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Side Effects of Psychiatric Medications in Long Term Care Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry UNMC.

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Presentation on theme: "Side Effects of Psychiatric Medications in Long Term Care Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry UNMC."— Presentation transcript:

1 Side Effects of Psychiatric Medications in Long Term Care Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry UNMC

2 Objectives Delineate common psychiatric medications used in long-term care Delineate common psychiatric medications used in long-term care Identify common side effects associated with those medications Identify common side effects associated with those medications

3 The Falling Man 78 year old white male 78 year old white male Parkinson’s disease Parkinson’s disease Hypothyroidism Hypothyroidism Hypertension Hypertension High cholesterol High cholesterol Constipation Constipation Insomnia Insomnia Cognitive decline Cognitive decline Depression Depression

4 The Falling Man Getting along fairly well up to a week ago Getting along fairly well up to a week ago Onset of delusions about wife and children stealing his money, staff is poisoning his food Onset of delusions about wife and children stealing his money, staff is poisoning his food Fearful, weight loss, verbal and physical aggression Fearful, weight loss, verbal and physical aggression CBC, CMP, TSH, UA, vital signs all normal CBC, CMP, TSH, UA, vital signs all normal Medical cause seems ruled out Medical cause seems ruled out Seroquel 12.5mg at bedtime started Seroquel 12.5mg at bedtime started Within a day his delusions decline Within a day his delusions decline Falls twice in three days Falls twice in three days Medication stopped, delusions return Medication stopped, delusions return

5 The Falling Man Other medications Other medications Sinemet and Mirapex Sinemet and Mirapex Zoloft Zoloft Aricept Aricept Synthroid Synthroid Lasix and Lopressor Lasix and Lopressor Colace, MOM Colace, MOM Trazodone Trazodone

6 Classes Antidepressants Antidepressants Anti-anxiety agents Anti-anxiety agents Mood stabilizers Mood stabilizers Antipsychotics Antipsychotics Sleep agents Sleep agents Dementia medications Dementia medications

7 Why do you get side effects? Medications try to alter brain chemicals Medications try to alter brain chemicals Just the wrong drug Just the wrong drug Reasonable choice, dosage, etc. Reasonable choice, dosage, etc. Dose may be too high Dose may be too high Dose-dependent Dose-dependent May not see at lower doses May not see at lower doses Many of these chemicals present throughout the body Many of these chemicals present throughout the body Medications cannot be specific only to the brain Medications cannot be specific only to the brain Targeting the brain, problems in the stomach Targeting the brain, problems in the stomach Allergic reactions Allergic reactions Rash to anaphylaxis Rash to anaphylaxis Drug to drug interactions Drug to drug interactions

8 Don’t all medications have side effects? Yes, so does breakfast cereal Yes, so does breakfast cereal Look at common side effects Look at common side effects Help you with recognition Help you with recognition Much more informed patients and guardians Much more informed patients and guardians Rare side effects not focus Rare side effects not focus Make your head swim Make your head swim Zillions listed Zillions listed Even if it happened once Even if it happened once Someone may have gotten this from the medication Someone may have gotten this from the medication Some times concurrent things happen Some times concurrent things happen Had gastroenteritis during the drug study Had gastroenteritis during the drug study

9 Antidepressants SSRIs SSRIs Selective Serotonin Reuptake Inhibitors Selective Serotonin Reuptake Inhibitors Most widely used class Most widely used class Relatively safe in overdose, few drug interactions Relatively safe in overdose, few drug interactions Readily prescribed in the elderly Readily prescribed in the elderly Prozac (fluoxetine) Prozac (fluoxetine) Zoloft (sertraline) Zoloft (sertraline) Paxil (paroxetine) Paxil (paroxetine) Celexa (citalopram) Celexa (citalopram) Lexapro (escitalopram) Lexapro (escitalopram)

10 Antidepressants SSRIs SSRIs Nausea, diarrhea Nausea, diarrhea Sexual dysfunction Sexual dysfunction Need to ask! Need to ask! Headache Headache Rash Rash Agitation, anxiety, restlessness, insomnia Agitation, anxiety, restlessness, insomnia Tend to be activating Tend to be activating Weight gain Weight gain Increased sweating Increased sweating Drowsiness Drowsiness Suicidal thoughts Suicidal thoughts

