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Pharmacological
Management of
Behavioral Problems
Should I give a medication…
Or just take one myself?
Dr. Gordon Thomas
Geriatric Psychiatrist
Royal Ottawa Mental Health Centre
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Psychotropic drugs
Part of the overall approach
• Psychotropic:
• Any drug capable of affecting the mind,
emotions, and behavior
• Examples
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Antidepressants
Antipsychotics
Anxiolytics/Sedatives
Mood stabilizers
Cognitive stabilizers
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Psychotropic drugs
Part of the overall approach
Behaviors that Do Not respond to Medication:
 Wandering / pacing
 Exit-seeking
 Sundowning
 Hoarding
 Rummaging
 Resistance to care
 Sexual disinhibition
 Inappropriate
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dressing/disrobing
Inappropriate
voiding/defecation
Swearing
Screaming/repetitive
vocalizations
Spitting
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Psychotropic drugs
Part of the overall approach
Causes of behaviors that May respond to Medication:
 Anxiety
 Depression
 Mania
 Psychosis
 Sleep disruption
 General medical illness
 Infections
 Medication side effects
 Delirium
 Pain
 Aggression
 Frontal disinhibition
 Agitation
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How the body handles drugs:
PHARMACOKINETICS
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Psychotropic drugs
Use in the Elderly
• Changes in how the body handles drugs
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Absorption
Distribution
Metabolism
Elimination
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Psychotropic drugs
Use in the Elderly
• Absorption
• Slower in elderly patients
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Decreased motility and gastric pH
• No clinical significance without overt disease
• Can be delayed by other medications
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Antacids
Aluminum containing cathartics
Calcium/Magnesium
Fibre
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Psychotropic drugs
Use in the Elderly
• Distribution (fat / water / protein bound)
• Higher fat:muscle and fat:water ratios
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Lipid soluble medications stored and take longer to clear
Most psychotropics are lipid soluble
• Lower protein (albumin) levels
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Not clinically significant by itself
Multiple medications bind protein and may compete
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Psychotropic drugs
Use in the Elderly
• Metabolism
• Phase I: oxidation before entering circulation
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Decreased in elderly = more active drug in system
• Phase II: conjugation/glucuronidation
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Relatively unaffected
Other changes decrease this process
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Reduced liver blood flow (40-45%)
Reduced liver mass
• Some activate or deactivate the process
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Decrease or increase levels of active drug
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Psychotropic drugs
Use in the Elderly
• Elimination
• Decreased renal function with age
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GFR decreases yearly from age 20
Calculated CrCl needed (eGFR is inaccurate)
• Decreased response to volume changes
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More likely to have abnormal electrolytes (SIADH)
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Psychotropic drugs
Use in the Elderly
• Illnesses alter handling of drugs
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Gastric surgery
Heart failure
Liver disease
Renal disease
Malnutrition
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How the drugs affect the body:
PHARMACODYNAMICS
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Psychotropic drugs
Use in the Elderly
• Changes in how drugs affect the body
• Increased sensitivity
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Changes in receptor density
Decreased responsiveness of regulatory systems
Direct sensitivities (stroke, Parkinson’s, dementia)
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Psychotropic drugs
Use in the Elderly
• Different approach to using medications
• “Start low and go slow”
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Overall therapeutic dose often unchanged
• Longer time to get a clinical response
• Can be toxic at “therapeutic levels”
• More vulnerable to some side effects
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The happy pill…
ANTIDEPRESSANTS
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Psychotropic drugs
Antidepressants
• Antidepressant usage
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Depression treatment/prevention
Anxiety
Sleep disruption
Agitation
Frontal symptoms / Behaviors
Pain control
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Psychotropic drugs
Antidepressants
• SSRI (Selective Serotonin Reuptake Inhibitor)
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Celexa (citalopram): few drug interactions
Cipralex (escitalopram): few drug interactions
Zoloft (sertraline): minor interactions
Luvox (fluvoxamine): more interactions, sedating
• Effective and well tolerated
• Depression/anxiety, agitation, behaviors
• Prozac (fluoxetine): half-life too long
• Paxil (paroxetine): too anticholinergic
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Psychotropic drugs
Antidepressants
• SNRI (Serotonin Noradrenaline Reuptake Inhibitor)
• Effexor (venlafaxine)
• Cymbalta (duloxetine)
• Effective and well tolerated
• Depression/anxiety, (behaviors)
• Neuropathic pain
• Nociceptive pain (new indication)
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Psychotropic drugs
Antidepressants
• NaSSA (Noradrenergic and Selective Serotinergic Antidepressant)
• Remeron (mirtazapine)
• Effective and well tolerated
• Depression/anxiety, sleep disturbance, appetite
• (behavior), (pain)
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Psychotropic drugs
Antidepressants
• NDRI (Norepinephrine-Dopamine Reuptake Inhibitor)
• Wellbutrin (bupropion)
• Effective and well tolerated
• Depression
• May worsen anxiety
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Psychotropic drugs
Antidepressants
• TCA (Tri-Cyclic Antidepressant)
• Nortriptyline, Desipramine
• Amitriptyline, Imipramine
• Effective but poorly tolerated
• Cardiac effects (hypotension, tachycardia)
• Increased fall risk
• Anticholinergic effects
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Dry mouth, confusion, constipation, confusion, urinary
retention, confusion, blurred vision, confusion
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Psychotropic drugs
Antidepressants
• MAOI (MonoAmine Oxidase Inhibitor)
• Parnate, Nardil
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Poorly tolerated due to need for diet (yuck!)
