Presentation on theme: "Dementia and Psych Meds"— Presentation transcript:
1Dementia and Psych Meds Andrew S. Rosenzweig, MD, MPHMedical Director, MedOptionsAssistant Clinical Professor, Brown University
2What Is A Geriatric Psychiatrist? A geriatric psychiatrist is a medical doctor with special training in the diagnosis and treatment of mental disorders that may occur in older adults. These disorders include, but are not limited to, dementia, depression, bipolar disorder, anxiety and late-life schizophrenia.
3Demographics of the Elderly Population By 2030, older adults will account for 20% of the population, up from 13% in 2000At age 85+, there are 241 women for every 100 menMental disorders in older adults are under-reportedThe rate of suicide is highest among older adults compared to any other age group
4Most Common Psychiatric Disorders in Late Life OutpatientDementiaDepressionSubstance Abuse (alcohol)Psychotic DisordersLong-Term CareDementiaOther Organic Mental DisordersMood DisordersMR-DDPsychotic Disorders
5Alzheimer’s Disease (AD): More Than Just Memory Loss AD is a progressive, degenerative disease involving:Loss of memory and other cognitive functionsDecline in ability to perform activities of daily livingChanges in personality and behaviorIncreases in resource utilizationEventual nursing home placementAD affects all aspects of life for both the patient and the caregiver
6“A Peculiar Disease of the Cerebral Cortex” Alzheimer’s Original Case Report (1907)The first case report of Alzheimer’s disease highlighted the presence of psychosis and agitation in these patients“The first noticeable symptom of illness was suspiciousness of her husband…believing that people were out to murder her”“She screams that her doctor wants to cut her open; at times, she seems to have auditory hallucinations”“A Peculiar Disease of the Cerebral Cortex”Alzheimer’s Original Case Report (1907)We often focus on the cognitive symptom domain of dementing illnesses such as AD. However, for the patient described in the first published case report of AD, behavioral and psychotic symptoms caused greater disability than cognitive changes. This finding has been corroborated in subsequent studies, illustrating that dementia is more than a disorder of cognition: it is also a psychiatric illnessPsychiatric symptoms, such as psychosis (delusional thought content, paranoia, hallucinations), agitated and aggressive behavior, depression, and sleep/wake cycle reversal, are common in patients with dementia. These behavioral disturbances are a significant cause of caregiver stress and of premature institutionalization of patients with dementiaSource: Alzheimer A. Allegmeine Zeitschrift für Psychiatrie. 1907;64:Alzheimer A. Uber eine eigenartige Erkraukung der Hirwrinde. Allegmeine Zeitschrift für Psychiatrie. 1907;64:Aronson SM. Treatment of behaviorally disturbed elderly patients: a clinical approach. In: Brunello N, Langer SZ, Racagni G, eds. Mental Disorders in the Elderly: New Therapeutic Approaches, Vol 13. Basel, Switzerland: S Karger AG; 1998:
7Behavioral and Psychological Symptoms of Dementia PsychosisDelusionsParanoiaHallucinationsAgitationAggressionCombativenessHyperactivity (including wandering)HypervocalizationDisinhibitionBehavioral and Psychological Symptoms of DementiaSymptomsParticipants at the IPA consensus conference felt that behavioral and psychological symptoms of dementia could be conveniently grouped into 2 categories:Symptoms that are primarily assessed on the basis of interviews with patients and/or relatives. These symptoms may be associated with psychotic behaviors and may include delusions, paranoid ideation, and hallucinationsSymptoms associated with agitation that are usually identified on the basis of observation of patient behavior. These may include aggression, combativeness, hyperactivity including wandering, screaming, sexual disinhibition, or culturally inappropriate behaviorsSource: Finkel et al. Am J Geriatr Psychiatry. 1998;6:Finkel SI, Costa e Silva J, Cohen GD, et al. Behavioral and psychological symptoms of dementia: a consensus statement on current knowledge and implications for research and treatment. Am J Geriatr Psychiatry. 1998;6:
8Behaviors Reported in Agitation and Aggression Physical: pacing, inappropriate robing/disrobing, trying to get to a different place, handling things inappropriately, restlessness, stereotypyVerbal: Complaining, requests for attention, negativism, repeated questions/phrases, screamingAggressionPhysical: hitting, kicking, pushing, scratching, tearing, biting, spittingVerbal: threats, accusations, name-calling, obscenitiesIt’s a good idea to take the next step in classifying agitation and aggression, this time by separating each into physical and verbal components. This is important as you’ll see later when we talk about target symptoms and management.