11 Antidepressants SNRIs SNRIs Serotonin and Norepinephrine Reuptake Inhibitors Serotonin and Norepinephrine Reuptake Inhibitors Effexor (venlafaxine) Effexor (venlafaxine) Pristiq (desvenlafaxine) Pristiq (desvenlafaxine) Hot flashes Hot flashes Chemical cousin to Effexor Chemical cousin to Effexor Newer, expensive Newer, expensive Cymbalta (duloxetine) Cymbalta (duloxetine) Neuropathic pain Neuropathic pain

12 Antidepressants SNRIs SNRIs Fatigue Fatigue Dizziness Dizziness Abnormal dreams Abnormal dreams Elevated blood pressure Elevated blood pressure Especially if used above recommended dosages Especially if used above recommended dosages Chest palpitations, fast heart rate Chest palpitations, fast heart rate Anxiety Anxiety Suicide Suicide

13 Antidepressants Remeron (mirtazepine) Remeron (mirtazepine) Abnormal dreams and thinking Abnormal dreams and thinking Increased appetite, weight gain Increased appetite, weight gain Especially at lower doses (7.5-15mg) Especially at lower doses (7.5-15mg) Sleepiness, fatigue, weakness Sleepiness, fatigue, weakness Especially at lower doses (7.5-15mg) Especially at lower doses (7.5-15mg) Constipation, dry mouth Constipation, dry mouth Dizziness Dizziness

14 Antidepressants Wellbutrin (bupropion) Wellbutrin (bupropion) Dry mouth, headache Dry mouth, headache Increased sweating Increased sweating Nausea/vomiting, constipation Nausea/vomiting, constipation Anxiety Anxiety Fatigue Fatigue But generally seen as activating But generally seen as activating Blurred vision Blurred vision Seizures Seizures Extended release lessens risk to 2/1000 chance from 4/1000 Extended release lessens risk to 2/1000 chance from 4/1000

15 Antidepressants Tricyclic antidepressants Tricyclic antidepressants Elavil (amitriptyline) Elavil (amitriptyline) Used more for pain, sleep Used more for pain, sleep Pamelor (nortriptyline) Pamelor (nortriptyline) Less robust side effects than amitriptyline Less robust side effects than amitriptyline Older antidepressants Older antidepressants Cheap, but effective Cheap, but effective Not very specific as to brain transmitters Not very specific as to brain transmitters Wide variety of side effects Wide variety of side effects Potentially fatal in overdose Potentially fatal in overdose Makes the heart beat irregularly Makes the heart beat irregularly

16 Antidepressants Tricyclic Antidepressants Tricyclic Antidepressants Increased appetite, weight gain, sleepiness Increased appetite, weight gain, sleepiness Blurry vision, constipation, urinary retention, racing heart beat, confusion Blurry vision, constipation, urinary retention, racing heart beat, confusion Dizziness upon standing Dizziness upon standing Sexual problems Sexual problems Dry mouth Dry mouth

17 Anti-anxiety Agents Benzodiazepines Benzodiazepines Dependency-producing Dependency-producing Be aware of the patient’s history Be aware of the patient’s history Difficult to use in the elderly Difficult to use in the elderly Sedation, confusion, ataxia Sedation, confusion, ataxia Xanax(alprazolam) Xanax(alprazolam) Ativan (lorazepam) Ativan (lorazepam) Klonopin (clonazepam) Klonopin (clonazepam) BuSpar (buspirone) BuSpar (buspirone) No dependency, sedation issues No dependency, sedation issues Efficacy, long time to work Efficacy, long time to work

18 Anti-anxiety Agents Benzodiazepines Benzodiazepines Epilepsy Epilepsy Restless leg syndrome Restless leg syndrome Depress the brain Depress the brain Sedation Sedation Slurred speech, aspiration Slurred speech, aspiration Confusion, delirium Confusion, delirium Falls Falls

19 Anti-anxiety Agents BuSpar (buspirone) BuSpar (buspirone) Dizziness Dizziness Nausea Nausea Headache Headache Nervousness, excitement Nervousness, excitement Lightheadedness Lightheadedness

20 Mood Stabilizers Bipolar disorder Bipolar disorder Agitation, aggression Agitation, aggression Eskalith, Lithobid Eskalith, Lithobid Lithium carbonate-pills, tablets Lithium carbonate-pills, tablets Lithium citrate-liquid Lithium citrate-liquid Anticonvulsants Anticonvulsants Depakote (valproate) Depakote (valproate) Tegretol (carbamazepine) Tegretol (carbamazepine) Lamictal (lamotrigine) Lamictal (lamotrigine)

