Antipsychotics Detect, Select, Effect (P.I.E.C.E.S. 6 th Ed)

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1 Antipsychotics Detect, Select, Effect (P.I.E.C.E.S. 6 th Ed) CLeAR Webinar February 14, 2014 Paula Diaz (Pharm) Carol Ward MD Carol Ward Tertiary Mental Health IHA

2 Hillside Centre (Acute Tertiary Mental Health Hospital IHA) Carol Ward Tertiary Mental Health IHA

3 Aim: Call for Less Antipsychotics in Residential Care (CLeAR) BC Patient Safety & Quality Council Achieve a reduction of 50% in the inappropriate use of antipsychotics in participating facilities across the province through evidence-based management of BPSD for seniors living in residential care by Dec. 31, 2014 Carol Ward Tertiary Mental Health IHA

4 Objectives Develop an understanding of the use of antipsychotics in the treatment of specific mental health disorders (Detect) Recognize the different classes of antipsychotics (typical and atypical) (Select) Review side-effects and related monitoring (Effect) Carol Ward Tertiary Mental Health IHA

5 Quick Facts: Mental Illness & Addiction in Canada (3 rd Ed) Mental illness is a serious disturbance in thoughts, feelings and perceptions that is severe enough to affect day to day functioning. Chances of having a mental illness in your lifetime 1 in 5 Carol Ward Tertiary Mental Health IHA

6 Quick Facts: Mental Illness & Addiction in Canada (3 rd Ed) At any given time percentage of Canadians who have mental illness:10.4% Lifetime Major Depression 8% Bipolar disorder 1% Schizophrenia 1% Anxiety disorder 12% Carol Ward Tertiary Mental Health IHA

7 Psychiatric Disorders in Late Life Mental illness does not discriminate; no one across the age span is immune to its effects (Mental Health Commission of Canada- Seniors Guidelines) Dignity Support Address Stigma Carol Ward Tertiary Mental Health IHA

8 Psychiatric Disorders in Late-Life (MHCC) Grow old with recurrent, persistent or chronic mental illness Develop late-onset mental illness Behavioural and Psychological Symptoms of Dementia (BPSD) associated with Major and Minor Neurocognitive Disorders (MCI/Dementia) Carol Ward Tertiary Mental Health IHA Chronic medical conditions with known neuropsychiatric symptoms (ie. Parkinson s Disease, stroke, COPD)

9 Prevalence of psychiatric disorders among older adults in LTC- a systematic review Dementia 58% (12-91%) BPSD in Dementia 78% (38-92%) Major Depressive Disorder 10% (5-25%) Clinically significant depressive symptoms 29% (14-82%) Other (Anxiety (3-10%),Schizophrenia (~6%),Bipolar Disorder (~3%) less well studied) Carol Ward Tertiary Mental Health IHA (Seitz D. et al, 2010)

10 Mental Health Issues in the Nursing Home (Conn D. The Canadian Review of Alzheimer s Disease 2007;9(1):12-17.) 80%-90% of NH residents suffer from a mental disorder >66% suffer from dementia 15%-25% have symptoms of major depression 77% have some degree of aggression or agitation 56% have delusions 33% have hallucinations Carol Ward Tertiary Mental Health IHA

11 Definition of Psychotropic Medication Psycho = the mind (Greek) Trop = a turning capable of turning the mind Any medication capable of affecting the mind, emotions and behaviour. (aka:psychodynamic, psychoactive, psychotherapeutic) Carol Ward Tertiary Mental Health IHA

12 Five Classes of Psychotropics 1. Antidepressants 2. Antipsychotics 3. Anxiolytics 4. Mood Stabilizers 5. Cognitive Enhancers Carol Ward Tertiary Mental Health IHA

13 Antipsychotics discovery of Chlorpromazine in 1952 surgical anesthetic ( calming effect ) discovered psychoactive effects great reduction in restraint, seclusion and sedation of agitated patients lead to research in other psychotropics Clozapine first atypical Carol Ward Tertiary Mental Health IHA

14 Antipsychotics classified based on chemical class and neuroreceptor affinity profiles antipsychotic activity absence of deep coma or anesthesia in large doses absence of physical or psychic dependence term tranquilizer and neuroleptic are outmoded Carol Ward Tertiary Mental Health IHA