• Mannerix (Moclobemide)
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No need for diet
Less effective and poorly studied in elderly
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Psychotropic drugs
Antidepressants
• Trazodone
• Not used for depression (need high doses)
• Used at low doses
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Sleep initiation
Anxiety
Agitation
Frontal symptoms
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Psychotropic drugs
Antidepressants
Class
Side Effects to watch for:
SSRI
HANDS:
Headache, Agitation, Nausea, Diarrhea, Dizziness, Sweating,
Sedation
SNRI
Headache, Nausea, Hypertension, Agitation
NaSSA
Sleepiness, Dizziness, Constipation, Weight gain
NDRI
SHARES:
Seizure, Headache, Agitation, Rash, Emesis, Sleep disturbance
Trazodone
Drowsiness, orthostatic hypotension, headache, tinnitus
TCA
Cardiovascular, Anticholinergic, Confusion
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Psychotropic drugs
Antidepressants
Drug
Typical initial doses
Typical dose range
Celexa (citalopram)
10 mg daily
20-40 mg daily
Cipralex (escitalopram)
5 mg daily
10-20 mg daily
Zoloft (sertraline)
25 mg daily
50-200 mg daily
Luvox (fluvoxamine)
25 mg qhs
50-200 mg qhs
Effexor XR (venlafaxine)
37.5 mg daily
150-300 mg daily
Cymbalta (duloxetine)
30 mg daily
60-120 mg daily
Remeron (mirtazepine)
15 mg qhs
30-45 mg qhs
Wellbutrin XL (bupropion)
150 mg daily
300-450 mg daily
Trazodone
25-50 mg qhs
12.5-25 mg tid
12.5–25 mg q4h prn
25-200 mg qhs
12.5-100 mg tid
12.5-50 mg q4h prn
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Psychotropic drugs
Antidepressants
• Common questions
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When should the dose increase?
When should the drug stop?
How long does it take to work?
What if it doesn’t work?
What other options are there?
What about ECT?
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Psychotropic drugs
Antidepressants
• Common Uses
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Depression and Anxiety
Pain (Effexor & Cymbalta)
Sleep (Remeron & Trazodone)
Frontal Disinhibition
Smoking Cessation (Wellbutrin)
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The crazy pill…
ANTIPSYCHOTICS
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Psychotropic drugs
Antipsychotics
• Antipsychotic usage
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Schizophrenia / Delusional disorders
Psychotic depression
Delirium
Dementia with behavioral problems
These are not first choice medications
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Psychotropic drugs
Antipsychotics
• Atypicals (newer medications)
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Risperidone (Risperdal)
Olanzapine (Zyprexa)
Seroquel (Quetiapine)
Zeldox (Ziprazidone)
Abilify (Aripiprazole)
• Fewer side effects than older medications
• Still need to be used cautiously
• Sedation, weight gain, risk of falls, risk of stroke
• Small increase in mortality
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Psychotropic drugs
Antipsychotics
• Typicals (older drugs)
• Haldol, Perphenazine, Nozinan, Loxapine,
Chlorpromazine, others…
• More side effects, higher risks
• Parkinsonian symptoms
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Tremor, rigidity, bradykinesia, restlessness, falls
• Cognitive blunting
• Tardive dyskinesia
• Increased mortality
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Psychotropic drugs
Antipsychotics
Drug
Typical doses
Comments
Risperidone
0.125-1.5 mg qhs
Risk of parkinson symptoms at higher doses
Less sedating
Little weight gain
Olanzapine
1.25–10 mg qhs
Most sedating
Large weight gain
Can cause problems with diabetic control
Seroquel
12.5–100 mg bid
Sedating
12.5-50 mg tid/qid Hypotension can be problem
Abilify
2-10 mg daily
Not sedating
Can increase anxiety or restlessness (rare)
Seems to work well for mood symptoms
Always need to use the lowest possible dose and review frequently
Most patients need these medications only for short periods (few months)
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Psychotropic drugs
Antipsychotics
• Common questions
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When should the dose increase?
When should the drug stop?
How long does it take to work?
What if it doesn’t work?
What other options are there?