21 Mood Stabilizers Lithium Lithium Usual medication in bipolar disorder Usual medication in bipolar disorder Narrow safety index Narrow safety index Therapeutic level Therapeutic level Overdose is a concern Overdose is a concern Look intoxicated Look intoxicated Sedation, coma Sedation, coma Causes of overdose Causes of overdose Sweating, vomiting, diarrhea Sweating, vomiting, diarrhea Excessive urination Excessive urination Goes along with excessive drinking Goes along with excessive drinking Use of diuretics Use of diuretics HCTZ, acetazolamide HCTZ, acetazolamide Tegretol (carbemazapine) Tegretol (carbemazapine)

22 Mood Stabilizers Lithium Lithium Mild-moderate overdose Mild-moderate overdose N/V, diarrhea N/V, diarrhea Drowsiness Drowsiness Weak muscles Weak muscles Slurred speech Slurred speech Lack of coordination Lack of coordination Severe overdose Severe overdose Giddiness Giddiness Ataxia Ataxia Blurred vision Blurred vision Tinnitus Tinnitus Large output of dilute urine Large output of dilute urine

23 Mood Stabilizers Lithium Lithium Caffeine, theophylline Caffeine, theophylline Lower lithium level Lower lithium level NSAIDs, ACEIs, CCBs NSAIDs, ACEIs, CCBs Worsen potential neurotoxicity Worsen potential neurotoxicity Chronic problems Chronic problems Damages kidney Damages kidney Nephrogenic diabetes insipidus Nephrogenic diabetes insipidus Damages thyroid Damages thyroid Hypothyroidism Hypothyroidism

24 Mood Stabilizers Anticonvulsants Anticonvulsants Depakote (valproate) Depakote (valproate) Slows down the brain Slows down the brain Therapeutic level Therapeutic level Oversedated, slurred speech, ataxia Oversedated, slurred speech, ataxia Epilepsy Epilepsy Migraine headache Migraine headache Bipolar disorder Bipolar disorder

25 Mood Stabilizers Anti-convulsants Anti-convulsants Depakote (valproate) Depakote (valproate) Sedation Sedation Blood cell abnormalities Blood cell abnormalities White blood cells White blood cells Platelets Platelets Hepatitis, pancreatitis Hepatitis, pancreatitis Nausea, vomiting, dyspepsia Nausea, vomiting, dyspepsia Dizziness Dizziness Abdominal pain Abdominal pain Weight gain Weight gain Rash Rash

26 Mood Stabilizers Anticonvulsants Anticonvulsants Tegretol (carbamazapine) Tegretol (carbamazapine) Therapeutic level Therapeutic level Overdose results in sedation, slurred speech and ataxia Overdose results in sedation, slurred speech and ataxia Low level may be due to medication itself Low level may be due to medication itself Epilepsy Epilepsy Trigeminal neuralgia, migraine Trigeminal neuralgia, migraine Bipolar disorder Bipolar disorder

27 Mood Stabilizers Anticonvulsants Anticonvulsants Tegretol (carbamazapine) Tegretol (carbamazapine) Many side effects are similar to Depakote Many side effects are similar to Depakote Dizziness Dizziness Drowsy Drowsy Dry mouth Dry mouth Nausea, vomiting Nausea, vomiting Unsteady gait Unsteady gait Less common Less common Hepatitis, pancreatitis Hepatitis, pancreatitis Blood cells Blood cells Anemia Anemia White blood cells White blood cells Platelets Platelets

28 Mood Stabilizers Anticonvulsants Anticonvulsants Lamictal (lamotrigine) Lamictal (lamotrigine) Rash Rash Can be severe and even fatal Can be severe and even fatal Under 1% Under 1% Various dosing schedules Various dosing schedules A bit higher risk if also on Depakote A bit higher risk if also on Depakote Otherwise Otherwise Sedating, dizziness, double vision, headaches Sedating, dizziness, double vision, headaches