15 Select (P.I.E.C.E.S.) What class of antipsychotic is it? Atypical Traditional Risperidone Olanzapine Quetiapine Clozapine Paliperidone Aripiprazole Ziprasidone Asenapine Lurasidone Haloperidol Loxapine Chlorpromazine Perphenazine Carol Ward Tertiary Mental Health IHA

16 DETECT When should antipsychotics be considered? Carol Ward Tertiary Mental Health IHA

17 Detect Antipsychotics may be used for: Specific treatment of a mental health disorder (DSM V). For example: Schizophrenia and related Psychotic Disorders Bipolar Disorder Major Depression psychotic and/or refractory Carol Ward Tertiary Mental Health IHA

18 Detect con t Antipsychotics may be used for: Supportive treatment. For example: Delirium Carol Ward Tertiary Mental Health IHA

19 Detect con t Antipsychotics may be used for: Treatment of a specific Behavioural and Psychological Symptoms of Dementia (BPSD): For example Delusions Hallucinations Physical/verbal aggression Manic-like Sexually inappropriate behaviour Carol Ward Tertiary Mental Health IHA

20 Reference Best Practice Guide for Accommodating and Managing Behavioural and Psychological Symptoms of Dementia in Residential Care A Client Centered Interdisciplinary Approach B.C. Ministry of Health 2012 Carol Ward Tertiary Mental Health IHA

21 Algorithm Coming soon! Carol Ward Tertiary Mental Health IHA

22 The Algorithm is meant to be used from the top down: Part I: Interdisciplinary Decisional and Practice Support for BPSD: Assessment (green) Problem Solving (yellow) Care Planning (blue) Antifeau & Drance

23 Part 2: Reassessment with GP or NP for BPSD Re-assessment with medical lens Pharmacological considerations: behaviour that is dangerous, distressing, disturbing, and damaging/ & not responding Distinguish behaviours that are/are not likely to respond to medications Antifeau & Drance

24 Part 2: Reassessment with GP or NP for BPSD Behaviours that may respond to medications Second-line intervention support Evidence-informed behavioural categories: sleep disturbance, anxiety, psychosis, aggression, depression and sexually inappropriate behaviour. Antifeau & Drance

25 What are the challenges when prescribing antipsychotics to seniors? Which medication works for which behaviour? Right dose? Side effects? Tapering off medication Changing medication How long before we see desired effect? Drug interactions MDs not familiar with psychotropics Colleagues wanting a quick fix Haldol Wobble Colleagues with differing opinions about meds Not giving enough time for desired effect Difficult to monitor P. Diaz (Pharm)

26 Remember! Team and Comprehensive Approach Informed and involved: Person and family at the centre. Informed interdisciplinary and intersectoral providers working together and sharing information. Prevent the preventable; support the supportable, treat the treatable. (Duncan Robertson) P. Diaz (Pharm)

27 Antipsychotics P. Diaz (Pharm)

28 Psychotropic Framework (P.I.E.C.E.S. 6 th Ed) 1. Detect: When should a psychotropic be used or considered? 2. Select: How do I contribute to the selection of the right medication? 3. Effect: How do I monitor the response and side effects? P. Diaz (Pharm)

29 Antipsychotics Detect: When should it be considered? Clinical purpose: (1) Psychotic disorders (2) Dementia with specific BPSD target symptoms (aggression, psychosis) (3) Mood Disorders (4) Delirium P. Diaz (Pharm)

30 P. Diaz (Pharm)

31 Safety and Antipsychotics Over-sedation Postural Hypotension Impaired cognition Falls Weight gain Hyperglycaemia QTc prolongation Extra-pyramidal symptoms (EPS) Tardive Dyskinesia Cerebrovascular events Mortality (VCHA, Antipsychotic Guidelines BPSD, 2011) P. Diaz (Pharm)

32 Newer /Novel/Atypical Antipsychotics Select Less effects on: EPS Tardive dyskinesia Cognition A different set of concerns: Diabetes control/weight gain, cholesterol levels In dementia increase mortality? In dementia, risk of cardiovascular events? P. Diaz (Pharm)

