false
Catalog
Psychotropic Medications and Older Adults: Update ...
Presentation and Q&A
Presentation and Q&A
Back to course
[Please upgrade your browser to play this video content]
Video Transcription
Hi, today we will talk about psychotropic medications in older adults and an update on safety considerations. The Clinical Support System for Serious Mental Illness, CSS-SMI, is a substance abuse and mental health services administration, SAMHSA-funded initiative implemented by the American Psychiatric Association. I'm Donna Roland, I'm the Director of the Psychiatric Mental Health Nurse Practitioner Program at UT Austin, and I'm on the clinical expert team of this project. I have no disclosures. The objectives today are to identify potentially inappropriate psychotropic medication for use in older adults, understand pharmacodynamics and pharmacokinetics, warranting special considerations when prescribing psychotropic medications for older adults in the attempt to prevent adverse drug events. We'll examine safety considerations and look at reasonable use of polypharmacy and deprescribing intentionally. We'll start by looking at the epidemiology of psychiatric issues in geriatric patients, look at pharmacodynamic and pharmacokinetic considerations as patients age, we'll outline the BRSAI criteria, FDA black box warnings, American Diabetes Association, and APA guidelines for best practices for the use of antipsychotics in older patients. We'll identify potentially inappropriate medications for use in this population and look at treating delirium, dementia, and behavioral disturbances that come with those disorders, treating anxiety and insomnia appropriately, and look at how teams can appropriately manage these conditions. And we'll end with some case studies in outpatient nursing home and inpatient settings. First we'll start with the scope of geriatric use of psychotropics in polypharmacy. Psychiatric issues are a problem in geriatric populations. 15% of older adults age 60 plus have a neuropsychiatric disorder, 7% of whom have a serious mental illness, which can be a disabling condition. Most commonly, those are dementia or neurocognitive disorders and depression. Anxiety disorders make up 4% of those. Substance use disorders 1%, that have been reported. 25% of deaths in the elderly population are related to self-harm among those age 60 or older. Psychosis is not specific to the disorder of schizophrenia. Psychosis can be found in depressive disorders, bipolar disorders, previously those two were combined as a category of mood disorders, functional mental disorders, including the depressive and bipolar disorders, and schizophrenia or schizophrenia spectrum disorders as outlined in the DSM-5. Also psychosis can be found in organic mental disorders, including substance-induced disorders and delirium or dementia, otherwise known as neurocognitive disorder, and amnestic disorders. Psychosis can be found, again, in many different disorders. Psychosis is the mental state of experiencing reality differently from others, having a loss of contact with reality. Most commonly, this is manifest in delusions and hallucinations. Delusions are fixed false beliefs that are very rigid. Hallucinations include perceptual disturbances, most commonly auditory hallucinations or hearing voices, sometimes those can be of the command nature, or visual hallucinations, seeing things that are not really there. Psychosis also can include disorganized thought processes and loose associations, disorganized behavior, including catatonia. This leads to why psychotropic meds are used in long-term care. Are long-term care residents anxious? They can be. They can have anxiety disorders. They can have anxiety brought on situationally. Are they depressed? A subset of patients in long-term care certainly will have depression. Are they in pain? Absolutely. There will be a set of patients in long-term care who have pain. Do long-term care patients have serious mental illnesses or psychosis? Certainly. They are part of our general population, and a certain percentage of our population has a serious mental illness, some of whom have psychosis. Do we think that long-term care residents should be sedated? I would say that the majority of clinicians would say no. What about long-term care residents with dementia? How should they be treated? Does dementia, otherwise known as neurocognitive disorder, always progress into behavioral issues? Most of the time, yes, almost always, and we'll see some statistics on this later. This chart looks at rates of psychotropic meds, specifically antipsychotics, in long-term care. What is appropriate? So let's look here. That top bar is the state median, below at the national median of use of antipsychotics in long-term care. This is from the state of Texas, for example. These rates can be looked up for any state in the United States. The third bar in the dark orange is a state 10th percentile, and below that is the national 10th percentile. So the state of Texas is doing worse, for example, than the national use in antipsychotic rates in long-term care. There are many theories behind this, one of which is that there are less preventative mental health strategies and resources for patients with mental health issues in the state of Texas, and perhaps they're being cared for in nursing homes and long-term care facilities, rather than having preventative mental health care, for example. This is a map showing the average proportion of nursing home residents on antipsychotic drugs across the United States, with the red pockets there being the highest use. California and Texas have the highest number of nursing facilities, with 1,219 and 1,212, respectively, in 2014. California, Florida, Illinois, New York, and Texas have among the highest numbers of nursing facility residents of any state. Excluding facilities where less than half of the residents are over age 65, Texas and New York lead all states in terms of the number of nursing home residents taking antipsychotic drugs without an exclusionary diagnosis of schizophrenia, Huntington's disease, or Tourette's syndrome, meaning that those nursing home facilities don't get dinged, if you will, for inappropriate use of antipsychotic medications. Kansas, Texas, Illinois have some of the highest proportions of residents on antipsychotic drugs. Looking at use of antipsychotics in long-term care, Centers for Medicare and Medicare Services did a study back in 2010 and found that 40% of long-term care residents with dementia without having a behavioral disturbance coded and without having psychosis were receiving antipsychotic prescriptions. They looked at claims and diagnoses. Sometimes this occurred because patients were admitted to long-term care after an acute illness for rehab. They might not get discontinued for long-term. They might have been prescribed Haldol for an acute delirium or agitation, and