29 Antipsychotics Many agents Many agents Older Older Haldol (haloperidol), Haldol decanoate Haldol (haloperidol), Haldol decanoate Newer Newer Risperdal (risperidone), Risperdal Consta Risperdal (risperidone), Risperdal Consta Invega (paliperidone), Invega Sustenna Invega (paliperidone), Invega Sustenna Zyprexa (olanzepine) Zyprexa (olanzepine) Geodon (ziprasidone) Geodon (ziprasidone) Seroquel (quetiapine) Seroquel (quetiapine) Abilify (aripirazole) Abilify (aripirazole) Clozaril (clozapine) Clozaril (clozapine) Saphris (asenapine) Saphris (asenapine)

30 Antipsychotics Psychosis Psychosis Main function Main function Schizophrenia to delirium Schizophrenia to delirium Behavioral problems in dementia Behavioral problems in dementia No evidence that they work No evidence that they work Everyone has some story… Everyone has some story… Bipolar disorder Bipolar disorder Newer indication with novel agents Newer indication with novel agents

31 Antipsychotics Main side effects Main side effects Motor problems Motor problems Extra-pyramidal side effects Extra-pyramidal side effects Blood sugar and cholesterol Blood sugar and cholesterol Metabolic syndrome Metabolic syndrome Risks in dementia Risks in dementia Increased mortality risk Increased mortality risk Others Others

32 Antipsychotics Movement problems Movement problems Dystonia Dystonia Sustained muscle contraction Sustained muscle contraction Wry neck Wry neck Rare in the elderly Rare in the elderly Problem of young people Problem of young people Easily treated if new Easily treated if new Benedryl (diphenhydramine), Cogentin (benztropine) Benedryl (diphenhydramine), Cogentin (benztropine) Harder to treat tardive dystonia Harder to treat tardive dystonia Botulinum toxin IM Botulinum toxin IM

33 Antipsychotics Movement problems Movement problems Akathisia Akathisia Cannot sit still Cannot sit still Very uncomfortable Very uncomfortable Especially in the legs Especially in the legs Rule out Restless Leg Syndrome, anxiety Rule out Restless Leg Syndrome, anxiety Treatment Treatment Beta blockers Beta blockers Benzodizepines Benzodizepines

34 Antipsychotics Movement problem Movement problem Parkinsonism Parkinsonism Drug-induced Parkinsonism (DIP) Drug-induced Parkinsonism (DIP) More likely in older patients More likely in older patients Tremor, stiff, slow Tremor, stiff, slow Both sides at once Both sides at once Stop medication or lower dose Stop medication or lower dose Seroquel, Abilify, Clozaril Seroquel, Abilify, Clozaril Takes weeks at least Takes weeks at least May not improve May not improve Parkinson’s medications don’t work too well Parkinson’s medications don’t work too well May cause worse psychosis May cause worse psychosis

35 Antipsychotics Movement problems Movement problems Tardive dyskinesia Tardive dyskinesia Repetitive non-purposeful movement Repetitive non-purposeful movement Mouth, head, limbs, trunk Mouth, head, limbs, trunk Usually takes years Usually takes years Common in persons with schizophrenia Common in persons with schizophrenia Less time, less drug with the elderly Less time, less drug with the elderly No treatment No treatment Recognition Recognition Stop medication Stop medication Change agents Change agents

36 Antipsychotics Blood sugar and cholesterol Blood sugar and cholesterol May be partially due to weight gain May be partially due to weight gain Induce or worsen diabetes Induce or worsen diabetes Induce or worsen elevated cholesterol Induce or worsen elevated cholesterol Fasting blood glucose and lipids recommended Fasting blood glucose and lipids recommended All can cause these symptoms All can cause these symptoms Zyprexa and Clozaril most likely Zyprexa and Clozaril most likely

37 Antipsychotics Risks with dementia Risks with dementia FDA warning FDA warning Increased mortality risk Increased mortality risk Almost double the rate of a sugar pill Almost double the rate of a sugar pill Sedation, Parkinsonism, tardive dyskinesia Sedation, Parkinsonism, tardive dyskinesia Aspiration pneumonia Aspiration pneumonia Cardiac conduction Cardiac conduction Strokes, especially Strokes, especially

38 Antipsychotics Other Other Sedation Sedation Low blood pressure upon standing Low blood pressure upon standing Especially Seroquel Especially Seroquel Prone to falls Prone to falls Cardiac conduction Cardiac conduction Especially Geodon Especially Geodon Prone to heart attack, stroke Prone to heart attack, stroke Low WBC count Low WBC count Clozapine Clozapine Prone to infection Prone to infection Requires weekly CBCs Requires weekly CBCs Neuroleptic malignancy syndrome Neuroleptic malignancy syndrome Rare Rare Emergency Emergency Very rigid, high fever, confusion Very rigid, high fever, confusion

