presentation

1. Picking the right drug
Drew Chenelly, Psy.D.

2. Lewy-Body…Vascular Dementia…Alzheimer's Disease
Normal Pressure Hydrocephalus
Fronto-Temporal Dementia…Delirium
Wernicke-Korsakoff…Binswanger's Disease
Parkinson Dementia…Olivopontocerebellar Atrophy
Multiple Sclerosis…Multiple Systems Atrophy
Progressive Supranuclear Palsy…Huntington's Disease
clinical depression…anxiety disorder…psychosis
bipolar disorder…residual schizophrenia

3.  Sudden change in mental status.
 Fluctuating course…worse at night.
 Disordered attention and arousal.
 Gross disorientation.
 Visual illusions or hallucinations.
 Disrupted sleep-wake cycle.
 Emotional disturbance:lability, apprehension, bewilderment, apathy.
 Delusions and bizarre behavior: disrobing in public, urinating in
inappropriate places, talking to nonexistent people.
 Fragmented or disordered stream of thought

4.  Insidious onset…gradual progressive downward course
 Memory impairment… remote less impaired
 Gradual decline in speech and ambulatory ability…leaning gait
 Impaired judgment and ability to abstract
 Late stage = vague visual hallucinations…paranoia
 Apathy…disorientation in space and time

5.  Patchy pattern of intellectual impairment…stuttering course.
 Memory impairment…dilapidation of cognitive functioning…perseveration
 Psychomotor slowing…lack of initiative, spontaneity and perseverance…
fatigue and loss of vigor…apathy.
 Irritability…paranoia…disinhibition… poor judgment
 Gait problems and falls…weakness, ataxia, rigidity, dysarthria, parkinsonism,
urinary incontinence.
 Nocturnal confusion…fluctuating mental status…vulnerability to delirium
and delirium-like episodes

6.  Sudden onset…rapid progression into sever dementia…Parkinson’s
symptoms.
 Cognitive dysfunction must precede the onset of Parkinson’s symptoms by
at least one year.
 Dramatic fluctuations in cognitive dysfunction…intermittent episodes of
confusion…visual hallucinations and paranoid delusions…wide swings in
mood and behavior.
 Acute confusion early in the disease process… episodes of gross confusion
alternating with more lucid intervals …the episodes suggest delirium but
are not due to an underlying reversible cause.
 Intellectual functioning generally better preserved than in Alzheimer’s
disease.

7.  Behavioral disinhibition
 Major personality change
 Vulgar socially inappropriate remarks
 Verbal steriotypies and perservation
 Loss of judgment & insight
 Economical language output

8. LBD PD DAT VaD
Dementia Early Late Gradual Stepwise
EPS Mild,
Parkinson
S Tremor
Severe Parkinson
C Tremor
Late
Rigidity
10 Gait
Fluctuation Sustained None None Diurnal
Syncope Common None None Common
Visual
Hallucination
Persistent
Well formed
Levodopa
Induced?
Late
Vague
Delirium-like
Episodes
Delusions Persecutory Infidelity Misidentification
Paranoia
Other Med
sensitivity
Course Memory
loss
Risk factors

10. and Treatment
Choices
and “delirium-like” ( )= high antidopaminergic drug
• Parkinsonism ( )= low antidopaminergic drug
• Depression uncommon in late
• Disinhibition ( )=mood stabilizer, antidepressant
treat underlying causes
possible VP shunt
= Thiamine Rx
( ) = antidepressant maintenance
antipsychotic = dysphagia

11.  Atypical depression signs: psychomotor agitation, restlessness, depressed
appearance, decreased responsiveness, depressive verbalizations, worry, help
seeking and reduced appetite and food intake =
 Psychotic symptoms: paranoia, hallucinations, illusions, delusions, bizarre
behavior, disorganized thinking, inappropriate affect =
 Emotional and behavioral disinhibition, fluctuating arousal and mental status,
impulsivity, mood swings =
 Anxiety: restless wandering, anguished expression, repetitive verbalizations…
picking, pulling, patting, rubbing =

