Transcript Managing “The Why & When”

Psychotropic Medications
 Broad term encompassing any medication used
to influence mood, mental status or behavior
 CMS guidelines break them into four categories:
- Anti-psychotics
- Anti-anxiety agents
- Hypnotics
- Antidepressants
 Additional important categories
– Cognitive enhancers
– Mood stabilizers
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QI Domains And Psychoactive Medications
Skin Care
Accidents
Behavioral/Emotional
Problems
Quality of Life
Psychotropic
Drug Use
QI Domains
Physical/
Functioning
Clinical
Management
Cognitive
Patterns
Nutrition/Eating
Infection Control
Elimination/
Incontinence
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Paradigm for Comprehensive Assessment
 Dementia
 Frontal lobe impairment
 Delirium
 Medical illness
 Psychotic disorder
 Affective disorder
 Anxiety disorder
Cognitive enhancers
Mood Stabilizers
Antipsychotics
Antidepressants
Anxiolytics
 Personality disorder
 Environment/stressors
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Acetylcholinesterase Inhibitors (AChI)
 Aricept (donepezil)
– Start: 5 mg qhs x 4 – 6 wks, then Increase to 10 mg qhs
 Exelon (rivastigmine)
– Start: 1.5 mg bid w/ meals x 2 - 4 wks
– Target dose 6 mg bid, titrate 1.5 mg q 2 - 4 weeks
 Reminyl (galantamine)
– Start 4 mg bid
– Target dose is 24 mg qd
– Titrate by 4 mg bid increase q 4 weeks
Treatment goal is to titrate to the highest dose tolerated 4
ACHI Treatment Effects
 Initial improvement may be seen @ 2 - 4 weeks
 At 26 wks: Approximately 20% of mild/mod pts will
have significant cognitive improvement
 Approximately 80% will remain above baseline for
function for 6-10 months
 Cost vs benefit analysis ongoing
 Watch for significant sudden decline when stopped
 Initial data indicates delay in NH placement >20
months in those with 4 years of donepezil use
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Memantine
 Marketed in Germany since 1982 for “Organic
Brain Syndrome” and spasticity
 Approved as Namenda in October 2003 for
“moderate to severe” Alzheimer’s Disease
 No significant food interaction, i.e., can be
administered without regard to meals
 Interactions with highly protein-bound drugs
unlikely
 No interactions with acetylcholinesterase
inhibitors
Slide courtesy of: Schneider L. Geriatrics. 2003(Aug);Suppl
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Memantine Study Results
 Memantine treatment was associated with less
decline vs. placebo on:
– Global, CIBIC-plus
– Cognition, Severe Impairment Battery
– Function, ADCS-ADL outcome measures
 Patients switched from placebo to Memantine
showed significant improvement relative to
projected decline
 Memantine treatment resulted in reductions in
caregiver time, institutionalisation rate and total
costs compared to the placebo group
 Memantine was well-tolerated with dropout rates
and side effects rates similar or lower than placebo
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Paradigm for Comprehensive Assessment
 Dementia
 Frontal lobe impairment
 Delirium
 Medical illness
 Psychotic disorder
 Affective disorder
 Anxiety disorder
Cognitive enhancers
Mood Stabilizers
Antipsychotics
Antidepressants
Anxiolytics
 Personality disorder
 Environment/stressors
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Frontal Lobe Impairment:
Pharmacologic Management
 Antipsychotics
– Conventionals
– Atypicals
 Risperidone
 Olanzapine
 Quetiapine
 Ziprasidone
 Mood stabilizers
– Carbamazepine
– Divalproex sodium
– Lithium
– Topiramate
– Gabepentin
 Benzodiazepines
 Aripiprazole
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Mood Stabilizers
 These pathways transmit gamma-aminobutyric
acid (GABA).
 Lower levels of GABA associated with
aggressive animal behavior.
 NH study of 56 agitated elderly patients given
Carbamazepine had significant improvement in
agitation and decreased staff time needed.