39 Sleep Agents Hypnotics Hypnotics Only for sleep Only for sleep Benzodiazepine-like Benzodiazepine-like Ambien (zolpidem) Ambien (zolpidem) Sonata (zaleplon) Sonata (zaleplon) Melatonin mediator Melatonin mediator Rozerem (ramelteon) Rozerem (ramelteon) Antidepressants Antidepressants Desyrel (trazodone) Desyrel (trazodone) Elavil (amitriptyline) Elavil (amitriptyline) Remeron (mirtazapine) Remeron (mirtazapine)

40 Sleep Agents Ambien and Sonata Ambien and Sonata Short term use Short term use Daytime drowsiness Daytime drowsiness Diarrhea Diarrhea Dizziness Dizziness Longer use Longer use Drugged feeling Drugged feeling Dizziness Dizziness Abnormal thinking, behavior changes, complex behaviors Abnormal thinking, behavior changes, complex behaviors Rare Rare Driving, eating, e.g. Driving, eating, e.g.

41 Sleep Agents Rozerem Rozerem Dizziness Dizziness Daytime drowsiness Daytime drowsiness Fatigue Fatigue Nausea, diarrhea Nausea, diarrhea Trazodone Trazodone Drowsiness, insomnia, fatigue Drowsiness, insomnia, fatigue Agitation Agitation Dry mouth Dry mouth Constipation Constipation Headache Headache Drop in blood pressure upon standing Drop in blood pressure upon standing Priapism Priapism

42 Dementia Medications All are capable of modestly slowing functional decline All are capable of modestly slowing functional decline Use both classes together Use both classes together Cholinesterase inhibitors Cholinesterase inhibitors Aricept (donepezil) Aricept (donepezil) Exelon (rivastigmine) Exelon (rivastigmine) Razadyne (galantamine) Razadyne (galantamine) NMDA antagonists NMDA antagonists Namenda (memantine) Namenda (memantine)

43 Dementia Medications Cholinesterase inhibitors Cholinesterase inhibitors Common Common Diarrhea, nausea and vomiting, loss of appetite Diarrhea, nausea and vomiting, loss of appetite Weight loss Weight loss Insomnia, sleepiness Insomnia, sleepiness Muscle cramps Muscle cramps Less common Less common Nightmares Nightmares Agitation Agitation Frequent urination Frequent urination Bruising Bruising

44 Dementia Medications Namenda Namenda Well-tolerated Well-tolerated No side effect occurred in 5% and double the placebo rate in controlled trials No side effect occurred in 5% and double the placebo rate in controlled trials Dizziness Dizziness Headache Headache Confusion Confusion Constipation Constipation

45 The Falling Man What to do? What to do? Falls Falls Parkinson’s disease gait Parkinson’s disease gait Parkinson’s disease orthostasis Parkinson’s disease orthostasis Parkinson’s disease medications Parkinson’s disease medications Plus could be contributing to the psychosis Plus could be contributing to the psychosis Trazodone orthostasis Trazodone orthostasis Dehydration, poor nutrition Dehydration, poor nutrition Hypothyroidism Hypothyroidism Zoloft hyponatremia Zoloft hyponatremia Apraxia from cognitive decline/dementia Apraxia from cognitive decline/dementia

46 The Falling Man Orthostasis Orthostasis Per standing, sitting blood pressure readings Per standing, sitting blood pressure readings Low blood pressure upon standing Low blood pressure upon standing Dizzy, fall Dizzy, fall Dementia changes Dementia changes Should be more insidious Should be more insidious Parkinson’s medications Parkinson’s medications Not changed in dose Not changed in dose Hypothyroidism, dehydration, nutrition, Zoloft, UTI Hypothyroidism, dehydration, nutrition, Zoloft, UTI All ruled out by lab tests All ruled out by lab tests Multiple influences Multiple influences Orthostasis from Parkinson’s disease, trazodone, Seroquel Orthostasis from Parkinson’s disease, trazodone, Seroquel Seroquel pushed the risk of orthostasis over the top Seroquel pushed the risk of orthostasis over the top Must stop Seroquel? Must stop Seroquel? Could stop trazodone Could stop trazodone Still psychotic Still psychotic Abilify or Clozaril Abilify or Clozaril

47 Questions? Questions?


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