12. = benzodiazepines suppress respiration
= use drugs cleared less through the kidney
= avoid highly antidopaminergic drugs
= use least cardiotoxic drugs
hypotension…cardiac conduction
= avoid drugs which seizure threshold
…attend to drug interactions
= antipsychotics can impaired glucose tolerance
= Avoid TCAs…Seroquel

13.  MAOI -with other antidepressant = hypertensive crisis
 Tegretol - numerous significant interactions
 Selegiline- with antidepressants coverts to MAOI-A
 Sinemet- avoid highly antidopaminergic drugs
 Additive anticholinergic effects (oxybutinin, atropine)
 Risperdal SSRIs
 Dilantin Seroquel clearance 5-fold
 Prozac VPA to toxic levels

14.  Avoid long acting benzodiazepines due to changes in
clearance and distribution
 Almost all psychotropics are lipophilic = larger distribution
due to more fat stores
 Zyprexa = reduced clearance in older female smokers
 Seroquel = larger decrease in clearance in older patients
than other antipsychotics

15.  Previous response
 Cost
 Avoid polypharmacy
 Lowest dose
 Regulations
 Family concerns
 Warnings
 Off label use
 ID baseline
 One drug at a time

16. Picking the right drug
 Tricyclics (TCA)- Amitriptyline ..Desipramine.. Doxepin.. Imipramine ..do not use
…anticholinergic side-effects
 Hetercyclic (HCA)- Ludiomil do not use
 Monoamine Oxidase Inhibitors (MAOI)- Nardil… do not use due to dietary
restrictions and severe side-effects
 Serotonin-2 Antagonist/ Reuptake Inhibitor(SARI) –Trazodone … highly sedating
 Norepinephrine Dopamine Reuptake Inhibitor (NDRI) –Welbutrin… can be used in
combination with other antidepressants…enhances energy
 Noradrenergic Specific Serotonergic (NaSSA)- Remeron faster onset…possible
sleep disruption…more sedating in lower doses
 Selective Serotonin Norepinephrine Reuptake Inhibitor (SNRI)- Effexor,
Cymbalta, Pristiq faster onset…increases energy…sleep disruption
 Selective Serotonin Reuptake Inhibitor(SSRI)- Celexa Lexapro Prozac Paxil Zoloft

17.  First Generation
low dose - high potency high dose - low potency
antidopaminergic side-effects (EPS) anticholinergic side-effects
Haldol ..Prolixin ..Navane..Stelazine Loxitane…Moban Mellaril…Thorazine
 Second Generation (Saphris) (Clozaril…Geodon)
Risperdal higher antidopaminergic (D2) also Serotonin blockade…long acting…fast acting
Zyprexa less EPS…more weight gain
Seroquel lower antidopaminergic (D2)… short acting…more sedating
 Third Generation
Abilify = Dopamine system stabilizers (Dss)…D2 D3 D4 all affected
Less sedation…fewer drug & disease interactions …less titration...no cardiac effects

18.  Benzodiazepines
short acting long acting
Ativan…Xanax Klonopin Valium…Librium
tolerance …dependence…toxicity…sedation…confusion…falls…respiratory depression..REM
(Serax not prn)
 SSRIs higher doses and longer latency than for depression…OCD type
symptoms…social anxiety …atypical depression signs…phobias Lexapro Paxil Celexa
 Buspirone long latency(12 weeks)…tid dosing…highest dose(90mg qd)
…additive serotonin (SS)

19.  Lithium (Li+) do not use unless Bipolar due to kidney damage
 Valproic Acid (VPA) sedating otherwise well tolerated… better
clearance…less anticholinergic…ER or t.i.d. dosing
 Tegretol induces it’s own metabolism, adjust dose after 8-weeks… monitor
for blood dyscrasias …many interactions…anticholinergic side effects
 Lamictal sedation…nausea…insomnia..rash
 Abilify…Zyprexa and other second generation antipsychotics