 Newer anticonvulsants advantageous due to
improved side effect profile but have few good
clinical studies
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Mood Stabilizers:
carbamazepine
divalproex sodium
gabapentin
lithium
topiramate
(Tegretol)
(Depakote)
(Neurontin)
(Lithium)
(Topimax)
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Mood Stabilizers
 Their role is uncertain at present
 No need to monitor serum/blood levels for
Lamictal or Topimax
 Behavior effects can be seen at low serum levels
 The role of multiple mood stabilizers concurrently
remains uncertain
 Documentation on the working diagnosis and
monitoring of benefits and side effects remains
important
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Divalproex Study in Dementia
 Randomized, double-blind, placebo-controlled trial1
 N=172 NH residents met criteria for secondary mania
 Target dose 20 mg/kg/day in 10 days





N=100 completers
Statistically significant improvement on CMAI score
Consistent with antiagitation, not antimanic effects
Study suspended due to side effects (sedation)
Follow-up indicated with lower doses/slower titration
1. Tariot et al, 2000
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Divalproex in Elderly Mania / Dementia
Cohen-Mansfield Agitation Inventory (Total Scores)
0
Placebo
*
-2
Mean Change -4
from
-6
Baseline -8
*
*
Divalproex
*
*
(SE=2.72)
-10
(SE=2.65)
-12
-14
-16
0
7
14
21
28
35
42
Days
*p<0.05 for group differences
Tariot et al,142001
Valproate Summary
 Clinical effects similar to Carbamazepine
  risk of drug interaction
  SE profile
 More definitive controlled trial underway
 Current clinically recommendations
–Initial dose 125-250 mg bid with 125-250 q 5d
–Usual range 500 - 1,250 mg/d
–Usual level 40-90 µg/ml
–Clinical response more important than serum level
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Paradigm for Comprehensive Assessment
 Dementia
 Frontal lobe impairment
 Delirium
 Medical illness
 Psychotic disorder
 Affective disorder
 Anxiety disorder
Cognitive enhancers
Mood Stabilizers
Antipsychotics
Antidepressants
Anxiolytics
 Personality disorder
 Environment/stressors
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OBRA Guidelines: Antipsychotics
 Use only if patients exhibit symptoms that impair
functioning or cause danger to themselves or others,
and/or interfere with provision of care
 Agitated behavior is an insufficient reason to use an
antipsychotic medication (i.e. must be psychotic or
aggressive)
 Considered unnecessary if initiated as treatment in the
absence of documentation of the approved indications
– Use requires approved diagnosis and symptoms
Stoudemire A. Gen Hosp Psych. 1996;18:77-94
The Long Term Care Survey.ACHA
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Accepted Diagnosis for Antipsychotic Use in LTC
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Schizophrenia
Schizo-affective Disorder
Delusional Disorder
Psychotic Mood Disorder
Acute Psychotic Episodes
Brief Reactive Psychosis
Schizophreniform Disorder
Atypical Psychosis
Tourettes Disorder
Huntington’s Disease
Organic Mental Syndromes IF certain
criteria are met
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Treatment with Antipsychotics Requires:
1. Quantitative and Objective Documentation that:
a) The behavior requires intervention
b) You determined if the behavior is permanent or
transitory
c) The behavior has been evaluated for possible social
or situational causes
d) Environmental causes have been ruled out
e) Medical causes have been ruled out
2. The symptoms are persistant
3. Not caused by preventable reasons
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Treatment with Antipsychotics Requires:
Organic Mental Syndromes with associated psychotic
and/or agitated behaviors defined by:
a) Specific Behaviors (biting, kicking, extreme fear, etc)
that have been quantified AND present a danger to
themselves or others (including staff)
b) Continuous crying out, screaming or pacing if
quantified and cause a functional impairment or actually
interfere with the staff’s ability to provide care
c) Psychotic symptoms (AH, VH, PI, delusions) that are not
dangerous but cause distress or an impairment in
functional capacity
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Antipsychotics Should NOT be used if:
the following symptoms are the ONLY criteria
Wandering
Poor self-care
Anxiety/Restlessness
Impaired memory
Uncomplicated Depression
Unsociability
Fidgeting
Nervousness
Uncooperativeness
Agitation without any danger to resident or others
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Antipsychotic Medication Guidelines
 F-tag 330: Use only as necessary to treat a specific condition
as diagnosed & documented in the clinical record
 F-tag 331: Gradual dose reductions & behavioral
interventions, unless clinically contraindicated, are required
in an effort to discontinue these drugs
 Currently, only IM Zyprexa is approved by the FDA for the
treatment of acute agitation in dementia
 Usually reserved for dangerous or very distressed psychotic
symptoms such as aggression, delusions or hallucinations
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Antipsychotic Medication Guidelines
The cause of the psychosis indicates the treatment duration:
– For psychosis as a symptom of dementia, stabilizing
behavior may take as long as 12 weeks and may require
treatment for at least several months and up to a year
– For Schizophrenia, antipsychotic treatment is lifelong
although the dose may decrease with age
– For Bipolar illness, antipsychotics are used during acute
mania or long term to prevent relapse
– For psychotic depression, antipsychotics are typically
needed for a few months in addition to a longer term
antidepressant
– For delirium, antipsychotics are needed for a few days
to a few weeks (even after medical problem is cleared)
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Antipsychotics
 “Typicals”
– Haldol (haloperidol )
– Thorazine (chlorpromazine)
– Many others
 “Atypicals”
–
–
–
–
–
–
Clozaril (clozapine)
Risperdal (risperidone)
Zyprexa/Zydis (olanzapine)
Seroquel (quetiapine)
Geodon (ziprasidone)
Abilify (aripiprazole)
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Atypical Antipsychotics and Increased Stroke Risk
 Data from four International studies revealed
increased incidence of CVA & TIA in Risperidone
treated pts 1
 In 2003, the FDA changed the Risperdal label
warning that the use of Risperidone dementia
patients has an increased risk of stroke
 Currently a similar label is pending for Zyprexa
 Perhaps increased stroke risk is a “class effect”
 Stroke risk should be included in the risk/benefit
assessment
1. Web site address http://www.hc-sc.gc.ca/hpb-dgps/therapeut/zfiles/english/advisory/industry/risperdal
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Antipsychotics: Summary
 Atypicals are effective in the management of
psychosis in the elderly
 In elders, atypicals offer improved safety and
tolerability compared with conventional agents
 Differences in tolerability/side effect profiles
between atypicals impact treatment selection
 It is critical to evaluate for Parkinson’s symptoms
before choosing the atypical to avoid worsening
motor symptoms.
