdrawal, daytime somnolence {circadian rhythm disturbances}, depression, disinhibition, etc.) Diagnosis: (Evaluate behaviour→ABC’s Antecedents (causes:Physical Intellectual Emotional Cultural Environmental Social), Behaviours & Consequences), Ö Assess history unique factors like Down’s Sx, physical exam, cognitive tests Feldman CMAJ’08 & nurse observations; collateral family info essential! Lab Tests: Recommend CBC, electrolytes, calcium, B12, glucose & TSH; Optional: BUN & SCr, ferritin, magnesium, LFTs, arterial blood gases, Young BMJ’07 ECG, CT/MRI if suggestion of structural lesion eg. renal failure, brain tumor, normal pressure hydrocephalus, subdural hemorrhage Eliminate delirium source – eg. meds eg. opiates, benzos, anticholinergics /withdrawal rxs/DI’s, dehydration & infections (if indicated: urinalysis/C&S, chest x-ray, lumbar puncture if suspicion of meningitis) Tx 1: Assess for and treat any comorbitities (eg. infection, pain, constipation, depression, psychosis} Tx 2: Explore environmental, exercise & behavioural measures Cope trial! Reserve drug therapy for situations where non- pharmacological interventions have been fully explored & implemented or in cases of significant danger. Specify problem behaviour (eg. "agitation" is less useful than "screaming", "hitting when bathed"). Identify what brings it on & what makes it go away. Identify whom the behaviour is bothering (pt, caregiver/staff or other pts). Human interactions eg. activiy, adequate staff eg. nursing home & proper environment most critical. Tx 3: Drug Treatment: consider if Sx having no physical cause, are unrelated to other drugs or unresponsive to non- Start Low, Go Slow! pharmacological interventions, generally start with 1/3 to 1/2 of usual adult dose & titrate up slowly; individualize dose Tx 4: Reevaluate drug regimen after 3 months; may attempt to taper/withdraw meds after 3 months of behavioural stability! MAJOR DEPRESSION PSYCHOSIS/AGITATION ANXIETY ↓ mood, apathy, amotivation delusions, hallucinations; agitation, aggression pacing, chanting, psychomotor agitation, etc. Mild→ non pharmacologic -use non-pharmacological intervention where possible! -use non-pharmacological intervention Psychosis:Positive Sx delusions, hallucinations or paranoia, -minimize provocation Moderate to severe→ Negative Sx poverty of thought, apathy, social withdrawal -consider antidepressant therapy if Agitation: aggression, shouting, ANTIDEPRESSANT Tx Start Low, Go Slow… anxiety is secondary to depression or very pacing, psychomotor chronic in nature Then Taper! Anxiety often coexists thus ANTIPSYCHOTIC Tx ANTIANXIETY Medication use antidepressants with -first designate target Sx (not wandering or mild Sx) - consider short term as needed anxiolytic properties -try to minimize sedation,↑confusion,hypotension & EPS; (titrate no more frequent then q1-2wks) lorazepam 0.5-2mg/day e.g. citalopram, sertraline, venlafaxine oxazepam 5-30mg/day CANMAT 09 suggests: -target Sx (hallucinations, delusions, hostility,
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