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Welcome to Seminar on Psychogeriatric Medications and their Effects on Behavior in the Long-Term Care (LTC) Meera Kaur, Ph.D, R.D. Assistant Professor.

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Presentation on theme: "Welcome to Seminar on Psychogeriatric Medications and their Effects on Behavior in the Long-Term Care (LTC) Meera Kaur, Ph.D, R.D. Assistant Professor."— Presentation transcript:

1 Welcome to Seminar on Psychogeriatric Medications and their Effects on Behavior in the Long-Term Care (LTC) Meera Kaur, Ph.D, R.D. Assistant Professor and Clinical Dietitian Department of Family Medicine 1

2 Objectives of the Session To understand: The common mental health issues in elderly residents of LTC facilities The drugs commonly used to manage mental health and behavioral issues Common side-effects The interactions with foods and other drugs The nutritional impacts and management Meera Kaur, PhD, RD 2

3 Outline of the Session Introduction Prevalence of mental health issues in LTC Common psychiatric diagnosis in LTC Commonly used psychogeriatric medications: Side-effects, Food / Drink interactions, Drug interactions Nutritional management Micronutrients and caffeine in LTC Adjunctive therapy Team approach Implications for the practitioner Case studies Summary Meera Kaur, PhD, RD 3

4 4 Introduction... Elderly population in developed countries has rapidly increased In Canada, the number of seniors receiving care in LTC homes is rising 1986 — 203, 000 1996 — 240, 000 2021 — 18% of 6.7 million Canadian 2031 — LTC bed will triple or quadruple Source: Health Canada, 1999 and 2002

5 Introduction Projected elderly population (1990-2050) in USA 5 Meera Kaur, PhD, RD Source: US Department of Commerce, 1989

6 Prevalence of Mental Health /Behavioral Issues in LTC Eighty percent of the residents in LTC suffer from some kind of mental health issues or behavioral problems (Conn et al., 2001). The classic study of Rovner et al. (1990): Total nursing home included in the study: 454 Dementia: 2/3rd (40% of demented residents had depression, delusion, delirium) Affective disorders:10% Schizophrenia or another psychiatric illness: 2.4% 6 Meera Kaur, PhD, RD

7 Common Psychiatric Diagnosis in LTC Settings Dementia Delirium Depression Disorders –Mood –Psychotic –Dysthymic –Adjustment –Personality Change 7 Meera Kaur, PhD, RD

8 Factors Affecting Drug Metabolism in the Elderly Key point: An elderly person is more susceptible to adverse drug reactions than younger one because of: Decreased lean body mass Increased body fat Decreased serum albumin Changes in –digestion/absorption, kidney and liver functions, drug receptor sensitivity and amount of neurotransmitters 8 Meera Kaur, PhD, RD

9 Dementia Key Points: Most common mental disorder in LTC homes (>50%) Alzheimer’s disease is the most common cause Residents with dementia will demonstrate –Cognitive impairment that affects their daily functioning –Behavioral disturbances (apathy, agitation,depression etc.) Demented residents have increased susceptibility to side-effects from psychoactive drugs Management:Multi-model 9 Meera Kaur, PhD, RD

10 Medications in Dementia Cholinesterase Inhibitors: prescribed for the treatment of mild to moderate AD. Donepezil (Aricept) Galantamine (Reminyl) Memantine HCl (Exiba) Rivastigmine (Exelon®) Herbal products Ginko Biloba Remember FX, 10 Meera Kaur, PhD, RD

11 Cholinesterase Inhibitors… Common side-effects Nausea Vomiting Diarrhea Loss of appetite Weight loss 11 Meera Kaur, PhD, RD Interaction with Foods/Herbal products –St. John Wort –Ginko Biloba Drugs –Cytochrome P450; Anti- cholinergic & cholinergic agent; Tacrine, Luvox, TCA

