Psychopharmacological Treatment of Geriatric Disorders

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Psychopharmacological Treatment of Geriatric Disorders

  1. 1. Organization of inpatient care for Geriatric Mental Health Care SHIV GAUTAM MD(psych), DPM, FAMS Sr.Professor, HOD & Supdt. Psychiatric Centre Jaipur Addl.Principal SMS Medical College Jaipur
  2. 2. Aging Physiology • Individuals become more dissimilar as they grow. • Abrupt decline in any system is always due to disease and not to normal aging. • Normal aging can be attenuated by modification of risk factors. • In the absence of disease decline in homeostatic reserve causes no symptoms and imposes few restrictions in activities of daily living regardless of age.
  3. 3. Aging Pathology • Multiple Pathology –Cataracts, deafness, degenerative joint diseases, like osteoarthritis or osteoporosis, varicose veins are all conditions which are likely to develop slowly and to progress. –Cancer, pernicious anaemia, thyrotoxicosis, myxoedema common due to deterioration of immune mechanisms. –Obesity, diabetes, depression and dementia frequently seen
  4. 4. Under reporting of illness • Callous Attitude Towards Health • Attitude of the Relatives
  5. 5. Barriers to Obtaining Proper History •Mental Confusion •Deafness •Concentration •Co-operation •Idiosyncrasis
  6. 6. Neuro-Psychiatric Disorders • Cerebrovascular Diseases • Depressive and other Psychiatric Disorders • Cognitive Impairment and Dementia • Neurodegenerative Disorders • Infections of the Central Nervous System, Sleep Disorders and Coma.
  7. 7. Laboratory Evaluation and Other Investigations • Routine Haematological Tests - Complete Blood cell count Platelets count Prothrombin time Serum Electrolytes Blood glucose level Renal Panel Hepatic Panel Routine Diagnostic Tests - • Lipid Profile, Blood sugar fasting, Electrocardiogram, Chest radiograph, • Optional – EEG, CT Scan, MRI
  8. 8. Facilities for an inpatients Geriatric Mental Health Care • Entrance with ramp and wheel chair • Adequate OPD space with waiting facilities • Consultation chambers for mental health team (Psychiatrists, Clinical Psychologist, Psychiatric Social worker) • Nursing Station and Drug dispensing • Inpatient wards with attendant facility • Semi ICU • Lab investigations facilities • Recreation room • Rehabilitation activities • Storage and Documentation space
  9. 9. INTERDISCIPLINARY TEAM CONSULTATION-LIASION • Medical internist Gynaecologist • Ophthalmologist Orthopaedician • Physiotherapist Dietician • Yoga trainer
  10. 10. Age related changes in the Central Nervous System  Gross brain atrophy  Ventricular enlargement  Selective regional neuronal loss  Remodeling of dendrite, axons & synapses  Appearance of intraneuronal lipofuschin  Selective regional decrease in neurotransmitter & neuropeptides.
  11. 11. Contd........... Selective modification of neurotransmitter metabolism Possible dysregulation of gaseous neurotransmitter metabolism Glucocorticoid neurotoxicity Changes in receptors Changes in neurotrophins Changes in signal transduction
  12. 12. …contd.  Impairment of calcium homeostasis  Possible changes in cell cycle regulations (eg, cyclins)  Possible changes in extra cellular matrix proteins (eg. Laminin, proteoglycans)  Possible regional decline in cerebral blood flow  Possible regional decline in metabolic rate  Appearance of senile plaque & neurofibrillary tangle
  13. 13. PHARMACODYNAMICS AND AGING Neurotransmitter Pharmacodynamic changes with aging Dopaminergic system ↓ Dopamine D2 receptor in the striatum Cholinergic system ↓ Choline acetyl transferase ↓ Cholinergic cell numbers Contd...........
  14. 14. Adrenargic system ↓ cAMP production in response to beta-agonists ↓ Beta – adrenoceptor number ↓ Beta – receptor affinity ↓ Alpha 2 – adrenoceptor responsiveness Gabaminergic system ↓ Psychomotor performance in response to benzodiazepines ? ↑ Post – synaptic receptor response to GABA. Contd...........
