Use of Psychotropic Medications in Older Adults with Dementia! Deepa Pattani, PharmD, RPh Owner: PrevInteract Health Deepa.Pattani@PrevInteract.com 972-372-9775
About Me Deepa Pattani, PharmD, RPh with over 13 years of experience as a Pharmacist Practiced in various aspects of pharmaceutical care Licensed to practice in 4 states throughout the country Contact info: Deepa.Pattani@PrevInteract.com 972-372-9775
Introduction: Dementia Dementia: decline in mental ability severe enough to interfere with daily activities. 2015: 47.47 million individuals affected worldwide. Alzheimer s dementia accounts for 60-80% of all dementia cases. Vascular dementia: occurs after stroke: 2 nd most common type of dementia. 15 million people provide unpaid care for people with dementia: 18.2 billion hours: $230 billion. Incorrectly labeled senile dementia and not a part of the normal aging process. 2017 cost to nation: $257 billion
Agenda After completion of this activity, the target audience should be able to: Describe different types of dementia and methods of identification. Describe at least 2 classes of psychotropic medications used in the treatment of dementia. Recognize side effects of psychotropic medications vs. symptoms of disease progression. Clinically determine how to screen a patient that may need medications or behavior modifications.
Types of Dementia Alzheimer s disease: difficulty remembering. Vascular dementia: impaired ability to make decisions. Dementia with Lewy bodies (DLB): early symptoms: sleep disturbance, visual hallucinations. Mixed dementia: multiple dementia symptoms seen. Parkinson s disease: gait disturbances.
Types of Dementia (contd) Frontotemporal dementia: behavior problems & difficulty with language. Creutzfeldt- Jacob disease: rapidly fatal: memory loss, coordination & behavior changes. Huntington s disease: involuntary movements, severe decline in reasoning, depression, mood changes. Normal pressure hydrocephalus: memory loss, loss of bladder control. Wernicke-Korsakoff syndrome: memory loss due to severe thiamine deficiency: alcohol misuse.
Treatment No treatment for dementia currently. Medications and non-drug therapy used in combination. Dietary supplements.
Psychotropic Medications Antidepressants Anxiolytics, sedatives and hypnotics Stimulants Mood stabilizers Neuroleptics Cognitive enhancers/ stabilizers
Psychotropics: Anti-depressants SSRIs: Fluvoxamine, Fluoxetine, Paroxetine, Citalopram, Sertraline, Escitalopram All Ages GI upset Serotonin Syndrome Akathisia Hyponatremia Older Adults Falls/ Hip fractures QTc prolongation (Celexa) Osteoporosis Anticholinergic side effects Increase risk of bleeding (anticoagulants)
Anti-depressants (contd) SNRIs Venlafaxine, Duloxetine TCAs Amitriptyline, Clomipramine, Desipramine, Doxepin, Imipramine, Nortriptyline, Protriptyline, Trimipramine MAOIs Isocarboxacid, Phenelzine, Selegiline (oral and patch), Tranylcypromine Misc Mirtazapine, Trazodone, Bupropion.
Psychotropics:Anxiolytics SSRIs, SNRIs, TCAs, and MAOIs Benzodiazepines Miscellaneous Buspirone, trazodone Propranolol, clonidine Antihistimines Antiepileptics (AEDs)
Psychotropics: Anxiolytics Benzodiazepines Long acting: Chlordiazepoxide, Clonazepam, Diazepam, Flurazepam & Quazepam. Intermediate-acting: Alprazolam, Oxazepam, Lorazepam, Clonazepam. Short-acting: Triazolam, Midazolam, & chlorazepate
Anxiolytics: Benzodiazepines Side-effects: FALL risk greatly increased. CONFUSION, CONFUSION, CONFUSION!!! Paradoxical reactions More likely to have withdrawal symptoms (and to have these symptoms misrecognized) Dementia: very hard to differentiate if effects are from BZDs or dementia. (Risk of mis-diagnosis) Depression Misuse
Psychotropics: Anxiolytics Miscellaneous Buspirone Trazodone: mild anticholinergic effects, sedation Propranolol, clonidine: hypotension, can potentially address 2 problems with 1 medication Antihistamines: anticholinergic side-effects
Psychotropics: Sedative/Hypnotics Benzodiazepines Non-benzodiazepine hypnotics: Falls, confusion, misuse Zolpidem Zaleplon Eszopiclone Melatonin receptor agonist: Ramelteon: well-tolerated Miscellaneous: Trazodone, mirtazapine, and chloral hydrate (effects similar to alcohol)
Psychotropics: Stimulants Used for apathy, amotivation, depression Worsen anxiety Buproprion: Anticholinergic properties Methylphenidate: tachycardia, hypertension, confusion, hallucinations