12 Cholinesterase Inhibitors…. Donepezil (Aricept): May be taken with or without foods Side effects: anorexia,  wt., dehydration, N/V, pain, GI bleeding, bloating, diarrhea, insomnia, fatigue, muscle cramp,  or  BP, headache, dizziness, syncope, tremor, ataxia, depression, blurred vision,  urination Galantamine (Reminyl ER): With breakfast or food Side effects: Same as above  dyspepsia, flatulence, difficulty swallowing, chest pain, seizures, falling,  blood K ++,  BP, UTI, fainting 12 Meera Kaur, PhD, RD

13 Cholinesterase Inhibitors Memantine HCl (Exiba): With or without foods Side effects: anorexia,  wt., N/V, constipation, flatulence, diarrhea, dehydration, confusion, hallucinations, sleep disorder,  BP Nutritional management: Nutrient-dense small frequent feeding with variety in color and taste; yogurt or other foods with probiotics; and, adequate hydration among others 13 Meera Kaur, PhD, RD

14 Herbal Products… Ginko Biloba: Edible portion is leaf (available as gummies, tablets, capsules, strips, lozenges, powders or liquids). The dose is also measured in drops, teaspoons or tablespoons. Side effect: Spontaneous bleeding Food interaction: St. John Wort, Garlic Drug/supplements interaction: Antiplatelet, ASA, NSAID, Heloperidol, fish oil, Vitamin E Source: Health Canada, 2008 14 Meera Kaur, PhD, RD

15 Herbal Products: Ginko Biloba… 15 Meera Kaur, PhD, RD

16 Herbal Products… Remember FX: Purified natural product obtained from roots of North American ginseng. Used for improving mental performance. Side effect: Spontaneous bleeding Food interaction: St John wort, Garlic Drug interaction: Blood thinner Coumadin (warfarin), MAOIs Source: 16 Meera Kaur, PhD, RD

17 Herbal Products North American Ginseng (Panax quinquefolius) 17 Meera Kaur, PhD, RD

18 Behavioral and Psychological Symptoms of Dementia (BPSD) Agitation Restlessness Wandering Mood disturbances Delusions Hallucinations Rage and violence Catastrophic reaction Phobias/fears Shouting/screaming Sleep disturbances Sundowning Apathy Sexual disturbances 18 Meera Kaur, PhD, RD

19 Medications in BPSD... Commonly used medications in BPDS are Antipsychotics. Typical Antipsychotics (TA) Atypical Antipsychotics (ATA), 19 Meera Kaur, PhD, RD

20 Typical Antipsychotics... Typical Antipsychotics (TA): Prescribed for: Psychotic syndrome (delusions, hallucinations etc.) that occurs in depression, mania, schizophrenia, paranoid disorders, delirium and dementia Agitation and aggression due to dementing illness Examples –Haloperidol (haldol) –Loxapine (Loxapac) –Zuclopenthixol (Clopixol), 20 Meera Kaur, PhD, RD

21 Typical Antipsychotics... Common side-effects Anticholinergic effects: dry mouth, constipation, blurred vision, tachycardia, urinary retention, sweating, delirium, disorientation, confusion, cognitive disorder Extrapyramidal symptoms (EPS): dystonias, parkinsonism, akathesia, tradive dyskinesia, sedation,  appetite,  wt.,  BP, ratinopathy, skin rash, pigmentation, jaundice, neuroleptic malignant syndrome (  temperature, muscular rigidity,  CPK, altered consciousness) 21 Meera Kaur, PhD, RD

22 Typical Antipsychotics Interactions with: Foods, Herbal Products, Drinks : coffee, tea, herbs, nutraceuticals Drugs: Cytochrome P450, alcohol opioids, methyldopa levodopa, TCA 22 Meera Kaur, PhD, RD

23 Atypical Antipsychotics… Atypical Antipsychotics (ATA): Prescribed as alternatives for typical antipsychotics, because they have lower rates of EPS than TA. In older residents with delirium+Parkinson’s disease, ATA are preferred over TA Example –Risperidine (Risperdal) –Olanzopine (Zyprexa) –Quetiapine (seroquel) –Clozapine (Clozaril) 23 Meera Kaur, PhD, RD