9Psychosis and Agitation: What We Know Common in Alzheimer’s disease and other dementing illnessesMajor source of caregiver distressContribute toPremature institutionalizationIncreased costPsychosis and Agitation: What We KnowPsychosis and/or agitation are common in the course of dementia, occurring in a majority of cases. In patients with dementia, the overall incidence of psychosis is estimated to be 34% to 50% and agitation 60% to 80%. Patients can experience delusions, hallucinations, and agitated behavior at any point in the course of their illnessBehavior changes are a major source of distress to caregivers and lead to caregiver depression and anxiety, premature institutionalization, and increased cost of careSources: Drevets et al. Biol Psychiatry. 1989;25:39-48./Ellgring. Neurology. 1999:52(suppl 3):S17-S20./Rabins PV. Int Psychogeriatr. 1991;3:Drevets WC, Rubin EH. Psychotic symptoms and the longitudinal course of senile dementia of the Alzheimer type. Biol Psychiatry. 1989;25:39-48.Ellgring JH. Depression, psychosis, and dementia: impact on the family. Neurology. 1999:52(suppl 3):S17-S20.Gormley N, Rizwan MR. Prevalence and clinical correlates of psychotic symptoms in Alzheimer’s disease. Int J Geriatr Psychiatry. 1998;13:Rabins PV. Psychosocial and management aspects of delirium. Int Psychogeriatr. 1991;3:
10Prevalence of Symptoms of Psychosis and Agitation in Dementia 20Prevalence of Symptoms of Psychosis and Agitation in DementiaSlide 20Cache County Study of Memory in Aging (CCSMA)First US population study of behavioral disturbances in dementiaEvaluated the prevalence and severity of mental and behavioral disturbances in the elderly5092 individuals were screenedParticipants with dementia (n=329) were compared to control group without dementia (n=673)Prevalence of Symptoms of Psychosis and Agitation in DementiaThe distribution of mental and behavioral disturbances in the elderly and the association of these disturbances with dementia were investigated in the Cache County Study of Memory in Aging (CCSMA) [Utah], the first US epidemiologic study (2000) to examine behavioral disturbances in Alzheimer’s disease in a community-based populationNinety percent (5092 individuals) of the Cache County population 65 years old were initially screened for dementia with a series of tests that included the Modified Mini-Mental State Examination (MMSE) or the Informant Questionnaire on Cognitive Decline in the Elderly, and the Dementia Questionnaire, along with clinical assessment. Of those, 329 individuals with dementia (65%, Alzheimer’s; 19%, vascular; 16%, mixed) and 673 individuals without dementia (total of 1002 participants) were further rated using the Neuropsychiatric Inventory (NPI) to determine whether they had experienced any of 10 domains in the previous month. Those domains included aberrant motor behavior, agitation, anxiety, apathy, delusions, depression, disinhibition, elation, hallucinations, and irritabilitySource: Lyketsos CG et al. Am J Psychiatry. 2000;157:
11Prevalence of Symptoms of Psychosis and Agitation in Dementia 21Slide 21Prevalence of Symptoms of Psychosis and Agitation in DementiaThe mean age of the participants with dementia was 84.2 ± 7.0 (standard deviation [SD]) years and the mean age of the participants without dementia was 80.8 ± 7.7 SD yearsIn all participants with dementia (n=329), the prevalence of agitation/aggression was 23.7%, delusions 18.5%, and hallucinations 13.7%. Compared to those without dementia, agitation/aggression was 8.5 times more frequent, delusions were 8 times more frequent, and hallucinations were 23 times more frequent in those with dementiaDementia category includes Alzheimer’s dementia and vascular dementia combinedDifferences were observed in the frequency of behavioral disturbances at different stages of illness. Significant differences occurred in the incidence of agitation/aggression (13%, mild dementia; 24%, moderate dementia; 29%, severe dementia) and in the incidence of aberrant motor behavior (9%, mild dementia; 7%, moderate dementia; 19%, severe dementia)Source: Adapted with permission from Lyketsos CG et al. Am J Psychiatry. 2000;157: American Psychiatric Association.