  15. 15. PHARMACOKINTIC CHANGES WITH AGING
  16. 16. Points to remember before prescribing medication in elderly Magnitude of effect (clinical response) = Pharmacodynamics x Pharmacokinetics x biological variance  In elderly medical complication of pharmacotherapy alone constitute a highly significant treatable health problem.  Adverse reaction to drugs of all types is seven times higher in those aged 70 to 79 years, than in those 20 to 29 years old.  Non compliance with therapy is a major problem for psychiatric patients, and this dilemma is exacerbated with age.  Age related health problems combines with physiological changes to increase the probability of adverse effect from medication which in turn increase the likelihood of non compliance.  Complexities of medication regimens are further complicated by communication difficulties arising from impaired hearing, cognitive impairment, language & cultural difficulties.
  17. 17. Psychopharmacological Treatment of Geriatric Disorders The psychiatrist of an 87 year old patient suffering from heart disease, arthritis and depression must ask a number of questions to himself. Q. What is the best treatment - Pharmacotherapy? Psychotherapy? E.C.T.? Q. If pharmacotherapy, what is the most appropriate drug? Q. Balancing the adverse effect and efficacy. What is the best dosage? Q. How soon will the patient’s symptom decrease? Q. If the drug is effective. How long will the treatment last? Q. If the drug is ineffective how long should the wait before changing the treatment?
  18. 18. GERIATRIC MANIA Risk of Mania decline in late life, nonetheless mania and hypomania affect 5-10% of psychiatric patients. Established mood stabilizers  Lithium salts  Valproate  Carbamazepine  Calcium channel blockers  E.C.T. Putative Mood stabilizes"  L. Thyroxine  Phosphatidyl choline  Progesterone  Clozapine,  Olanzapine  Magnesium salt Newer Anticonvulsants  Lamotrigine,  Gabapentin  Topiramate,  Tigabine Omega 3 fatty acid
  19. 19. Antidepressants in old age depression • Cumulative incidence of depression in people aged upto 70 years is 26.95% for men & 42.5% for women, still most of the drug trials exclude elderly subjects. • In addition, most of the drug trials also exclude subjects with medical comorbidity, which is a rule rather than exception. Hence the results of drug trials done in young adults can't be generalized to elderly.
  20. 20. …Antidepressants in old age depression contd. • Prior to 1995, there were occasional studies which evaluated the use of antidepressants in elderly. But fortunately in the last 10 years many studies have evaluated the use of antidepressants in the elderly. • These studies can be broadly classified as: • Noncomparative studies • comparative studies using either placebo or another antidepressant or both and • meta-analyses of the above studies.
  21. 21. Antidepressant Drugs and Dosages Preferred for Use in the Elderly Geriatric dosage (mg per day) Side EffectsDrugs Starting dosage Maintenance dosage Sedation Agitation Anticholinergic effects Orthostatic hypotension Tricyclic antidepressants Desipramine 25 50 to 150 Low Low Low Low Nortriptyline 10 to 25 40 to 75 Moderate Low Low Selective serotonin reuptake inhibtiors Citalopram 20 20 to 40 Low Low - - Fluvoxamine 50 50 to 200 Low Low - - Paroxetine 10 20 to 30 Low Low - - Sertraline 25 to 50 50 to 150 Low Low - - Miscellaneous Bupropion 100 100 to 400 - Moderate - Low Nefazodone 100 100 to 600 Moderate -- Low Low Trazodone 25 to 50 50 to 300 High - Low Moderate Venlafaxine 75 75 to 350 Low Low Low Low
  22. 22. Cardiovascular  Renal  Diabetes  Hepatic ?  Hematological   Thyroid    Arthritis  Infectious disorders  Metabolic  Disorders Lithium CBZ VPA Anticonvulsants in Depression with medical comorbidity
  23. 23. Psychotic agitation in the elderly with mania Initial treatment  Haloperidol 0.25 to 0.5 mg IM or PO  After one hour, administer lorazepam 0.5mg IM or PO Stabilization  Repeat alternating doses every hour until calm  Monitor carefully to avoid over sedation  Alternative regimen if extra pyramidal symptoms develop  Atypical antipsychitic riseperidone (0.5mg), or olanzapine (2.5 - 5 mg)  Avoid chlorpromazine and thioridazine due to their anticholinergic and hypotensive side effects. Chronic medication  Daily dose of medication is determined by adding the total dose of each medication required to calm the patient and dividing it equally throughout the day.