that prescription persisted. Antipsychotic use might have been appropriate acutely, but again, it never got discontinued. Antipsychotic use is appropriate with indicated use. Those appropriate uses would be, for example, schizophrenia or schizoaffective disorder, bipolar disorder, or depressive disorders as an adjunct to an antidepressive therapy. CMS, or the Centers for Medicare and Medicaid Services, have quality initiatives. They have something called Nursing Home Compare, and this is a rating system that is public, and you can look at these ratings anytime online at that website, and they expanded their five-star quality rating system for nursing homes a few years ago, and they added two quality measures. Antipsychotic use in nursing home for these five-star calculations added short-stay residents without a diagnosis of schizophrenia and long-stay residents without a diagnosis of schizophrenia, Huntington's, or Tourette's, as I mentioned in the previous slide. This is problematic because, as I mentioned, antipsychotic medications have indications for additional diagnoses, such as schizoaffective disorder, bipolar disorder, and adjunctive treatment of depression. These quality measures may be problematic for patients with serious mental illness. Long-term care facilities may not accept patients who are on these medications for appropriate diagnoses. If patients are accepted into these facilities, they may not get appropriate treatment for their serious mental illness that they had prior to admission into a facility and will continue to have for the rest of their lives. Psychiatric providers and case reviewers may endorse appropriate clinical exceptions for these patients if that service is part of that long-term care facility appropriately. We'll talk about that when we get to the section on team management. Do elderly patients really take that many medications? Yes, they do. Polypharmacy is a serious issue, and at times it can be appropriate, but it is important to examine medications periodically for review and see if it can be minimized. The most recent study shows that the average elderly patient is taking 15 medications daily. How can this possibly be consistently done right? Polypharmacy is associated with adverse drug reactions, falls, mortality, and declines in function and cognition. Thirty percent of hospitalizations for elderly people are related to adverse drug reactions. Twenty percent of older adults are prescribed at least one high-risk medication, and five percent are prescribed two or more high-risk medications. Now we'll switch gears and talk about age-related changes in pharmacokinetics and pharmacodynamics. Look at, we'll start with physiologic changes in the different systems. The gastrointestinal system, we'll be looking at absorption of medications. GI system shows decreased acid secretion and stomach pH, decreased blood flow, decreased peristalsis and gastric emptying, as well as saliva production. This can, of course, impact the absorption of medications. And hepatic metabolism is impacted. There's decreased hepatic mass, blood flow as well. Metabolism is reduced, increasing drug half-life and serum level, as those drugs linger in the system. The cytochrome P450 enzyme activity is decreased in elderly patients most often, specifically in the 1A2 and the 3A systems. This leads to less elimination via phase one metabolism. So phase two UGT metabolism is not normally affected by aging. Renal excretion is impacted by aging. There's a decreased GFR, decreased kidney mass, blood flow, and tubular secretion. This leads to prolonged drug half-life and serum level. Consider GFR and or creatinine clearance with dosing for elderly patients consistently. And GFR is a more accurate measure. But most of the time, guidelines are based on creatinine clearance. And the terms tend to be used interchangeably, although they are not interchangeable measures. Body composition affects distribution of medications. Decreased lean body mass and muscle leads to an increased proportion of body fat in elderly patients. What this means is that there is an increased volume of distribution of fat-soluble drugs into those relatively higher fat stores. And there's a decreased volume of distribution of water-soluble drugs. Additionally, decreased levels of albumin increases effects of highly protein-bound drugs. This can make a huge difference in the distribution of many, many medications. Most of the psychotropic medications are fat-soluble. So this change in body composition will increase the half-life of those fat-soluble psychotropic medications. They will be removed slowly from fat stores in unstable serum levels, which are released from those fat stores very erratically. Lithium is a water-soluble medication. And its half-life will be decreased, it will stay in the circulation, and it should be given in lower doses, particularly short-acting, once at night. Now I should look at critical lab values for psychotropic med monitoring and a few specific things to look at in our elderly patients. This is a whole panel that should be looked at for any patients on psychotropic meds. It will point out specifically the CBC should be monitored for platelets. And the CMP should be monitored for, or the BMP, should be monitored for hyponatremia, which is very common for our patients on SSRIs and psychotropic medications. The metabolic panel should be looked at for patients that are in antipsychotic medications. And the renal function, of course. The BEERS criteria, which we'll talk about more shortly, has a nice table outlining common psychotropic drugs that should be examined closely and adjustments made if a patient does have renal impairment. And like I said earlier, the guidelines usually look at creatinine clearance as that marker of the time at which the renal function impairment requires dose reduction. So duloxetine here should be avoided at a creatinine clearance less than 30. Gabapentin and pregabalin should have a reduced dose if the creatinine clearance is less than 60. And tramadol at a reduced dose if the creatinine clearance is less than 30. And it shows the risk here in that third column. Now we'll look at some guidelines for prescribing for older adults. We'll start with the guidelines from the American Psychiatric Association for the use of antipsychotics to treat agitation or psychosis in patients with dementia. They have 15 statements. And we will look at statements one, two, and three here. First I recommend assessment of the symptom type, frequency, severity, pattern, and timing, of course. Next, assessing pain, modifiable contributors, and the subtype of dementia, as some of those subtypes will be treated in a different way. Third statement, quantitative measurement of treatment response, before and after. Some of those that are in red need to be looked at more intently. Statement four and five, for example. Statement