Psychotropics: Mood Stabilizers May be useful for impulsivity and irritability Divalproex, valproic acid, valproate: dizziness, falls, elevated liver enzymes, elevated ammonia, weight gain, hair loss. Carbamazepine: blood dyscrasias, elevated liver enzymes, interactions with other medications
Psychotropics: Neuroleptics Typical (first generation): Chlorpromazine, thioridazine, trifluoperazine, fluphenazine, perphenazine, prochlorperazine, thiothixene, loxapine, pimozide, haloperidol Atypical (second generation): Clozapine, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole
Neuroleptics Appropriate Indication Acute psychotic episode, atypical psychosis, brief reactive psychosis Delusional disorders Schizophrenia, schizo-affective disorder Huntington s disease Mood disorder w/ psychotic features Tourette s syndrome Dementia & delirium with agitated behaviors Short term (< 7 days): hiccups, pruritic, nausea & vomiting Inappropriate Use Agitated behaviors that is not a threat to patient or others Depression without psychosis Anxiety, nervousness Fidgeting, restlessness, wandering Impaired memory Indifference to surrounding, poor self care/hygiene Unco-operativeness, unsociability Insomnia
Neuroleptics: cont d Weight gain All Ages Diabetes/ metabolic syndrome Akathesia Sedation Dystonic reactions Older Adults Sudden death (Black Box Warning) EPS, Parkinsonism Cardiac dysrhythmias Anticholinergic effects Hyponatremia Seizures
Neuroleptics: Black Box Warning Increased risk of death when used in elderly patients treated for dementia-related psychosis
Psychotropics: Cognitive Enhancers Acetylcholinesterase inhibitors Donepezil, galantamine, rivastigmine Side effects: GI, vivid dreams (donepezil) Peripheral cholinergic side effects (cardiac) NMDA antagonist: Memantine GI side-effects, paradoxical agitation
Cognitive Enhancers (cont d) FDA approval Alzheimer s disease/dementia Beneficial in vascular dementia, dementia related to Parkinson s disease, and perhaps in some FTD Beneficial in neuropsychiatric symptoms of dementia!
Neuroleptics Common side effects: EPS (akathisia, dystonia, pseudoparkinsonism, dyskinesia), sedation, and orthostatic hypotension Long term use of drugs such as Haldol, Risperdal, Zyprexa increase risk of falls by 81%. Recommended to use the smallest possible dose for the shortest duration of action.
Drug Selection Appropriate and documented diagnosis associated with medication being prescribed. Document trials of behavioral management. Document assessment of medication s side effects. Document benefit of medication. Documentation of dose reduction trial. Explanation for continued medication.
Clinical Decision Making: Side-effect vs. Symptom Management What is the issue/behavior? What might be causing it or contributing to it? Is there a way to quantify or measure the degree of symptomatology (e.g., a screening instrument)? Is it an issue that can be completely or partially addressed without medication?
Clinical Decision Making: Side-effect vs. Symptom Management Non-drug symptom management Monitor personal comfort. Avoid being confrontational. Redirect the person's attention (use of art/ music). Create a calm environment. Allow adequate rest Provide a security object. Acknowledge requests, and respond to them. Look for reasons behind each behavior.. Explore various solutions. Don't take the behavior personally.
Clinical Decision Making: Sideeffect vs. Symptom Management Supplements used for dementia patients: Ginger Gingko biloba Omega 3 fatty acids Vitamin C Curcumin
Clinical Decision Making: Side-effect vs. Symptom Management So, a medication is needed Is there a current medication that can be adjusted to address the behavior? What are the individual s comorbidities and do they prevent the use of any medications? What are the most benign medications that can be used? Are there any side effect profiles that can be useful?
Clinical Decision Making: Side-effect vs. Symptom Management Once a medication has been selected: Monitor and document response of symptoms. Monitor and document screening for side effects (e.g., sodium, falls, AIMS). Periodically conduct trials of a decreased dose. Try tapering off the medication to determine if it s still needed.