12Causes of Distress to Caregivers Disturbing symptomsPhysical violenceCatastrophic reactionsHittingMaking accusationsSuspiciousnessIncontinenceMemory disturbanceInappropriate sexual behaviorCauses of Distress to CaregiversCaregivers, both family at home and staff in extended-care facilities, do not always describe behavioral abnormalities according to physicians’ definitions. When physicians are called, the complaints may be about patients being bothersome, irritable, uncooperative, and intrusive, as well as being aggressive and agitatedThe widespread nature of this problem was addressed in a study conducted by Rabins. He surveyed 55 caregivers of patients with AD and asked what symptoms were most problematic. Five of the 7 most commonly reported disturbing symptoms were of a behavioral nature. These included physical violence and related behaviors, as well as suspiciousness, making accusations, and hypervocalizationMace NL, Rabins PV. The 36-Hour Day: A Family Guide to Caring for Persons with Alzheimer’s Disease, Related Dementing Illness, and Memory Loss in Later Life. Revised. New York: Warner Books; 1992.Rabins PV. Psychosocial and management aspects of delirium. Int Psychogeriatr. 1991;3:Stoppe G, Brandt CA, Staedt JH. Behavioural problems associated with dementia: the role of newer antipsychotics. Drugs Aging. 1999;14:41-54.Sources: Rabins PV. Int Psychogeriatr. 1991;3: /Stoppe et al. Drugs Aging. 1999;14:41-54.
13Delusions in Alzheimer’s Disease Delusional thought content (eg, paranoia) is common (studies suggest 34% to 50% incidence)Common delusionsMarital infidelityPatients, staff are trying to hurt meStaff, family members are impersonatorsPeople are stealing my thingsMy house is not my homeStrangers living in my homeMisidentification of peoplePeople on TV are realDelusions in Alzheimer’s DiseaseBehavioral agitation in patients with dementia can be caused by delusions and/or confusion. Delusions are especially frequent in dementia, and it is sometimes difficult for the clinician to differentiate between delusion and confusion in these patients. Misidentification of individuals and misplacement of personal belongings are examplesAbuse of the elderly and theft are not uncommon. Sometimes there is a basis in reality for these complaintsRegardless of the cause of behavioral disturbance in patients with dementia, early intervention with both pharmacologic and nonpharmacologic treatments can alleviate symptoms, improve quality of life, and delay nursing home placementDeutsch LH, Bylsma FW, Rovner BW, et al. Psychosis and physical aggression in probable Alzheimer’s disease. Am J Psychiatry. 1991;148:Drevets WC, Rubin EH. Psychotic symptoms and the longitudinal course of senile dementia of the Alzheimer type. Biol Psychiatry. 1989;25:39-48.Sources: Deutsch et al. Am J Psychiatry. 1991;148: /Drevets. Biol Psychiatry. 1989;25:39-48.
14Effect of Losses in Dementia Normal Feelings Thoughts BehaviorsDementia Feelings Short Circuit BehaviorsThoughts are impaired by losses of:memory of coping with past situationsjudgment to select among alternative actionsinsight needed to solve problemsinhibitions and impulse control needed to show restraint
15Practical Recommendations: Decrease Escalation Approach in a calm mannerUse distraction: food, drink, musicMaintain eye contact and comfortable postureMatch verbal and non-verbal signalsIdentify and state the affect observed in the patientIdentify what is triggering the behaviorModify the environment
16Target Symptoms for Treatment Physical aggressionAgitationDelusions/paranoiaHallucinationsSleep/wake cycle changesDepression, withdrawalEating problemsVerbal outburstsTarget Symptoms for TreatmentThe reason for initiating drug therapy must be clearly defined at the outset, and the desired management goals must be identified and communicated to the patient’s family and staff on all shiftsWritten description of target behaviors in the patient’s chart at baseline will provide a guide for evaluation of the efficacy of a given treatment intervention (whether pharmacologic or nonpharmacologic). Documentation will prevent inappropriate concern regarding regulatory issuesThis portion of the presentation will focus on the management of physical aggression, agitation, and delusions because they are so prevalent in dementia
17Pharmacotherapy Medications for treating target symptoms AnticonvulsantsAntidepressantsBeta-blockersBenzodiazepinesTrazodone, buspironeAcetylcholinesterase inhibitorsAntipsychoticsMemantinePharmacotherapyMedications for treating target symptomsMedications used in the management of agitation include a broad spectrum of pharmacologic agents, including anticonvulsants, antidepressants, benzodiazepines, beta-blockers, acetylcholin-esterase inhibitors, and antipsychotics. However, it is important to note that there are currently no FDA-approved medications specific for the treatment of agitation and psychosis in dementiaThe following slides will review the evidence-basis for the current clinical practice of pharmacotherapy for behavioral and psychological symptoms of dementiaKaufer DI, Cummings JL, Christine D. Effect of tacrine on behavioral symptoms in Alzheimer’s disease: an open-label study. J Geriatr Psychiatry Neurol. 1996;9:1-6.Lott AD, McElroy SL, Keys MA. Valproate in the treatment of behavioral agitation in elderly patients with dementia. J Neuropsychiatry Clin Neurosci. 1995;7:Raskind MA, Sadowsky CH, Sigmund WR, et al. Effect of tacrine on language, praxis, and noncognitive behavioral problems in Alzheimer’s disease. Arch Neurol. 1997;54:Sultzer DL, Gray KF, Gunay I, et al. A double-blind comparison of trazodone and haloperidol for treatment of agitation in patients with dementia. Am J Geriatr Psychiatry. 1997;5:60-69.Tariot PN, Erb R, Podgorski CA, et al. Efficacy and tolerability of carbamazepine for agitation and aggression in dementia. Am J Psychiatry. 1998;155:54-61.