four says comprehensive treatment plan with person-centered nonpharmacological and pharmacological interventions is required. And statement five, non-emergency antipsychotics for agitation and psychosis only for symptoms which are severe, dangerous, or of significant distress to the patient. So these are not a first-line treatment choice for patients with agitation or psychosis in dementia. Statement six, review the response to nonpharmacological interventions prior to the use of non-emergency antipsychotic medication. Statement seven, review the risk and benefits with family prior to using. Statement eight, initiate antipsychotic medication at a low dose to be titrated up to a minimum effective dose. Statement nine, with side effects, clinicians should review risk and benefits to determine if tapering and discontinuation is indicated. Statement 10, a gradual dose reduction attempt after four weeks without adequate clinical response. So this means if a patient is not responding clinically to an antipsychotic medication, a gradual dose reduction and discontinuation preferably is warranted. And I'll skip to statement 12 for a moment. If a patient is responding well to a medication, an antipsychotic medication, after four months, a gradual dose reduction should still be attempted. Maybe the medication will not be discontinued, but it will be reduced to the point at which it is effective at the minimal dose necessary. Back up to statement 11, with adequate clinical response, continuing tapering decision-making should be reviewed with patient family regarding preferences, concerns, benefits, and risk-benefit ratio. Statement 13, during this gradual dose reduction process, monthly symptom assessment until four months after discontinuation should occur to identify recurrence. So just when a medication was discontinued, monitoring of that patient should not cease at that point. Statement 14, except in cases of delirium, Haldol should not be used as a first-line agent for agitation, psychosis, and dementia. And later on, we'll get to the preferred agents and doses for patients with, for elderly patients. Statement 15, long-acting injectable antipsychotics should not be utilized unless indicated for co-occurring chronic psychiatric disorders. So for agitation and psychosis and dementia, long-acting injectables are not indicated. However, if the patient has a serious mental illness for which they are indicated, that patient may use them, but not specifically for dementia, agitation, or psychosis. Okay, the BEERS criteria is another guideline to try to lead medication prescribing for geriatric patients in a safe way. It is called BEERS Criteria for Potentially Inappropriate Medication Use in Older Adults, Potentially Inappropriate Medication. The abbreviation for that is PIM, or PIMS. And this long name is usually known as the BEERS list or BEERS criteria. It is developed by the American Geriatric Society, and it was recently updated two months ago in this year, 2019. The previous iteration came out in 2015. It is developed by an expert consensus panel using a Delphi method. They look at systematic reviews and research of evidence on efficacy and safety in older adults specifically. It was established in 1991, and it has been updated five times. Examples of the BEERS criteria are for an educational tool for practicing clinicians to improve medication selection and decrease adverse drug reactions in the elderly population. It is a quality measure for facilities. It is not intended to be utilized as a punitive tool, although one might see how that could happen. These are the 10 tables that are included in the BEERS criteria this year in 2019. These vary slightly from year to year. So we have designations of quality, evidence, and strength, how the evidence was determined. Then we have Table 2, which is a very important table, the criteria for Potentially Inappropriate Medication Use in Older Adults. Then there is a table on Drug Disease or Drug Syndrome Interactions. Then there is a table on Drugs to be Used with Caution. Then there's another table on Drug-Drug Interactions. Table 6, Medications to be Avoided with Varying Levels of Kidney Function. Table 7, Drugs with Strong Anticholinergic Properties, which is a new table this year. Table 8, medications criteria removed since the last edition. Table 9, medications added since the last edition. And table 10, criteria that were modified since the last edition. Relevant updates this year, there was a clarification of the warning about avoiding 3 plus concomitant CNS active drugs, because this increases the risks of falls and fractures. These CNS active drugs include antidepressants, benzodiazepines, and opioids. This warning came out in 2015, and this year it was just clarified. A new update, or a new warning, was the second point here, use with caution. Dextromethorphan plus quinidine, which is a compound known as Nutexta, limited efficacy in dementia behaviors, increases the risk of falls and drug interactions. The only FDA indication for this medication right now is for PVA or pseudobulbar affect, although this work is in trials for other conditions. Tramadol was added to the list of drugs to monitor sodium for the risk of hyponatremia. And as I just mentioned, new Table 7 drugs for anticholinergic properties, and new interaction was added for opioids plus gabapentin and pregabalin. Another guideline for the use of prescribing in geriatric patients is called Stop-Start Guidelines. This is a European toolkit for medication review by system for elderly patients, by body system. Stop stands for Screening Tool of Older People's Potentially Inappropriate Prescriptions, and Start stands for Screening Tool to Alert Doctors to Right Treatments. And the link is there to the version two, which is the most current. And this guideline includes several chapters, starting with prescribing resources, evidence-based approach to prescribing in the elderly, gastrointestinal system, nervous system, all of the systems, chapter on nutrition, a chapter on anticholinergic burden, et cetera. They look at examining the different types of medications by admissions to hospitals and adverse drug reactions. And notably, they found that antidepressants and lithium cause 7.1% of adverse drug reaction admissions. This is a UK guideline, but notably, the antidepressants and lithium cause more adverse drug reaction admissions than do opiates, which are at 6%. And their system is colorful. They have the red, which is a medication to consider stopping in patients over 65, green, medication to consider starting in patients over 65, that are the appropriate medications in those categories. And then they have, in blue, the NICE guidelines for other supporting or useful information. And NICE is the UK guideline based on what's called National Institute of Health and Care Excellence. Next, we have black box warnings guiding