Download Management of Geriatric Psychiatric Disorders

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
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Establishment of a Diagnosis
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Development of Treatment Plan
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Treatment of Cognitive Dysfunction
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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
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Tacrine (Cognex)
Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Reminyl)
Other Medications
• Memantine
• Metrifonate
Preventive Treatment
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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
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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
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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
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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
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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
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5-20 mg/day
Inhibits P450
High risk of seizure in >80 mg/day
Long half life
• Paroxetine
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10-30mg/day
Inhibits P450
Decreases seizure threshold
Anticholinergic effects
SNRIs
• Venlafaxine
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75-300 mg/day
Minimal to no P450 inhibition
Well tolerated in elderly
Hypertension, ADH secretion
• Duloxetine
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20-60 mg/day
Minimal to no P450 inhibition
Milder Cardiac effects
Increased LFT