18Anticonvulsants Divalproex, carbamazepine Open trials, case reports, and 4 controlled studiesMay have specific utility for paroxysmal and aggressive behavior dyscontrol in the absence of psychotic symptomsAnticonvulsantsSimilar to their increased usage in other areas of psychiatry, anticonvulsant agents such as divalproex and carbamazepine are increasingly utilized for control of agitated behavior in neuropsychiatric conditions such as traumatic brain injury, pervasive developmental disorder (mental retardation syndromes), and dementia-related behavior disturbance. Since many of the studies of these agents have been open-label and uncontrolled, the interpretation of the findings is limited. More well-controlled studies are needed to evaluate their effectivenessNewer anticonvulsants, such as topiramate, lamotrigine, and gabapentin, are currently being studied for the management of behavioral symptoms in the elderlyLott AD, McElroy SL, Keys MA. Valproate in the treatment of behavioral agitation in elderly patients with dementia. J Neuropsychiatry Clin Neurosci. 1995;7:Mellow AM, Solano-Lopez C, Davis S. Sodium valproate in the treatment of behavioral disturbance in dementia. J Geriatr Psychiatry Neurol. 1993;6:Tariot PN, Erb R, Leibovici A, et al. Carbamazepine treatment of agitation in nursing home patients with dementia: a preliminary study. J Am Geriatr Soc. 1994;42:Tariot PN, Erb R, Podgorski CA, et al. Efficacy and tolerability of carbamazepine for agitation and aggression in dementia. Am J Psychiatry. 1998;155:54-61.Tariot PN, Jakimovich LJ, Erb R et al. Withdrawal from controlled carbamazepine therapy followed by further carbamazepine treatment in patients with dementia. J Clin Psychiatry Oct;60:Sources: Chambers et al. IRCS Med Sci. 1982;10: /Lott AD et al. J Neuropsychiatry Clin Neurosci. 1995;7: /Mellow et al. J Geriatr Psychiatry Neurol. 1993;6: /Tariot PN et al. J Am Geriatr Soc. 1994;42: /Tariot et al. Am J Psychiatry. 1998;155:54-61./Tariot et al. J Clin Psychiatry 1999;60:684-9.