us to tell us what high-level safety issues are. Black box warning is the strongest FDA warning in a package insert in our detailed prescribing information. I have a sample here about the use of atypical antipsychotics in the elderly that came out when the FDA issued this black box warning in 2005. Prescribing of antipsychotics for elderly fell steeply after this. And this is one that came out in the Risperdal packaging, for example, but it's a class warning, and so it's labeled in all antipsychotics. It says, warning, increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Blank antipsychotic is not approved for use in patients with dementia-related psychosis. This black box warning for use in elderly with dementia leads to an increased risk of CVA, MI, cognitive decline, and mortality in persons with dementia. I just read this to you, but it's quoted here again. In actuality, it has a 1.2 to 1.6 odds ratio, or times higher risk of death than placebo. Research published in the New England Journal of Medicine has found this risk of sudden death from antipsychotic drugs to have a dose-response relationship. And the risk of death is associated more with increased age, lower level of education, male gender, worse cognition, EPS, psychosis, and high doses than exposure only to the antipsychotic. But the label remains. Our recommendation is also to follow from the American Diabetes Association. For patients with serious mental illness, we are to carefully monitor changes in weight and glycemic control, as well as cholesterol levels. Annually, patients with SMI should be screened that are on second-generation antipsychotics. If any significant changes are noted, treatment regimen should be reassessed. Patients who have a serious mental illness and diabetes should incorporate monitoring of diabetes self-care activities into treatment goals. The clinician should be doing this for these patients. So back to Beer's criteria and their recommendations. On the topic of antipsychotics, avoid antipsychotics, first-generation and second-generation or atypical antipsychotics, except with the diagnosis of schizophrenia, bipolar disorder, or chemotherapy. For Parkinson's disease, pemivansirin was added in 2019 as the preferred agent. Clozapine is preferred secondarily. Quetiapine is acceptable, and others are to be avoided, according to Beer's recommendations. Risks are associated with use in elderly with dementia. Beer says that there's an increased risk of CVA and greater rate of cognitive decline and mortality in persons with dementia, echoing the black box warning. Avoid unless non-pharmacological options have failed and threats of substantial harm to self or others. There's other evidence of hypotension with falls, cardiac dysrhythmias, QTC prolongation on an EKG, fractures, unnecessary hospitalizations, extrapyramidal side effects, swallowing issues, aspiration pneumonia. These are also risks that are associated with the use of antipsychotic medications in the elderly. So the new table included in the Beer's criteria this year talks about drugs with strong anticholinergic properties. We have antidepressants, antiemetics, antihistamines, antiperkinsonian agents, antipsychotics, and drugs that may exacerbate SIADH or hyponatremia requiring monitoring of sodium levels. So antidepressants include tricyclic antidepressants and paroxetine is the only SSRI that made the list. Antiemetics, we have procorperazine or compazine and promethazine or phenergan. Antihistamines have stayed the same here. And the antiperkinsonian agents, we have benztropine or cogentin, which is an antagonist of acetylcholine and histamine. And we have trihexylphenidyl, which is artane, which antagonizes acetylcholine receptors. And for the antipsychotics, we have chlorpromazine or thorazine and two second-generation antipsychotics, clozapine and olanzapine. And the drugs that may exacerbate SIADH or hyponatremia include antipsychotics, carbamazepine, mirtazapine, oxcarbazepine, SNRIs, SSRIs, TCAs, and newly listed is Triamval. So next we'll look at beer's potentially inappropriate meds by category and disease state. First, we'll look at antiemetics. And even though these aren't being prescribed here as psychiatric medications, they are indeed psychoactive medications, at least in mechanism of action. First, we have metoclopramide or Reglan, and the beers recommends avoiding. It can cause EPS, including TD. Their recommendation is duration is not to exceed 12 weeks. There is a black box warning for Reglan that after 12 weeks, there's a risk of TD, especially in females. And the mechanism of action of this drug is that it antagonizes central and peripheral dopamine receptors. The second box on the anticholinergic list in beers includes prochlorperazine, formerly known as compazine. This drug has a black box warning that it's not approved for dementia-related psychosis. And the mechanism of action of this medication is that it non-selectively antagonizes central and peripheral H1 receptors and that it's also categorized as a phenobiazine antipsychotic. Also in that middle box, promethazine or Finnegan has a black box warning of respiratory depression less than age two and another black box warning of severe tissue injury or gangrene. And the mechanism of action of this drug is that it is non-selectively antagonized central and peripheral H1 receptors and it is also a phenobiazine antipsychotic. And in the last box, all three antiemetics should be avoided with Parkinson's disease. Dopamine receptor antagonists have the potential to worsen symptoms of Parkinson's disease. Beers has also guidelines for patients who have a history of falls on the left column and for patients who have a history of syncope in the right column. So drugs to avoid the history of falls and fractures including antipsychotics, benzodiazepines and benzodiazepine receptor antagonists or Z-drugs, antiepileptics, opioids, antidepressants including tricyclics, SSRIs and this year SNRIs were added to that list. They do have disclaimer language on the antidepressant language, which I will read. Following a principle that applies to all criteria the panel recognizes there may be situations when SNRIs, other antidepressants and other medications listed in this criterion may be appropriate for people with a history of falls or fractures based on potential benefits and the lack of availability of safer alternatives. So these medications can be used but prioritized last and after other options have been trialed. The second column looks at drugs to avoid with a history of syncope and the list starts with acetylcholinesterase inhibitors for dementia, non-selective peripheral alpha-1 blockers such as prazosin, tertiary tricyclic antidepressants which include amitriptyline, clopiramine and mipramine and doxepin, specific antipsychotics thorazine, melaril and olanzapine. This next table, actually I want to back