side effects of psychiatric medications in long term care thomas magnuson, m.d. assistant professor...
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Side Effects of Side Effects of Psychiatric Psychiatric
Medications in Medications in Long Term CareLong Term Care
Thomas Magnuson, M.D.Thomas Magnuson, M.D.Assistant ProfessorAssistant Professor
Division of Geriatric PsychiatryDivision of Geriatric PsychiatryUNMCUNMC
Objectives Objectives
Delineate common psychiatric Delineate common psychiatric medications used in long-term caremedications used in long-term care
Identify common side effects Identify common side effects associated with those medicationsassociated with those medications
The Falling ManThe Falling Man
78 year old white male78 year old white male Parkinson’s diseaseParkinson’s disease HypothyroidismHypothyroidism HypertensionHypertension High cholesterolHigh cholesterol Constipation Constipation Insomnia Insomnia Cognitive declineCognitive decline Depression Depression
The Falling ManThe Falling Man Getting along fairly well up to a week agoGetting along fairly well up to a week ago
Onset of delusions about wife and children Onset of delusions about wife and children stealing his money, staff is poisoning his foodstealing his money, staff is poisoning his food
Fearful, weight loss, verbal and physical Fearful, weight loss, verbal and physical aggressionaggression
CBC, CMP, TSH, UA, vital signs all normalCBC, CMP, TSH, UA, vital signs all normal Medical cause seems ruled outMedical cause seems ruled out
Seroquel 12.5mg at bedtime started Seroquel 12.5mg at bedtime started Within a day his delusions declineWithin a day his delusions decline Falls twice in three daysFalls twice in three days Medication stopped, delusions returnMedication stopped, delusions return
The Falling ManThe Falling Man
Other medicationsOther medications Sinemet and MirapexSinemet and Mirapex ZoloftZoloft AriceptAricept SynthroidSynthroid Lasix and LopressorLasix and Lopressor Colace, MOMColace, MOM Trazodone Trazodone
Classes Classes
AntidepressantsAntidepressants Anti-anxiety agentsAnti-anxiety agents Mood stabilizersMood stabilizers AntipsychoticsAntipsychotics Sleep agentsSleep agents Dementia medicationsDementia medications
Why do you get side Why do you get side effects?effects?
Medications try to alter brain chemicalsMedications try to alter brain chemicals Just the wrong drugJust the wrong drug
Reasonable choice, dosage, etc.Reasonable choice, dosage, etc. Dose may be too highDose may be too high
Dose-dependentDose-dependent May not see at lower dosesMay not see at lower doses
Many of these chemicals present throughout the Many of these chemicals present throughout the bodybody
Medications cannot be specific only to the brainMedications cannot be specific only to the brain Targeting the brain, problems in the stomachTargeting the brain, problems in the stomach
Allergic reactionsAllergic reactions Rash to anaphylaxisRash to anaphylaxis
Drug to drug interactionsDrug to drug interactions
Don’t all medications have Don’t all medications have side effects?side effects?
Yes, so does breakfast cerealYes, so does breakfast cereal Look at common side effectsLook at common side effects
Help you with recognitionHelp you with recognition Much more informed patients and guardiansMuch more informed patients and guardians
Rare side effects not focusRare side effects not focus Make your head swimMake your head swim
Zillions listedZillions listed Even if it happened onceEven if it happened once
Someone may have gotten this from the medicationSomeone may have gotten this from the medication Some times concurrent things happenSome times concurrent things happen
Had gastroenteritis during the drug studyHad gastroenteritis during the drug study
Antidepressants Antidepressants
SSRIsSSRIs Selective Serotonin Reuptake InhibitorsSelective Serotonin Reuptake Inhibitors
Most widely used classMost widely used class Relatively safe in overdose, few drug Relatively safe in overdose, few drug
interactionsinteractions Readily prescribed in the elderlyReadily prescribed in the elderly