33 Recently published article concludes deaths are due to symptoms rather than antipsychotic medications. P. Diaz (Pharm)

34 Parkinson s-like Symptoms Tremor Akinesia Akathisia Rigidity (cogwheel) Drooling Pisa Sign Rabbit Sign Gait disturbance P. Diaz (Pharm)

35 Should the Parkinson s- like symptoms be treated with medication? Anticholinergics such as benztropine NOT recommended in the elderly may worsen cognition, in addition can cause adverse effects such as dry mouth, constipation and urinary retention. Levodopa (e.g. sinemet) is for Parkinson's disease NOT for druginduced symptoms P. Diaz (Pharm)

36 Side Effect Profiles EPS Hyperlipidemia Weight Gain QTc Prolongation Sexual Dysfunction Sedation Aripiprazole Olanzapine Quetiapine Risperidone Ziprasidone EPS: extrapyramidal side effects Neutral - Low risk Moderate risk High risk Harrigan EP et al. J Clin Psychopharmacol. 2004;24(1): Keck PE et al. J Clin Psychiatry. 2006;67(4): Kim B et al. J Affect Disord. 2008;105(1-3): Miller D et al. J Clin Psychiatry. 2001;62(12): Olfson M, et al. Am J Psychiatry. 2006;163(10): Yatham LN et al. Bipolar Disord. 2009;11(3):

37 Newer Antipsychotics: Effect DASH Dizziness Agitation - Somnolence - Hypotension Olanzapine (anticholinergic) may cause weight gain, diabetic dyscontrol Risperidone may cause EPS at higher doses Quetiapine watch for sedation P. Diaz (Pharm)

38 Guidelines for Dosages in Dementia Risperdone 0.25 to 1.5 Target 1.0 mg Olanzapine 2.5 to 10 mg Aripiprazole 2 to 10 mg Quetiapine mg Note: may need to use higher dosages ( mg) for Quetiapine; always titrate to response and tolerability: GO SLOW P. Diaz (Pharm)

39 When should p.r.n. doses be used? Uses: Urgent situation ie. Physical aggression, acting on hallucination/delusion Pre-task ie. Bathing, x-ray, dental work Titration with goal of finding the therapeutic dose P. Diaz (Pharm)

40 Drug interactions a concern for elderly residents taking multiple medications Pharmacokinetic- a drug effects the absorption, distribution or metabolism/ excretion of another to alter the quantity of medication at the active site Pharmacodynamic- two or more drugs have additive or opposite beneficial or adverse effects at their receptors P. Diaz (Pharm)

41 Examples of Pharmacokinetic interactions with antipsychotics Quetiapine is primarily metabolised by an enzyme CYP3A4: Inducers (e.g. phenytoin and carbamazepine) will cause faster metabolism and less effect of quetiapine and higher doses may be required Inhibitors (e.g. erythromycin, grapefruit juice) can slow down the metabolism of quetiapine and lead to enhanced effects both beneficial and adverse P. Diaz (Pharm)

42 Examples of Pharmacodynamic drug interactions Additive sedation: opioids, benzodiazepines, zopiclone, sedating anti-depressants, anti-histamines Additive hypotension and dizziness: diuretics, ACE inhibitors, beta-blockers, calcium channel blockers, tamsulosin, terazosin Additive anti-cholinergic effects: oxybutynin, opioids, inhaled tiotropium/ipratropium Additive parkinsonian effects: SSRIs, metoclopramide, prochlorperazine P. Diaz (Pharm)

43 QTc Prolongation-detected by ECG Anti-psychotics have potential to prolong QTc, can lead to Torsade de Points, syncope and sudden death Risk factors: female, older age, bradycardia, low potassium and magnesium levels, liver or cardiac disease Effects of drugs may be additive extensive list includes: domperidone, SSRI e.g. citalopram, antibiotics e.g. clarithromycin, moxifloxacin, cardiac medications e.g. amiodarone, sotalol P. Diaz (Pharm)

44 Antipsychotic medication templates as part of the algorithm P. Diaz (Pharm)

45 Antipsychotic medication templates as part of the algorithm

46 THE END Carol Ward Tertiary Menatl Health IHA

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