up and say something about the falls. In an article from Walcott in the archives of internal medicine they looked at odds ratios and falls in the elderly and benzodiazepines and antipsychotics and antidepressants, all three had similar odds ratios but I wanted to have 1.6, 1.7 and 1.7 but I wanted to point out that they were all higher than the odds ratios of causing falls from antihypertensives, diuretics, beta blockers and even narcotics. This table looks at potentially clinically important drug interactions. So of course there is a drug interaction with opioids and benzodiazepines. There's a black box warning related to this we'll look at shortly. This new warning is the second row, opioids and gabapentin and pregabalin, this was added this year increased risk of severe sedation related adverse events including respiratory depression and death. Anticholinergics, interacting with other anticholinergics and building up that cumulative anticholinergic burden and CNS active drugs as I mentioned before, three or more of those combined is risky causing an increased risk of falls and fractures. Lithium and acetylcholinesterase inhibitors and lithium and loop diuretics causing an increased risk of lithium toxicity. So what are we supposed to do to treat delirium and dementia and the behavioral and psychotic manifestations? First we'll start with defining delirium. It is a temporary reversible medical condition that can result in impaired cognitive function and causes are outlined here with some mnemonics. I watch death. Causes include infections, withdrawal from substances, acute metabolic issues, trauma, CNS pathology, hypoxia, deficiencies, endocrinopathies, acute vascular issues, toxins or drugs and heavy metals. Delirium is treatable and reversible, but do note that delirium and dementia can co-occur. Patient can have dementia already and then also on top of that develop an acute delirium. The distinguishing signs of delirium are that it has an acute onset, cognitive fluctuations over hours of delays rather than an insidious development of a dementia. With delirium there's impaired consciousness and attention, sleep cycles begin to be altered very quickly and again delirium is reversible and dementia is not. Once the underlying cause of delirium is treated, the person returns to their prior level of functioning. Dementia with behavioral disturbance and psychosis as I mentioned earlier behavioral symptoms associated with dementia occur in most patients. 90 to 100% of patients will have behavioral issues or mood issues or psychosis as the disease progresses. These can look like depression or mood instability, anxiety, agitation, aggression, psychosis or executive dysfunction. Executive dysfunction can include disinhibition, apathy or diminished motivation, sexually inappropriate behavior even in a person who would not normally do that. This can be, you know, the family coming in and telling you, I can't believe my dad did that. He would never in a million years do that and would be so ashamed. Intrusive silly comments, ingestion of non-food objects, perseveration or repetition of phrases. CMS regulations for long-term care include targets that are inappropriate for antipsychotic treatment or things that should not be prescribed in antipsychotic medication. These include wandering, exit seeking, insomnia, poor self-care and cooperation, sadness or crying if a patient does not have an indicated psychiatric disorder, nervousness, fidgeting, restlessness, memory impairment, indifference or yelling. So BEARS has a couple of guidelines on drugs which may exacerbate delirium and those which may exacerbate dementia or cognitive impairment. So to start with delirium, antipsychotics, benzodiazepines, opioids, specifically Demerol, H2 receptor antagonists. Those are seemingly benign things like Pepsit, Tagamet, Zantac. The H2 receptor antagonists were removed from the dementia cognitive list below. As they didn't have strong evidence for worsening cognition. However, they may still exacerbate delirium. Anticholinergics were added to the list this year of drugs which may exacerbate delirium. Moving on lower there to drugs which may exacerbate dementia or cognitive impairment. We have antipsychotics, whether they're scheduled daily or used as needed. Benzodiazepines, non-benzodiazepine receptor antagonist hypnotics or the Z drugs and anticholinergics were added to this category as well this year. We'll look at treatment of dementia and behavioral disturbance and psychosis. Before prescribing psychotropic meds, we must rule out medical and neurological causes. Very commonly a UTI can cause behavioral disturbance in a patient with a previous diagnosis of dementia. It can cause delirium, can cause this activation. Pseudobulbar affect is something else that can be ruled out in this patient before giving antipsychotics or some other psychotropic medication. First line pharmacological treatment is of the underlying disease or progression of the disease. So we would maximize the dosing of acetylcholinesterase inhibitors including denepazil or aricept, ribostigmine or exsilon or galantamine and add an NMDA antagonist or memantine. There's even a combination pill called namxeric that combines denepazil and memantine. So maximizing those doses and targeting the underlying disease progression is the first line treatment. Second line calls for SSRI specifically sertraline and escitalopram or mood stabilizers such as depakote. This can be depakote sprinkles in low doses or oxcarbazepine, gabapentin or carbamazepine. And then the combination of SSRIs and mood stabilizers before moving on. And here is a flow chart of the first line, second line, third line and fourth line medications. So level one is memantine being added on to an acetylcholinesterase inhibitor. Level two antidepressants, level three divulproics and derivatives and lastly antipsychotics specifically quetiapine, aripiprazole, risperdal and olanzapine. Is off-label use of antipsychotics in elderly patients legal? Use is considered off-label if a patient has no psychosis or not treating bipolar or adjunctive depression for which there's an FDA indication. Off-label use is not an FDA violation. It is commonly done. However, documentation is required to show failed attempts of standard treatments, patient-centered benefits outweighing the risks, education to patient, family or legal representative of the off-label status and that the benefits outweigh the risks and that the previous treatments have not been completely successful. It is a last-line effort to use antipsychotics in this population only after documented failure of prior efforts and use those lowest possible doses. Atypicals are recommended and best tolerated. Again, that's quetiapine, aripiprazole, risperdal and olanzapine. And again, CMS requires quarterly attempts at gradual dose reduction as we mentioned before earlier in the APA