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Management of Geriatric Psychiatric Disorders Arash Mirabzadeh Psychiatrist University of Social Welfare and Rehabilitation Sciences Management of Disease • Recognition of disease • Opinion of patients & relatives • Availability of treatment The Main Geriatric Psychiatric Disorders • Dementia • Mood Disorders • Psychotic Disorders “Objectives” Key Questions • Diagnose of Dementia – Alzheimer`s Disease or Other Dementias • Determine of Indication of Pharmacological Approach – Cognitive/ BPSD • Select a Medication – When? What? • Psychopharmacology of Aging/ Type of Medications • Determine of Indication of Non Pharmacological Approach – Patients/ Caregivers Clinical Steps in Pharmacological Treatment of AD • Establishment of a Diagnosis • Development of Treatment Plan • Treatment of Cognitive Dysfunction • Diagnosis and Pharmacotherapy of BPSD Therapeutic Approaches to AD • Stopping the disease • Prevention of disease onset • Slowing symptomatic progression Psychopharmacology of Aging pharmacokinetics pharmacodynamics • Absorption • Distribution • Metabolism • Receptor Function • Neurotransmitter Function – First Pass Metabolism – Phase I • Oxidation – Phase II • Glucuronidation • Acetylation • Sulfation • Excretion AchEIs • • • • Tacrine (Cognex) Donepezil (Aricept) Rivastigmine (Exelon) Galantamine (Reminyl) Other Medications • Memantine • Metrifonate Preventive Treatment • • • • • Anti-oxidative agents Anti-inflammatory agents Estrogen replacement therapy Ginkgo biloba Nootropics When to start? • MMSE score between 10 & 24 • May be effective in other dementia How & What? • How to choose? • How to monitor? • What to tell relative? When to stop? • Primary Treatment failure • Secondary Treatment failure BPSD • • • • • • Common & more prominent in moderate stages Depression Anxiety Agitation & Aggressive behavior Delusion & Hallocination Sleep disturbances Response Behavior PSYCHOSIS FDA Risperidone is only Atypical Antipsychotic officially labeled for: ‘Severe Dementia, Short term management of inappropriate behavior due to aggression and/or Psychosis’ BBW/OLU Dosage of Antipsychotics in Dementia Drug Class Chemical Name Start Dosage (mg) Antipsychotics 1, 2nd-generation Haloperidol Aripiprazole Risperidone Quetiapine Olanzapine Clozapine 0.25 2.5 0.25 12.5 1.25 6.25 Usual Dosage (mg) Maximal Dosage (mg) 0.5-1 5-10 0.5-1 75-100 5-10 6.25-12.5 2 15 2 125 15 100 Good Practice • Starting – Low Dose – Slow Upward Titration • Continuing – Until 6 Weeks – Monitor for Effectiveness Every 6 weeks – Monitor for Adverse Effects • Discontinuing – Safe in Low doses & Symptom Free Conditions – Nursing Homes Cerebrovascular Adverse Events CVAEs • Haloperidol> Risperidone> Quetiapine • With Olanzapine !!! • Dose dependent Mortality • Mortality Rate: 54%, 60-70% • Mortality usually caused by cardiac event or infection or CVA • Mechanism of CVA adverse events is unknown • 2012: Haloperidol> Risperidone> Olanzapine >Quetiapine • Dose dependent Diabetes Mellitus • More with Clozapine & Olanzapine • No with Aripiprazole & Ziprasidone Weight Gain • Clozapine>Olanzapine>Quetiapine>Risperidone • Lower with Aripiprazole & Ziprasidone • No dose dependent Dyslipidemia • Clozapine> Olanzapine> Quetiapine> Ziprasidone> Aripiprazole • No with Risperidone Sedation • Long Half-life and Significant Antihistaminic Activity = Sedation • Clozapine> Olanzapine> Quetiapine> Risperidone EPS • Risperidone: Dose dependent > 6mg/day • Olanzapine: Rarely • Quetiapine: No Prolactin Levels • Risperidone> Olanzapine>Clozapine> Quetiapine> Other Side Effects • Rash, Hypertension with Ziprasidone • Cataract with Quetiapine !! • Seizure with Clozapine & Olanzapine • Agranulosytosis with Clozapine Nonpharmacologic strategies • Reality Oriented Therapy – Using clocks and calendars to maximize orientation • Reminescence Therapy – Using old music & photos • Attention to the environment – Over & Under Stimulation – Keeping daily activities routine • Family intervention – Education – Treat the caregiver • Preventive Strategies – Life Style DEPRESSION Choosing an Antidepressant • • • • • • • • • • Profile of Side effects Past Use of Antidepressant Patient`s Preference Expertise of Psychiatrist Co-morbidity Associated Symptoms Drug Interactions Safety in Overdose Availability Costs Profile of Side Effects • • • • • • • • Postural Hypotension Cardiac Anticholinergic Delirium Hyponatremia GI Bleeding Sexual Akathisia Principles of Acute Phase • Appearing of significant therapeutic effects • It takes up to 2-4 weeks • Effective Trial • Ideal time: 6-8 weeks • Clinical Guide • A minimal response up to 2 weeks is a significant predictor of subsequent response after 6-8 weeks • No Response or Partial Response after 2- 4 weeks • Continuation • No Response after 4- 6 weeks / Partial Response after 8 weeks • Ineffective • Changing • Cross Tapering • No Remission after 4- 6 weeks / Partial Remission after 8 weeks • Augmentation Principles of Maintenance Phase • Maintenance Treatment • Three episodes of Depression • Two episodes of Depression if • Episodes that less than 2.5 yrs apart • Seriousness of previous episode • • • • Severity Significant suicidal ideation Genetic predisposition Impairment of psychosocial functioning • One episode of Late onset Depression Long term treatment for 2 – 5 years SSRIs • Citalopram • 10-40mg/day • Minimal to no P450 inhibition • Well tolerated in elderly and those with comorbid medical conditions • Serteraline • 12.5-50mg/day • Less P450 inhibition • Well tolerated, most GI effects, most response with increased dosing SSRIs • Fluoxetine • • • • 5-20 mg/day Inhibits P450 High risk of seizure in >80 mg/day Long half life • Paroxetine • • • • 10-30mg/day Inhibits P450 Decreases seizure threshold Anticholinergic effects SNRIs • Venlafaxine • • • • 75-300 mg/day Minimal to no P450 inhibition Well tolerated in elderly Hypertension, ADH secretion • Duloxetine • • • • 20-60 mg/day Minimal to no P450 inhibition Milder Cardiac effects Increased LFT