19Divalproex: Dementia-Related Agitation Efficacy data emergingGastrointestinal intolerance and excessive sedation may limit utility*Hepatotoxicity and thrombocytopenia are rare but serious potential side effectsDivalproexDementia-Related AgitationSeveral small uncontrolled studies suggest that divalproex may be beneficial in some patients with dementia-related agitationDue to side effects, the use of divalproex should be carefully monitored. Excessive sedation and gastrointestinal side effects (eg, nausea, dyspepsia) may limit the utility of divalproex. According to the manufacturer (C. Spath, RPh, oral communication, January 2000), a placebo-controlled trial of divalproex for the treatment of behavioral disturbances in the elderly was recently halted due to excessive somnolence and weight loss in the divalproex group. As a result, a lower dose and slower titration schedule will be utilized in future trialsGastrointestinal side effects can be minimized by the use of the divalproex form of valproic acid and by dosing with food. The use of a low initial starting dose of 62.5 to 125 mg (at bedtime only for at least the first week) may minimize the potential for sedationAlthough the risk of hepatotoxicity in adults is low, there is a potential for thrombocytopenia. Therefore, baseline lab tests should include complete blood count (CBC) with platelets and transaminases. Periodic monitoring of CBC and liver function should also be conducted during extended treatment with divalproex*A placebo-controlled trial of divalproex for the treatment of behavioral disturbances in the elderly was recently halted due to excessive somnolence and weight loss in the divalproex group (C. Spath, RPh, oral communication, January 2000). As a result, a lower dose and more conservative titration schedule will be utilized in future trials.Source: Lott et al. J Neuropsychiatry Clin Neurosci. 1995;7: /Mellow et al. J Geriatr Psychiatry Neurol. 1993;6:
20Benzodiazepines Minimal efficacy data Sedating Cause falls Further inhibit learning and memoryParadoxical disinhibitionCommonly usedlorazepamoxazepamBenzodiazepinesBenzodiazepines are widely used in the elderly, although data supporting their use for the management of agitation and psychosis in this population are very limited, and side effects are of great concernBenzodiazepine use in older adults carries the risk of further cognitive impairment, sedation, falls, and paradoxical behavioral disinhibitionBenzodiazepines should be used only if absolutely necessary, at the lowest effective dose, and for a short period of time, until the primary pharmacotherapy (antipsychotic or other agent) begins to work. Short-acting agents (lorazepam, oxazepam) are preferredOther AgentsZolpidem, a nonbenzodiazepine hypnotic, has been studied in elderly patients with insomnia. One study of 14 elderly psychiatric patients with severe insomnia found that use of zolpidem improved total sleep time, sleep efficiency, and percentage of rapid eye movement sleep. There have also been anecdotal reports that zolpidem may be useful for dementia-related insomnia and nighttime wandering, although confirmation of these findings with controlled clinical trials is lackingSource: Coccaro. Am J Psychiatry. 1990;147:
21Acetylcholinesterase Inhibitors Drugs used to treat Alzheimer’s disease act by inhibiting acetylcholinesterase activityThese drugs block the esterase-mediated metabolism of acetylcholine to choline and acetate. This results in:Increased acetylcholine in the synaptic cleftIncreased availability of acetylcholine for postsynaptic and presynaptic nicotinic (and muscarinic) acetylcholine receptorsNordberg A, Svensson A-L. Drug Safety. 1998;19:
22Memantine in AD FDA approved for moderate-to-severe AD Studies show slowing of cognitive decline, stabilization or improvement over baseline for >6 monthsSlowing of decline in functional outcomesSome behavioral symptom reduction (especially apathy, anxious/depressive features)
23Antipsychotic Drug Prescriptions AntipsychoticPrescriptions for the ElderlyElderly13%24%OtherAntipsychotic Drug PrescriptionsAlthough the elderly account for about 13% of the population in the United States, 24% of antipsychotic drug prescriptions are written for elderly patients. It is important for the clinician to ensure appropriate use of these medications in order to produce safe and efficacious clinical outcomesThe Omnibus Budget Reconciliation Act (OBRA) regulations were developed in response to a perception of overuse of these medications in long-term care facilities. The OBRA regulations provide guidelines that can be followed in prescribing antipsychotic drugs. Although perceived as placing restrictions on the use of these medications, the OBRA regulations provide a framework for planning appropriate treatmentA thoughtful approach to treatment that provides for suitable psychotropic drug intervention as part of an interdisciplinary treatment plan helps to ensure that patients receive antipsychotic medications when appropriateIMS Health, National Disease and Therapeutic Index Audit, Plymouth Meeting, Pennsylvania. August 1999.United States PopulationTotal PrescriptionsSource: IMS Health, NDTI. Plymouth Meeting, Pennsylvania. August 1999.