guidelines. The quarterly, excuse me, the gradual dose reduction with or without clinical benefit and that was four weeks and four months, but CMS requires quarterly attempts at gradual dose reduction for patients who are in long-term care facilities ongoing as long as they are in those facilities. I'm going to take a quick look at antipsychotic mechanism of action. First and second generation and even some are calling the newest atypicals third generation, all reduced dopaminergic transmission targets targeting positive symptoms of psychosis by blocking D2 receptors, postsynaptic receptor, through postsynaptic receptor antagonism. First generations bind to D2 receptors more tightly, second generations dissociate rapidly from D2 receptors. The so-called third generation antipsychotics have D2 partial agonism. That's aripiprazole, brexpiprazole and criprazine. First and second generations can also block H1M1 and alpha-1 receptors. Second generations more potently antagonize 5-HT2A receptors much more so than antagonizing D2 receptors. Some second generations and third also agonize 5-HT1A receptors increasing dopamine release in the prefrontal cortex which reduces glutamate release as well. So this 5-HT2A antagonism is supposed to decrease depressive symptoms and the 5-HT1A agonism is supposed to work to decrease anxiety to symptoms anxiety symptoms much like it does for buspirin as it is the mechanism main mechanism of action for that medication and glutamate causes neurotoxicity as in Lou Gehrig's migraine seizures psychosis and mood instability. Receptor affinity and binding are the key properties that distinguish the first generation dopamine antagonists from the succeeding generations of drugs. Receptor affinity refers to the extent a ligand binds to a receptor and activates neural firing. The first generations primarily are D2 agonists, second generation primarily 5-HT2A antagonists primarily and the third generations are being considered as dopamine modulators. And the four dopaminergic pathways are illustrated here. They are related to the effects and the side effects of antipsychotics of the nigrostriatal, mesolimbic, tubero-infandibular and mesocortical which we'll look at on the next slide as well. We're trying to target symptoms we also have to anticipate these side effects. So the mesolimbic pathway is where the positive symptoms of psychosis are targeted auditory visual hallucinations and delusions. Mesocortical where the negative symptoms of psychosis are targeted the emotional flattening apathy and anergia. Nigrostriatal is where the EPS symptoms are found apathesia, pseudoparkinsonism and also tardive dyskinesia and tubero-infandibular pathway is where prolactin function is located. Antipsychotic targets what we ideally try to do is target 60 to 80 percent D2 receptor occupancy between these two lines we get the effect of the antipsychotic without exceeding threshold for EPS. This slide and these histograms represent simplified receptor binding affinity profiles for atypical antipsychotics. Blue represents receptors whose effects are potentially therapeutic red potentially leading to red representing those potentially leading to side effects. In the middle 5-HT2C and D2 may lead to either. So from left to right we have 5-HT1A then 5-HT2A then 5-HT2B, 5-HT2C, D2, Alpha 1A, Alpha 1B, M1 and H1. I really like these in this illustrated manner for aripiprazole, olanzapine, catepine and risperidone. This table shows the binding for the so-called third generation antipsychotics aka dopamine modulators aripiprazole, brexpiprazole and cariprazine and all the receptors involved. The lower the number the stronger the affinity therefore the stronger the clinical effect of these partial agonists of D2. They all and the four strongest receptors of each the first four rows they all impact D2 and 5-HT2A like the second generation agonists. Some also 5-HT1A plus D3 seems to be a big impactor in these medications. Here we have recommended doses of antipsychotics in elderly patients for schizophrenia, for Parkinson's and for dementia. We have Abilify, olanzapine, Vega, Seroquel and Risperdal listed here and you'll note that the doses are much lower than they are for schizophrenia or bipolar or depressive, depressed antidepressant adjunct. This information is from an article that Stahl put out recently. His new hope for Alzheimer's dementia as prospects for disease modification fade, symptomatic treatments for agitation or psychosis and these are drugs that are in the pipeline. Brexpiprazole is being studied for agitation and dementia. Pimivanserin that's being used for Parkinson's psychosis, the non-dopaminergic antipsychotic and again the dextromethorphan that is in the current product new dextra for PVA is being studied by many companies. The quinidine for its use in 2d6 and lengthening the half-life deuterated version of it and bupropion also for dementia agitation. Hopefully we'll hear more about this soon. And I just mentioned Pimivanserin the non-dopaminergic antipsychotic was released two years ago and targets symptoms of hallucinations and delusions and it is an inverse agonist antagonist of 5-HT2A and C. Currently only FDA indicated for Parkinson's disease psychosis. It also is known to decrease depressive symptoms but is targeted to decrease hallucinations and delusions. Now we'll look at some non-pharmacological approaches to avoid antipsychotics. These tend to be more directive. First discerning the emotion underlying the psychotic symptom and responding First discerning the emotion underlying the psychotic symptom and responding to that for example the delusion of I need to see my father. The staff response they can sense grief but redirect them to a pleasurable reminiscence tell me about your father what's your favorite thing you did together for example. Before a patient who might be overstimulated or disorganized or disoriented offering offering gentle commands being more directive instead of requests for example you need to come this way the van is waiting instead of won't you please get in the van. Now we'll shift to anxiolytics and safety warnings for elderly use. Common diagnosis for the use of anxiolytics include GAD panic disorder social anxiety OCD major depressive disorders PTSD and adjustment and trauma dementia and personality disorders. Mechanism of action all anxiolytics work on gamma amino butyric acid or transmitter or GABA which decreases anxiety in the body. We'll focus on benzodiazepines here which bind to benzodiazepine receptors of the GABA-A ligand gated chloride channel complex and enhancing the inhibitory effects of GABA. Commonly used benzodiazepines with hepatic impairment are listed here. You can remember the mnemonic lot lorazepam oxazepam and temazepam which have no hepatic metabolism. Common side effects of anxiolytics in the elderly include of course increased falls dizziness problems