24 Atypical Antipsychotics... Common side-effects: Tradive Dyskinesia Akathisia Hyperglycemia Obesity  wt.,  appetite,  TG,  liver enzymes,  thirst  wt.,  appetite, anorexia, 24 Meera Kaur, PhD, RD

25 Atypical Antipsychotics Interactions with: Foods, Herbal Products, Drinks: coffee, tea, herbs, nutraceuticals, grapefruit juice Drugs: Cytochrome P450, SSRI, fluvoxamine, barbiturates, phenytoin, antifungal, arythromycin Smoking is an induction to CP450 system, which induces drug metabolism & decreases the drug efficacy 25 Meera Kaur, PhD, RD

26 Depression Key Points Common mental health problem in LTC (15%) The causative agents in depression are biological, psychological and social (Final Common Pathway) Residents with dementia may exhibit –Depressed mood, loss of interest/pleasure, suicidal ideation –Changes in weight or appetite, insomnia, hypersomnia Treatment: Medication, Psychotherapy, Social modalities, Electroconvulsive therapy (ECT) 26 Meera Kaur, PhD, RD

27 Medications in Depression Selective Serotonin Reuptake Inhibitors (SSRI): Prescribed for mild to moderately severe depression. Used if TCA is contraindicated or not tolerated Trycyclic Antidepressants (TCA): Prescribed for severe depression with melancholic features. Other Antidepressants 27 Meera Kaur, PhD, RD

28 SSRI... Commonly used SSRIs Citalopram (Celexa) Fluoxetine (Prozac) Escitalopam (Cipralex) Fluvoxamine (Luvox) Common Side effects: Taste change, Anorexia,  or  wt., N/V, Diarrhea, Constipation, Dry mouth, sexual Dysfunction 28 Meera Kaur, PhD, RD

29 SSRI Interactions Foods, Herbal Products, Drinks - St John Wort - Tryptophan supplement Drugs - Non selective MAO Inhibitors ( phenelzine) - carbamazepine - phenytoin - nafcillin 29 Meera Kaur, PhD, RD

30 TCA... Commonly used TCAs Desipramine (Norpramin) Nortriptyne (Aventyl) These two TCAs are the most appropriate for older residents. Common Side effects Sedation Orthostatic  BP Anticholinergic effects 30 Meera Kaur, PhD, RD

31 TCA Interactions Foods, Herbal Products, Drinks - St John Wort - Tryptophan supplement - High fibre diet Drugs - Medication specific 31 Meera Kaur, PhD, RD

32 Other Antidepressants... Commonly used other antidepressants Bupropion (Wellbutrin) Venlafaxine Duloxetine Nefazodone Monoamine Oxidase Inhibitor (MAO1) Common Side effects Sedation Orthostatic  BP Anticholinergic effects 32 Meera Kaur, PhD, RD

33 Other Antidepressants Interactions Foods, Herbal Products, Drinks - St John Wort - Tryptophan supplement Drugs - Medication specific 33 Meera Kaur, PhD, RD

34 Monoamine Oxidase Inhibitors Interactions Foods, Herbal Products, Drinks: Aged or matured cheese( e.g.,Cheddar, Blue, Swiss); Aged or fermented meats and fish (e.g., pepperoni, corned beef, pickled herring, etc.);Meat, Brewer’s yeast and yeast extracts, (e.g., Bovril,Marmite, Oxo etc.); Broad bean pods Drugs: SSRI, Cold Medications Meera Kaur, PhD, RD 34

35 Sedatives... Commonly used sedatives Benzodiazepines (Clonazepam, Lorazepam) Common Side effects Amnesia, Drowsiness Interactions Foods, Herbal Products, Drinks –St John Wort, Alcohol, Kava Drugs –Other Sedatives 35 Meera Kaur, PhD, RD

36 Herbal Sedatives Commonly used herbal sedatives Ashwagandha* Valerian** Marijuana Common Side effects: Drowsiness, CNS depression Interactions Foods, Herbal Products, Drinks: –Alcohol, Chillies* Drugs –Other Sedatives,  -Blocker, **Phenytoin 36 Meera Kaur, PhD, RD