When should they not be used?
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The sleepy pill…
ANXIOLYTIC / SEDATIVE HYPNOTICS
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Psychotropic drugs
Anxiolytics
• Anxiolytics / Sedative Hypnotic use
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Use is controversial in elderly patients
Sleep
Anxiety
Behavioral management
Alcohol withdrawal
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Psychotropic drugs
Anxiolytics
• Benzodiazepines
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Alprazolam (Xanax)
Diazepam (Valium)
Flurazepam (Dalmane)
Clonazepam (Rivotril)
• Lorazepam (Ativan)
• Oxazepam (Serax)
• Temazepam (Restoril)
• Non-benzodiazepines
• Zopiclone (Imovane)
• Zolpidem (Ambien)
• Zaleplon (Starnoc)
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Psychotropic drugs
Anxiolytics
• Side effects
• Drowsiness / fatigue
• Memory impairment / confusion
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Chronic use can meet criteria for dementia
Weakness
Incoordination / ataxia
Depression
Disinhibition / behavior problems
Paradoxial reactions
Decreased sleep quality and worsened apnea
Tolerance and withdrawal symptoms
• Elderly (especially with dementia) are more sensitive
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The steady pill…
MOOD STABILIZERS
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Psychotropic drugs
Mood Stabilizers
• Mood stabilizer use
• Bipolar disorder (mania & depression)
• Augmentation of antidepressants
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Psychotropic drugs
Mood Stabilizers
• Lithium
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Effective for mania and depression
Effective in lower doses for augmentation
Water soluble and cleared by kidneys
Serum levels must be monitored
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0.4 – 0.7 mmol/L (not 0.8 – 1.5 mmol/L)
Lower levels for augmentation (0.3 - 0.6 mmol/L)
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Psychotropic drugs
Mood Stabilizers
• Lithium side effects
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nausea, anorexia, diarrhoea,vomiting
weight gain, sedation
subjective memory loss and slowing
tremor, parkinsonism, ataxia
• High serum levels are toxic
• Increased side effects, delirium
• Hold and check level if losing fluid
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Psychotropic drugs
Mood Stabilizers
• Anticonvulsants
• Valproic acid (Epival)
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GI upset, somnolence, alopecia, tremor, weakness,
increased liver enzymes, gait instability
• Lamotragine (Lamictal)
• Gabapentin (Neurontin)
• Carbamazepine (Tegretol)
• some evidence of cognitive impairment caused by these drugs
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The memory pill…
COGNITIVE STABILIZERS
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Psychotropic drugs
Cognitive Stabilizers
• Cognitive Stabilizer use
• Stabilizers not Enhancers
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Preservation of Abilities
Management of Behaviors
Stabilization of Cognitive function
Decrease caregiver time
Delay Entry into LTC setting
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Psychotropic drugs
Cognitive Stabilizers
• Cholinergic agents
• Aricept (donepezil)
• Reminyl (galantamine)
• Exelon (rivastigmine)
• Effective for Mild to Severe dementias
• Stabilize cognition for 1-2 years
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Still some benefits even when decline resumes
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Psychotropic drugs
Cognitive Stabilizers
• Cholinergic agents
• Side Effects (MIND)
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Muscle cramps
Insomnia / nightmares
Nausea ***
Diarrhea
• Caution with:
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COPD, heart block, seizures, ulcers
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Psychotropic drugs
Cognitive Stabilizers
• Glutaminergic agents
• Ebixa (memantine)
• Effective for Moderate to Severe dementias
• Stabilize cognition for 1-2 years
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Small number have some improvement
Small number get more confused
• Not covered by ODB ($120 per month)
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Psychotropic drugs
Cognitive Stabilizers
• Glutaminergic agents
• Side Effects (CHECK)
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Confusion
Headache
Equilibrium (dizziness)
Constipation
Kidney function
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Dosage depends on CrCl (eGFR is not adequate)
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Psychotropic drugs
Cognitive Stabilizers
• Who might benefit?
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Alzheimer’s dementia
Vascular dementia
Mixed Dementia
Lewy-Body Dementia
Other neuropsychiatric disorders
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i.e. Parkinsons-related Dementia
Fronto-temporal dementia can get worse
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Psychotropic drugs
Cognitive Stabilizers
Drug
Starting dose
Treatment dose
Aricept (donepezil)
5 mg qam
5 or 10 mg qam
Reminyl ER (galantamine)
8 mg qam
16-24 mg qam
Exelon (rivastigmine)
1.5 mg bid
3-6 mg bid
Patch 5 daily
Patch 10 daily
5 mg qam
5 or 10 mg bid
Exelon patch
Ebixa (memantine)
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Psychotropic drugs
Cognitive Stabilizers
• Common Questions
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Which medication?
When and how to switch medications?
How to monitor?
Are combinations useful?
When should they be stopped?
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