with judgment and cognition sedation dependence tolerance and ideally it should be used short-term only. What the beers criteria has to say about benzodiazepines is here. Avoid them because older adults are sensitive to benzos have decreased metabolism increased risk of cognitive impairment delirium falls fractures motor vehicle accidents accidents adverse events mimic psychiatric symptoms however lung acting agents may be appropriate for seizure disorders from sleep disorders benzodiazepine or alcohol withdrawal and anesthesia with severe GAD being added as an exception this year using clonazepam or diazepam is recommended also the beers list list clonidine as a central alpha agonist to avoid. Z-drugs or GABA benzodiazepine receptor antagonists versus benzodiazepines in the elderly. Z-drugs include zolpidem or ambien zaloplan or somata or s-zopiclone or lunesta. Beers says to avoid them their adverse drug reactions are similar to benzos however the Z-drugs have less incidence of daytime sleepiness orthostatic hypotension respiratory depression and retrograde amnesia the Z-drugs do carry class effect however of delirium sleepwalking and fractures. Appropriate medications to treat anxiety and elderly population include SSRIs SNRIs there is that warning about history falls and antidepressants augmentation with buspirone antihypertensive meds alpha and beta blockers other antidepressant medications as well mirtazapine and walbutrin. There are a lot of interactions with anxiolytics in addition to elderly patients having increased risk of drug-drug interactions due to comorbid medical and psychiatric conditions um but for everyone depakote interacts with benzodiazepines increasing the benzodiazepine level mirtazapine interacts with benzodiazepines increasing increasing cns depression and cns depressants with benzodiazepines here alcohol and benzodiazepines combined increase cns depression as do opioids combined with benzodiazepines we'll look at that black box warning in just a moment non-pharmacological approaches to avoiding xylitics include things like progressive relaxation yoga hypnosis cbt biofeedback and breathing retraining here's that black box warning the FDA issued in 2016 that is not specific to the elderly this is for everyone and it reads like this risks from contaminant concomitant use with opioids concomitant use of benzodiazepines and opioids may result in profound sedation respiratory depression coma and death reserve concomitant prescribing of these drugs for use in patients whom alternative treatment options are inadequate limit dosages and durations to the minimum required follow patients for signs and symptoms of respiratory depression and sedation this is very serious and it is unfortunately too common that these medications are prescribed in combination comprehensive team care approach is very important check the pdmp for every patient what is a pdmp people might ask prescription drug monitoring program is an electronic database that tracks control controlled substance prescriptions in a state pdmps can provide health authorities timely information about prescribing and patient behaviors that contribute to the epidemic and facilitate and nimble and targeted response it is legally required for prescribers to use a pdmp in some states promising features include universal use real time actively managed and ease easy to use and access systems i've put a link here for online databases for people to find which system is used in each state i have a hospital case example of mine here where one time last year i had a patient who was about 80 years old female she was admitted for alcohol detox but once assessed it was found that she was acutely depressed and suicidal and the nurse was asking us to reconcile her home medications because she was not a good historian and our pmp system showed that her pcp last month had prescribed on the same day 91 milligram atavans and 90 norco tablets i can't remember the dose of those but it was shocking because she was suicidal and had a history of some overdose attempts as well and she was in for a very serious amount of alcohol ingestion then for detox so these can be very very useful tools for reconciling medications not only but keeping patients safe team approaches to management psychotropics and elderly include close collaboration with an interdisciplinary team this can include close patient monitoring and ongoing staff communication more ideally monthly psychotropic team review meetings can be essential this can include the director of nursing the psych mental health aprn or psychiatrist pharmacist and social work in these meetings would identify any medications with the potential to cause psychomotor agitation or other symptoms assessment for akathisia from psychotropic meds assess labs medical conditions rule out any infections or delirium loss of consciousness changes and level of consciousness attention fluctuation look at the data in the chart on behaviors prn utilization review etc intentional deprescribing includes a five-step process this is very important in reviewing patients who are elderly as medication and determining whether they need to stay on a bunch of medications indefinitely it includes five steps the first one is ascertaining that all drugs a patient is currently taking and the reasons for each one ask patients and caregivers to bring all drugs prescribed complementary and alternative medicine and over the counter ask about any regularly prescribed drugs not being taken and if so why not the second step is consider overall risk of drug-induced harm in individual patients and determining the required intensity of deprescribing information the number of drugs the use of high-risk drugs past or current toxicity patient factors like age cognitive impairment comorbidities substance use multiple prescribers past or current non-adherence third step assess each drug for its eligibility to be discontinued its indication actual or potential harm of a drug clearly outweighing potential benefit and if if it's ineffective or symptoms have completely resolved any unacceptable treatment burden identify drugs prescribed to counteract adverse effects of other drugs identify drugs to avoid in older patients such as through the guidelines that we've been looking at ask a patient since you started this medication hasn't made much difference in how you feel or that you would prefer to stay on it do you feel the medication is still required determine the patient's expectations and preferences fourth step prioritize drugs for discontinuation deciding the order of discontinuation of drugs that first those are the greatest harm and least benefit second those easiest to discontinue and third those that the patient is most willing to discontinue first and finally the fifth step implement and monitor drug discontinuation regimen communicated plan and contingencies to all health