37 Other Mood Disorders… Bipolar Disorders: best managed by Psychotherapy and family-focused treatment (FFT) Pharmacotherapy is less effective without FFT Mania: Commonly used drugs are: Lithium carbonate –Side-effect: tremor (resting, intentional); myoclonus, dehydration, salt depletion –Food interaction: caffeine –Drug interaction: NSAID, thiazide and K ++ sparing diuretics. 37 Meera Kaur, PhD, RD

38 Other Mood Disorders (Mania) Carbamazepine (antiepileptic): Little data on use in late life Antipsychotics: We have already discussed. Slide # 20, 21,22, 23, 24 and 25 Valporic acid Side-effect: sedation; rashes; dehydration, salt depletion;  platelet counts, liver toxicity Food interaction: caffeine Drug interaction: alcohol, ASA, warfarin 38 Meera Kaur, PhD, RD

39 39 Meera Kaur, PhD, RD Mental health status of residents in LTC homes plays a great role in food acceptance or tolerance, and thus poises challenges to the LTC dietitians Psychogeriatric drugs further add to the challenges

40 Nutritional Management... Key points: Thorough understanding of the- current health status of the resident (physical, mental, social) current medication and their side effects drug-drug and drug-nutrient interaction age-related changes in: –sensory attributes –GI system/ functions –endocrine system changes in over all metabolism 40 Meera Kaur, PhD, RD

41 Nutritional Management Principles Achievements/management of satisfactory body weight and over all health through: –adequate intake of nutrients both in quantity and quality –possible physical activities/exercise Dietary management (whenever possible) of drug-related complications (constipation, dehydration, liver functions, kidney functions, BP, blood lipid profile etc.) 41 Meera Kaur, PhD, RD

42 Nutrition Checklist (general)... Has there been a loss of more that 10% usual weight in the past 6 months? Is the diet being limited in some way that may result in missing nutrients and energy? Is fibre being completely avoided? Are milk or milk products being avoided? 42 Meera Kaur, PhD, RD

43 Nutrition Checklist (general) Are caffeine, alcohol, sugar or fat being substituted for other foods? Is the resident on texture modified diet? Is a non-prescribed diet being followed? Are meals or snacks being skipped, or is food consumption less than usual? 43 Meera Kaur, PhD, RD

44 Role of Specific Nutrients Folate and Vitamin B 12 : Deficiency of folate and vitamin B 12 — overt or latent — is mainly a problem for the elderly and a challenge to health care professionals. –Combination of oral cobalamin (1 mg/day) and folate (5 mg/day) for 2 months improved the clinical state of mildly/moderately demented residents with elevated homocysteine level (Nilsson et al., 2001). 44 Meera Kaur, PhD, RD

45 Caffeine in Long-Term Care Literature related to role of caffeine in the elderly population is limited. However, researches have shown that –People who consume caffeine regularly, build tolerance to its diuretic effects –Caffeine may interact with the medication used to treat: Schizophrenia, anxiety and panic disorder (Benzodiazepines), bipolar disorder, mania (Lithium), insomnia and sundowning (TCA, haloperidol, benzodiazepines). 45 Meera Kaur, PhD, RD

46 Adjunctive Therapies... The overall vision of Adjunctive Therapies is a well-rounded and diverse program of treatment, as different people tend to respond to different treatment modalities. These are Art Therapy, Dance Movement Therapy, Psychodrama, Poetry Therapy, Recreational Therapy, Pet Therapy, and Psychosocial Education. 46 Meera Kaur, PhD, RD

47 Adjunctive Therapies 47 Meera Kaur, PhD, RD

48 Team Approach 48 Meera Kaur, PhD, RD

49 Implications for the Practitioners Dietary intervention for the restoration of general health and nutritional status Dietary management of drug-related complications Food rich in natural stimulants and protectants may be considered for the management of GI functions and over all health Whenever possible and applicable, LAB containing yogurt may be included in the diet of residents to improve liver function and promote gut health Team approach and adjunctive therapy help provide optimal nutrition support 49 Meera Kaur, PhD, RD