24Conventional Antipsychotics Extensive clinical experienceModest efficacySide effects can hinder treatmentHigh risk of tardive dyskinesiaCommonly used in geriatricsHaloperidolThioridazineConventional AntipsychoticsAlthough virtually all classes of psychotropic agents have been used to treat agitation in dementia, the mainstay of therapy historically has been the conventional antipsychotic agentsConventional antipsychotics include dopamine–receptor blocking agents such as thioridazine and chlorpromazine, low potency conventional agents, and haloperidol, a high potency conventional agent. All have shown rather modest clinical efficacySide effects have made their use less desirable, and this is one reason why atypical antipsychotics are supplanting the use of the older drugsSchneider LS, Pollock VE, Lyness SA. A meta analysis of controlled trials of neuroleptic treatment in dementia. J Am Geriatr Soc. 1990;38:Tune LE, Steele C, Cooper T. Neuroleptic drugs in the management of behavioral symptoms of Alzheimer’s disease. In: Davidison M, ed. Psychiatric Clinics of North America. Philadelphia, Penn: WB Saunders Co. 1991:Source: Tune et al. In: Davidson M, ed. Psychiatric Clinics of North America. Philadelphia, Penn: WB Saunders Co. 1991:
25Conventional Antipsychotics: Side Effects Are Predictable Extrapyramidal symptomsAnticholinergic effectsCognitive toxicitySedationOrthostatic hypotensionTardive dyskinesiaConventional AntipsychoticsSide Effects Are PredictableThe side effects of the conventional antipsychotic drugs are predictable, given a basic understanding of their receptor binding profilesThe high potency agents (eg, haloperidol) predictably cause a high rate of extrapyramidal side effects (EPS) (eg, iatrogenic parkinsonism) due to their dopamine receptor affinityThe low potency agents (eg, thioridazine, chlorpromazine) block 1-adrenergic receptors in smooth muscle cells in the vasculature, causing orthostatic hypotension; block CNS histamine receptors, causing sedation; block peripheral cholinergic receptors, causing tachycardia, blurred vision, constipation/ileus, and urinary retention; and block CNS cholinergic receptors, causing confusion and deliriumThis wide range of side effects makes conventional antipsychotics difficult to tolerate (engendering noncompliance and poor clinical outcome) in patients of all ages. However, these predictable side effects can be particularly toxic in older patients. Hence, the combination of minimal efficacy and poor tolerability explains the burgeoning interest in the atypical antipsychotic agentsSource: Tune et al. In Davidson M, ed. Psychiatric Clinics of North America. Philadelphia, Penn: WB Saunders Co. 1991:
26Atypical Antipsychotics ClozapineOlanzapineQuetiapineRisperidoneZiprasidoneAripiprazoleAtypical AntipsychoticsFour agents are currently available in this class: clozapine, olanzapine, quetiapine, and risperidone. Others are in developmentThe atypical agents, which are a recent addition to the antipsychotic drug armamentarium, differ from the conventional antipsychotics in several important ways. Conventional antipsychotic agents include drugs that have been available since the 1950s (eg, chlorpromazine, the prototype of the low-potency antipsychotics, and haloperidol, the prototype of the high-potency conventional antipsychotics). These agents are presumed to exert their antipsychotic effects (and their significant extrapyramidal side effects) through blockade of CNS dopamine receptorsThe atypical antipsychotic drugs block a subset of serotonin receptors, in addition to dopamine receptors, which may be the reason for their superior efficacy and safety
27Risperidone In Dementia-Related Psychosis And Agitation • Most studied antipsychotic in the elderly• 3 pivotal placebo-controlled trials in dementia patients (N = 1306)• Side-effects equivalent to placebo in therapeutic dose range• Recommended dosing regimen in dementia– Starting dose: 0.25 mg to 0.5 mg hs– Target dose range: 0.5 mg to 1.5 mg hsAronson SM. Mental Disorders in the Elderly: New Therapeutic Aproaches De Deyn PP et al. Neurology Falsetti AE. Am J Health-Syst Pharm Jeste DV et al. J Clin Psychiatry Snowdon J et al. Am J Geriatr Psychiatry 2002.
28Risperidone In Dementia 625 Patients With Dementia• Prospective, 12-week, multicenter, placebo-controlled• Randomized to (12 weeks)– Risperidone fixed dose (0.5 mg/d, 1 mg/d, 2 mg/d)– Placebo• Mean age 83 ± 8y; 68% female• Mean MMSE 6.6/30Katz IR et al. J Clin Psychiatry 1999.
29Risperidone In Dementia: Results • 1 mg and 2 mg doses efficacious on outcome measures (BEHAVE-AD, CMAI)• 2 mg dose resulted in higher rate of EPS• 1 mg dose side effect rate equivalent to placeboKatz IR et al. J Clin Psychiatry 1999.