professionals and other relevant parties lastly we'll look at three very brief case studies first is an outpatient case study a 74 year old female presents to her outpatient psychiatrist office with her daughter after visiting the er for increased confusion falls and unsteady gait her daughter report said the patient has been having worse worsening cognition over the past several weeks with increased falls the patient has a history of bipolar 2 disorder but no history of dementia her current med medications include the following the razapam 0.5 bid depakote er 250 bid metoprolol 25 bid benadryl 25 qhs lipitor 10 qhs what could be causing the patient's current symptoms and what should be done to fix the problem oops so this patient is on the razapam which could be increasing her falls or worsening cognition it's on the beers list she's getting depakote er and lorazapam which interact depakote raises lorazapam levels causing increased side effects she's also getting benadryl which is anti-cholinergic which could cause these symptoms as well we would want to closely monitor her vital signs including blood pressure get a depakote level to start and then take it from there next we'll move to a case study in the nursing home 82 year old man is being seen in the nursing home who continues to report some increased tiredness constipation and weakness in his legs the staff at the nursing home report he's had several falls over the past month the patient has no psychiatric history except for increasing anxiety and agitation with adls and here are his meds hydrocodone 5 325 bid gliburide 10 qam metformin 500 bid alprazolam 0.5 tid lisinopril 20 qhs benadryl 50 qhs peer and allergies what could be causing the patient's current symptoms and what should be done to fix the problem so for this case alprazolam increases fall risks again on the beers list hydrocodone and alprazolam interact causing an increased risk for falls due to both being sedating and causing poor judgment and again is on the it has the black box warning for increased sedation or risk of death he's getting benadryl which is anti-cholinergic and all anti-cholinergic meds cause increased falls and can contribute to cognitive issues i would discontinue alprazolam by a very slow taper and change to an approved agent ssri snri buspirone carefully because again he has history of falls have a pc have the pcp change hydrocodone to a better opioid medication that causes less sedation and fall risk or perhaps tramadol tylenol-3 codeine etc discontinue peer and benadryl and change to a better medication for allergies that are not anti-cholinergic such as claritin or zyrtec and see how that goes and continue to monitor and the last case inpatient psychiatry 66 year old female admitted to inpatient hospital for aggression towards son impulsivity attempted to set his car on fire quote so he would burn in hell for taking my keys away from me he steals everything from me unquote she believes that quote everyone in here is recording everything i say i we say with their illegal phone devices they carry around end quote patient has history of progressing alzheimer's dementia that's no other psychiatry history patient is ambulatory and study taking other patients walkers from them and using them to hit staff visitors quote intruders unquote she sees and hears and here are her current medications ericep 5 qhs stefakos sprinkles 125 vid lisinopril 30 qam plaquenil 200 vid haldol 10 vid what are our care priorities and what medication adjustments would be recommended so here haldol interactions include lisinopril increasing hypertension ericept um i would increase the levels of ericept oh sorry increase haldol increases the levels of ericept um inhibiting the hepatic metabolism and haldol also increases the risk of cns depression psychomotor impairment so safety of the unit would be a strong priority but also we need to decrease the behavioral disturbance impulsivity and aggression ericept qhs is not at an optimal dose so it depends on how long she's been on that five milligram dose we may need to increase it and potentially add an amenda our third priority our third priority is the paranoia and the psychosis she believes that um her son is stealing things and that everyone is recording and intruders are out to get her so the haldol is not an ideal um antipsychotic for her age so we potentially change her to seroquel starting at 25 milligrams and quickly tapering that up and potentially increasing the deprecate sprinkle dose for her impulsivity and moodly ability and that is the end of this presentation thank you very much for your attention
Video Summary
The video discusses the use of psychotropic medications in older adults and provides an update on safety considerations. The video is presented by Donna Roland, Director of the Psychiatric Mental Health Nurse Practitioner Program at UT Austin, and a member of the clinical expert team for the Clinical Support System for Serious Mental Illness (CSS-SMI), a SAMHSA-funded initiative implemented by the American Psychiatric Association.<br /><br />The objectives of the video are to identify potentially inappropriate psychotropic medications for use in older adults, understand the pharmacodynamics and pharmacokinetics that require special considerations when prescribing psychotropic medications for older adults to prevent adverse drug events. The video also examines safety considerations, polypharmacy, and intentional deprescribing.<br /><br />The video starts with an overview of the epidemiology of psychiatric issues in geriatric patients, followed by a discussion on the pharmacodynamic and pharmacokinetic considerations as patients age. The video outlines the BRSAI criteria, FDA black box warnings, American Diabetes Association, and APA guidelines for best practices in the use of antipsychotics in older patients. Potentially inappropriate medications for use in this population are identified, and the video discusses the treatment of delirium, dementia, and behavioral disturbances. It also explores the appropriate management of anxiety and insomnia.<br /><br />The video concludes with case studies in outpatient, nursing home, and inpatient settings to illustrate the application of the discussed concepts. The importance of team management and the role of the Prescription Drug Monitoring Program (PDMP) are highlighted. The video emphasizes the need for a comprehensive approach to prescribing in older adults, including close collaboration with interdisciplinary teams and a focus on intentional deprescribing.<br /><br />No credits are mentioned in the video transcript.
Keywords
psychotropic medications
older adults
safety considerations
pharmacodynamics
pharmacokinetics
adverse drug events
polypharmacy
intentional deprescribing
geriatric patients
best practices
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
×
Please select your language
1
English