50 Ms. B An 84-year old women with advanced dementia was bedridden and severely apathetic. She neither fed herself, nor responded to staff attempting to feed her. After IV rehydration, family was asked to consent for tube feeding (TF). Family was concerned about TF. A trial of psychostimulent (methylphenidate) was successful in treating the apathy enough so that she was able to be fed, and she ultimately lived for another two years without requiring TF. Implications: Treating the underlying causes such as apathy, depression etc. is crucial. Stimulation and rewarding activities are helpful for dietary intervention. 50 Meera Kaur, PhD, RD

51 My Mom 70 year old widow, vegetarian. Since last 8 months she is suffering from episodes of copious diarrhea followed by constipation. She has developed resistance to many medications. She is diabetic (NIDDM) with  BP and on medications. Poor GI functions. Can not tolerate most of the foods, especially vegetables and fruits (cooked or raw). Oral Intake is always poor. My brother phoned me describing her chronic illness and asked for dietary advise. What I did? I Discussed with her doctor. We put her on a synbiotic capsule (one/day) for 40 days. Then I suggested to add plain yogurt (1-2 tsp) in most of the foods that she can eat (rice, barley, lentil, milk, stew, soup etc). Did it work? 51 Meera Kaur, PhD, RD

52 Summary The prevalence of mental health issues in LTC facilities is at least 80%. Psychogeriatric medication (P M) is essential while caring for LTC residents with mental health issues, but clearly it is a double-edged sword. Elderly people are at high risk of having side-effects of drugs, and their interactions with foods, drinks, other drugs, which affect their behavior. P M adds challenges to the dietitians while striving to provide optimal nutrition support to residents at LTC settings. Understanding the common psychogeriatric drugs, their action and interaction should help dietitian plan and implement optimal nutrition support for LTC residents. Team approach and adjunctive therapy are important to implement nutrition care plan successfully in LTC residents, specially those residents who are on P M. 52 Meera Kaur, PhD, RD

53 Selected References Canadian Coalition for Seniors’ Mental Health (www.ccsmh). National guidelines for seniors’s mental health. 2006 Conn, D., Herrmann, N.,Kaye, K., Schogt, DRB (Eds). Practical Psychiatry in the Long-Term Care Facility. Hogrefe and Huber Publishers. 2001 Conn Et al., National guidelines for seniors’s mental health. Ca. J Geri. 9, supp (2):S36-S71, 2006 Mallet, L., Spinewine, Huang A. The challenge of managing drug interactions in elderly. The Lancet, 370:185-91, 2007. Maughan, RJ., Griffin, J. Caffeine ingestion and fluid balance: a review. J Human Nutr. Diet. 16:411-420, 2003 Pronsky, ZM, Food Medication Interactions. Birchrunville, PA, 2004 Simmons, DH. Caffeine and its effects on persons with mental disorders. Arch. Psy. Nur, X (2), 1996 Watson, E. Depression and other Mood Disorders (seminar). Seven Oak General Hospital. May 15, 2008 53 Meera Kaur, PhD, RD

54 Acknowledgement I gratefully appreciate: The Dietitians of Canada, 2008 Conference Committee for giving me the opportunity to speak in this session The Gerontology Network for hosting the session and Healthcare Food Services for sponsoring the session. Dr. E. Watson, MB., BCh., FRCPC., Dr. M. Shane, FRCPC.,Ms. M. Lam, RD., Ms. L. Bohn, MSc., RD., Seven Oaks General Hospital; Ms. J. Helps, RD., Deer Lodge Centre; Ms. C. Eisenbraun, RD., Ms. J. Crawford RD., Ms. V. Bright, RD., Dietitians of Canada; Ms. W. Smith-Windsor, RD., Ms. C. Tuan, RD., Selkirk Mental Health Centre for their valuable information while preparing the speech 54 Meera Kaur, PhD, RD

55 55 Meera Kaur, PhD, RD Society, Friendship and Love... Divinely bestowed upon men! Oh! had I the wings of a dove… How soon would I taste you again……

56 Thank you for gracing the session! Any question? 56 Meera Kaur, PhD, RD

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