30LATE-LIFE DEPRESSION Four Hallmarks: Depressed mood Anhedonia Physical symptomsPsychological symptoms8
31DEPRESSED MOOD Hallmark 1 Neither necessary, nor sufficientCan be misleadingBeware of asking the question, “Are you depressed?”9
32ANHEDONIA Hallmark 2 Loss of interest or pleasure May be most important anduseful hallmarkAsk, “What do you enjoy doing?”10
33PHYSICAL SYMPTOMS Hallmark 3 Sleep disturbanceAppetite or weight changeLow energy or fatiguePsychomotor changes11
34PSYCHOLOGICAL SYMPTOMS Hallmark 4 Low self-esteem or guiltPoor concentrationSuicidal ideation or persistentthoughts of death12
35MANAGEMENT Support Psychotherapy Psychopharmacology Electroconvulsive therapy
36NON-SPECIFIC SUPPORT Reflective listening If I understand you correctly, you…Empathic communicationI can see you feel very sad…(reflection)I can understand…(legitimation)Specific offer of supportI am here to help you…PartnershipLet’s you and I together…RespectI am very impressed by…
37PSYCHOTHERAPIES Cognitive-behavioral therapy Negative thinking, expectations of self and worldInterpersonal psychotherapyRole changeProblem-solving therapy (pleasant activities)Life narrative reviewIntegrity vs. despairGrief counseling
38PSYCHOTHERAPY Mild to moderate major depression EffectiveMild to moderate major depressionAdjunct to antidepressantsChronic depressionPossibly effectiveMinor depressionFor patients in life transitions or with personal conflictsDepression in long-term careDepression in AD40
39PHARMACOTHERAPY Effective Inconclusive evidence to date Major depressionChronic depression (dysthymia)Inconclusive evidence to dateMinor depressionDepression of AD (7 RCT)Lyketsos, Am J Psych 200028
40TREATMENT GUIDELINES Titrate agent to achieve therapeutic dose or remissionFull effect may take 4-6 weeksContinue for 4-9 months after full remissionUse maintenance medication for recurrent depressions29
42ADVANTAGES OF SSRIs AND OTHER NEW AGENTS Fewer side effectsSafety profileIncreased patient satisfactionImproved adherence to therapyCost savings34
43CHOOSING AMONG SSRIs AND OTHER NEW AGENTS Evaluate:half-lifedrug interactionsside effects35
44HALF-LIFE fluoxetine (Prozac) other SSRIs (once a day) Long (longer than 1 day)fluoxetine (Prozac)Shortother SSRIs (once a day)Effexor XR (once a day)Wellbutrin SR (1-2x/day)other new agents (2x/day)36
45DRUG INTERACTIONS Obtain medication history Be aware that all drugs canaffect the action and serumlevels of other drugsMonitor the clinical effects andserum levels of all medications36
46SIDE EFFECTS (SSRIs) Sexual dysfunction Agitation/insomnia GI distress 38
47MANAGING SIDE EFFECTS Sedation GI distress Give medication HS Give medication after mealsAnticholinergic effectsBulk in diet, lemon dropsPostural hypotensionHydration, change position slowly, support hose
48Illicit Drug or Alcohol Dependence or Abuse, by Age: 2003 Percent Dependent or Abusing in Past YearAge 50+12-1314-1516-1718-2021-2526-2930-3435-3940-4445-4950-5455-5960-6465+Age in Years
49Alcohol and Illicit Drug Dependence or Abuse, as a Percentage of Total Substance Dependence or Abuse, by Age: 2003Percent of Substance Dependence/AbuseAlcohol OnlyIllicit DrugAge 12 to 25Age 26 to 49Age 50+
50Alcohol and Drug Treatment Admissions: Age 50+, 1992-2002 Admissions in ThousandsAlcohol OnlyDrugs
51Key Themes in Late-Life Alcohol Addiction Significant underdiagnosisAgeism, shame, misperceptionsIncreased vulnerability to negative effects of ETOHIncreased sensitivity and tolerance
52ComorbiditiesIncreased risk of hypertension, arrhythmia, mi, cardiomyopathyHemorrhagic StrokeCirrhosisGI bleedingDecreased bone densityMalnutritionDepression, anxiety
53Risk Factors Gender Marital Status Bereavement and other losses Lessening of Role ResponsibilitiesFamily historyHealth care settingsDepression
54Adverse Effects of Late-life Drinking Decreased quality of lifeFamily burdenMedication interactionsTraumaIncreased suicide risk (10.6 fold increase with 1-2 drinks/day)Adverse medical outcomes