Psychotropic Strategies Handout Package

Transcription

1 Psychotropic Strategies Handout Package

2 Psychotropic Strategies Learning Objectives Utilize all clinical information available Assess the patient s overall condition this is essential Basic Principles in Treating the Elderly with Drugs Lower starting doses Smaller increases Longer intervals between increases 1

3 Typical/Traditional Antipsychotics Choice of antipsychotic Loxapine (Loxapac) and its advantages Utilization of PRNs (as needed medications) Modify behaviour Reduce agitation & aggression Assist in establishing appropriate daily dosage Atypical Antipsychotics First line of treatment for problem behaviour in the demented elderly with psychotic features Fewer side effects Enhances various aspects of cognition Clozapine (Clozaril) the first atypical on the market 2

4 Risperidone (Risperidal) Commence with a 0.25 mg 0.5 mg B.I.D. dosage High potency and effective in treating positive symptoms Dose related side effects Olanzapine (Zyprexa) Commence with a 2.5 mg 5 mg daily dosage Well tolerated ODTs = oral disintegrating tablets (Zydis) Other uses of Olanzapine Quetiapine (Seroquel) Commence with a 25 mg daily or 25 mg B.I.D. dosage Low potency and effective in treating both positive and negative symptoms Low incidence of side effects Other uses of Quetiapine 3

5 Atypical Antipsychotics Dosage adjustments weekly Initial trial = 6 to 8 weeks PRN usage of Atypicals Cost is a debate Basic Principles for Switching Typical and Atypical Antipsychotics High potency discontinued and new antipsychotic initiated without overlap Low potency discontinued gradually and new antipsychotic initiated gradually The lowest effective dose should be used Side effects should first be treated by dose reduction 4

6 Antidepressants SSRIs = Sertraline (Zoloft), Citalopram (Celexa) Trazodone (Desyrel) Benzodiazepines Less effective Use short acting agents Lorazepam (Ativan) Usually used as a PRN Anticonvulsants Used as mood stabilizers Carbamazepine (Tegretol) Valproic Acid (Depekene) Gabapentin (Neurontin) 5

7 Sedatives Insomnia and sleep disturbances can be a major concern Zopiclone (Imovane) Temazepam (Restoril) Cholinesterase Inhibitors: Aricept (Donepezil) Exelon (Rivastigmine) Reminyl (Galantamine) Dementia continues to progress throughout the duration of the drug therapy. The Cholinesterase Inhibitors do NOT appear to alter the underlying disease process. 6

8 ARICEPT (Donepezil) Slows the decline by: 2 points with 5 mg per day 3 points with 10 mg per day Start with 5 mg daily Increase in 4-6 weeks to 10 mg daily The progression of the disease is delayed by 6 months Long term efficacy - 7 year follow up Safety issues EXELON (Rivastigmine) Doses 1-4 mg = to placebo in effect Doses 6-12 mg slows the decline by 2.4 points Start with 1.5 mg twice daily First increase after 2-4 weeks Next increase(s) at 4 week intervals REMINYL (Galantamine) Slows the decline by 4.5 points No clinical significant difference between 16 mg per day and the 24 mg per day Start with 4 mg twice daily Increase dose after a minimum of 4 weeks to 8 mg twice daily 7

9 Cholinestrase Inhibitors also used to reduce behavioural symptoms (or delay them) MEMANTINE (Ebixa) New aspect in treating dementia: The first drug to slow the progression of dementia in later stages of the disease Deterioration is HALF as much as placebo More research needed - may be more effective in combination with a Cholinesterase Inhibitor Low level of side effects For now we are left dealing with the loss of cognition and function and dealing with behaviours. 8

10 The GOAL Improve quality of life Maximize function Improve mood Reduce Behaviours Use ALL medications with care Evaluate the benefits and risks of ALL drugs Ensure an appropriate and complete care plan 9