  24. 24. Adjunctive antipsychotic medication Risperidone  Daily divided doses of .5 to 3mg  Monitor patient carefully for orthostatic hypotension and EPS as dose is increased Olanzapine  Daily doses of 2.5 to 10 mg /day’  Transient elevation in liver enzyme have been reported Risepeidone plus olanzapine  Observe for increased agitation or other manic symptom because of breakthrough mania with risperidone. Clozapine  Reserved for patients who are intolerant of risperidone and olanzapine,  Daily doses start at 12.5mg, increase to 50mg  If history of seizure disorder should be maintained on an anticonvulsant  Monitor for orthostatic hypotension and weekly complete blood count
  25. 25. ATYPICAL ANTIPSYCHOTICS IN THE ELDERLY Drug Metabolite t½ (h) CLR and T½ changes in elderly CYP enzyme involved in metabolism (potential drug interactions) Geriatric doses mg per day Clozapine Norclozapine, clozapine N- oxide (very limited activity) 4-12 CLR decreased CYP1A2, CYP2D6, CYP3A4 (theophylline, digoxin, warfarin) 50 Risperidone 9 hydroxy risperidone (active) 20 CLR decreased t½ prolonged CYP2D6 (inhibitor drugs such as quinidine) 2 Olanzapine 10-N-glucoranide, N- demethyl-olanzapine (inactive) 30 CLR decreased t½ prolonged CYP2D6 (inhibitor drugs such as quinidine) 10 Quetiapine Multiple (main metabolite is a sulphoxide, usually inactive) 6' CLR decreased t½ prolonged CYP3A4 (phenytoin, Thioridazine) 200
  26. 26. COMMON ANTIPSYCHOTIC DRUG INTERACTION IN THE ELDERLY Combination Effect TCAs and conventional antipsychotics Raises blood antidepressant concentrations SSRIs and clozapine Raises blood clozapine concentrations Risperidone and clozapine Raises blood clozapine concentration Smoking Lower blood antipsychotic concentration Cimetidine Lower blood antipsychotic concentration Anticholinergic drugs Additive memory and delirious effects Anticonvulsant, antihypertensive and sedative drugs Additive sedative and delirious effects
  27. 27. Expert consensus guidelines SPECIAL ISSUE IN USING ANTIPSYCHOTICS IN THE ELDERLY  Formulatory decision should be based on cost when drug of comparable efficacy are available.  It is especially important to consider safety and tolerability along with efficacy and cost.  Avoid low and mid-potency conventional antipsychotics as well as clozapine & ziprasidone in elderly patients who have corrected QTc interval prolongation.
  28. 28. …Expert consensus guidelines DISEASE DRUG INTERACTION  Avoid low & mid potency conventional antipsychotics, clozapine and olanzapine in patients who have diabetes mellitus, dyslipedimia and or obesity.  Avoid ziprasidone, low and mid potency conventional antipsychotics and clozapine in patients who have a prolonged QTc interval or congestive heart failure.  Quetiapine is the first line recommendation for a patient with Parkinson’s disease , also consider low dose olanazapine or clozapine for patients with Parkinsons  Avoid high dose of risperidone in patients with Parkinson’s disease
  29. 29. Management of Cognitive symptoms-Dementia • Cholinesterase inhibitors-mild to moderate dementia (Cummings et al., 2004). – Prescription only for- • probable Alzheimer’s disease • duration of illness > 6months • MMSE > 10 – 3 phase response evaluation- • Early (2 wk)-assess tolerance & side effects • Late (3 mth)-assess cognition • Continued (6 mth)- assess disease state
  30. 30. …Management of Cognitive symptoms contd. –Stop treatment if- • Early evaluation-poor tolerance or compliance • Deterioration continues at pretreatment rate after 3-6 month of medication • On maintenance doses, accelerated deterioration
  31. 31. Drugs useful for reducing the signs of dementia Drug Dose Donepezil 5-10 mg daily Rivastigmine 1.5-6 mg b.i.d. Galantamine 4-12 mg b.i.d. Memantine 5-20 mg daily

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