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Paradigm for Comprehensive Assessment
 Dementia
 Frontal lobe impairment
 Delirium
 Medical illness
 Psychotic disorder
 Affective disorder
 Anxiety disorder
Cognitive enhancers
Mood Stabilizers
Antipsychotics
Antidepressants
Anxiolytics
 Personality disorder
 Environment/stressors
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Treatment of Major Depression
 There is no ‘good reason’ for depression to ever go
untreated
 Start low, go slow, but go!
 Strive for maximum recovery/function
– Compare GDS or Cornell
 Treat the sleep disturbance initially then change to a
prn after 2-3 wks
 The dose that gets them well, keeps them well
 Continue for 6-12 months or perhaps even lifelong…?
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Common Antidepressants
 SSRI’s
– Fluoxetine (Prozac)
– Paroxetine (Paxil)
– Sertraline (Zoloft)
– Citalopram (Celexa)
– Escitalopram (Lexipro)
 SNRI’s
– Bupropion (Wellbutrin)
– Mirtazapine (Remeron)
– Venlafaxine (Effexor)
– Trazodone (Desyrel)
 too sedating to treat depression
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Depression Therapy
 TCA’s vs. SSRI’s vs. SNRI’s
 Select the drug based on target symptoms
and the side effects wanted, for example
– Dep. + anorexia – mirtazapine
– Dep. + lethargy – activating antidepressant
– Dep. + constipation – sertraline
– Dep. + psychosis - cymbiax
Insomnia can be effectively treated with the addition of
Trazodone, Ambien, or Sonata
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Paradigm for Comprehensive Assessment
 Dementia
 Frontal lobe impairment
 Delirium
 Medical illness
 Psychotic disorder
 Affective disorder
 Anxiety disorder
Cognitive enhancers
Mood Stabilizers
Antipsychotics
Antidepressants
Anxiolytics
 Personality disorder
 Environment/stressors
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Anxiolytic Therapy Guidelines
 F-tag 329: Guidance to Surveyors
– Short-acting & maximum doses indicated
– Behavioral monitoring charts needed
 Does not indicate how to monitor
– Gradual dose reduction al least twice within one
year before can conclude dose reduction is
clinically contraindicated per regulations
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Anxiolytic Therapy Guidelines
 Indications for use:
- other reasons for the distress have been
considered & eliminated
- use results in maintenance/improvement of
resident’s functional status
- reduction must be attempted by 4 months
- specific diagnoses (anxiety disorder, organic
mental syndromes, panic disorder, anxiety in
concert with another psychiatric disorders)
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Anxiolytic
lorazepam
alprazolam
oxazepam
buspirone
temazepam
klonzepam
(Ativan)
(Xanax)
(Serax)
(BuSpar)
(Serax)
(Klonopin)
0.25 – 2.0 mg /d
0.25 – 1.5 mg / d
7.5 – 30 mg / d
10 – 45 mg / d
0.25 -3.0 mg / d
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Benzodiazepines
 Minimal efficacy data
 Sedating
 Further inhibit learning and memory
 Ataxic gait is episodic - difficult to assess
 Associated with falls
 Paradoxical disinhibition possible
 Avoid long acting benzodiazepines in the elderly
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Anxiety Disorder: Treatment
 Short-acting benzodiazepines
– sedating, inhibit learning, increases fall risk
 Trazodone
– check orthostatic BP and Pulse
 Buspirone?
 If paranoid or psychotic component, consider
Atypicals
 Consider antidepressants, may need empiric trial
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Insomnia - Hypnotics
 F-tag 329: Unnecessary drugs: GTS
 Address “sleep hygiene” issues
 Daily dose 10 or more continuous days requires
documentation of necessity for maintenance or
improvement of functional status.
 Maximum hypnotic dosages
 Dose reduction attempts at least 3 times within 6
mo. before declaring further reductions are
contraindicated.
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Insomnia – Hypnotics - 2
 Trazodone 25-200 mg @hs
 Mirtazepine (Remeron) 7.5-45 mg @hs
 Short-acting benzodiazepine
 Zolpidem (Ambien) 5-10 mg @hs
 Zalepion (Sonata) 5-10 mg @hs
 Melatonin 3 mg @ 6 pm
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Remember, Psychotherapy Can Also Help Some Residents
Summary
 Distressed behaviors are only symptoms
 Unless urgent, a complete assessment to
determine/develop a working diagnoses should
guide the long term treatment approach.
 Consider nonpharmacologic management in
every case.
 Monitor treatment benefits: MMSE, GDS,
FAST, Cornell dementia in depression scale,
Behave AD, Cohen Mansfield Agitation
Inventory
 Optimal care requires teamwork, education,
and respect.
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