Prozac (fluoxetine)Prozac (fluoxetine) Zoloft (sertraline)Zoloft (sertraline) Paxil (paroxetine)Paxil (paroxetine) Celexa (citalopram)Celexa (citalopram) Lexapro (escitalopram)Lexapro (escitalopram)
Antidepressants Antidepressants SSRIsSSRIs
Nausea, diarrheaNausea, diarrhea Sexual dysfunctionSexual dysfunction
Need to ask!Need to ask! HeadacheHeadache Rash Rash Agitation, anxiety, restlessness, insomniaAgitation, anxiety, restlessness, insomnia
Tend to be activatingTend to be activating Weight gainWeight gain Increased sweatingIncreased sweating DrowsinessDrowsiness Suicidal thoughtsSuicidal thoughts
Antidepressants Antidepressants
SNRIsSNRIs Serotonin and Norepinephrine Reuptake Serotonin and Norepinephrine Reuptake
InhibitorsInhibitors Effexor (venlafaxine)Effexor (venlafaxine) Pristiq (desvenlafaxine)Pristiq (desvenlafaxine)
Hot flashesHot flashes Chemical cousin to EffexorChemical cousin to Effexor
Newer, expensiveNewer, expensive
Cymbalta (duloxetine)Cymbalta (duloxetine) Neuropathic painNeuropathic pain
Antidepressants Antidepressants
SNRIsSNRIs FatigueFatigue DizzinessDizziness Abnormal dreamsAbnormal dreams Elevated blood pressureElevated blood pressure
Especially if used above recommended Especially if used above recommended dosagesdosages
Chest palpitations, fast heart rateChest palpitations, fast heart rate Anxiety Anxiety Suicide Suicide
Antidepressants Antidepressants
Remeron (mirtazepine)Remeron (mirtazepine) Abnormal dreams and thinkingAbnormal dreams and thinking Increased appetite, weight gainIncreased appetite, weight gain
Especially at lower doses (7.5-15mg)Especially at lower doses (7.5-15mg) SS leepiness, fatigue, weaknessleepiness, fatigue, weakness
Especially at lower doses (7.5-15mg)Especially at lower doses (7.5-15mg) Constipation, dry mouthConstipation, dry mouth DizzinessDizziness
Antidepressants Antidepressants
Wellbutrin (bupropion)Wellbutrin (bupropion) Dry mouth, headacheDry mouth, headache Increased sweatingIncreased sweating Nausea/vomiting, constipationNausea/vomiting, constipation AnxietyAnxiety FatigueFatigue
But generally seen as activatingBut generally seen as activating Blurred visionBlurred vision Seizures Seizures
Extended release lessens risk to 2/1000 chance from Extended release lessens risk to 2/1000 chance from 4/10004/1000
Antidepressants Antidepressants Tricyclic antidepressantsTricyclic antidepressants
Elavil (amitriptyline)Elavil (amitriptyline) Used more for pain, sleepUsed more for pain, sleep
Pamelor (nortriptyline)Pamelor (nortriptyline) Less robust side effects than amitriptylineLess robust side effects than amitriptyline
Older antidepressantsOlder antidepressants Cheap, but effectiveCheap, but effective
Not very specific as to brain transmittersNot very specific as to brain transmitters Wide variety of side effectsWide variety of side effects
Potentially fatal in overdosePotentially fatal in overdose Makes the heart beat irregularlyMakes the heart beat irregularly
Antidepressants Antidepressants
Tricyclic AntidepressantsTricyclic Antidepressants Increased appetite, weight gain, Increased appetite, weight gain,
sleepinesssleepiness Blurry vision, constipation, urinary Blurry vision, constipation, urinary
retention, racing heart beat, confusionretention, racing heart beat, confusion Dizziness upon standingDizziness upon standing Sexual problemsSexual problems Dry mouthDry mouth
Anti-anxiety AgentsAnti-anxiety Agents BenzodiazepinesBenzodiazepines
Dependency-producingDependency-producing Be aware of the patient’s historyBe aware of the patient’s history
Difficult to use in the elderlyDifficult to use in the elderly Sedation, confusion, ataxiaSedation, confusion, ataxia
Xanax(alprazolam)Xanax(alprazolam) Ativan (lorazepam)Ativan (lorazepam) Klonopin (clonazepam)Klonopin (clonazepam)
BuSpar (buspirone)BuSpar (buspirone) No dependency, sedation issuesNo dependency, sedation issues Efficacy, long time to workEfficacy, long time to work
Anti-anxiety AgentsAnti-anxiety Agents
BenzodiazepinesBenzodiazepines EpilepsyEpilepsy Restless leg syndromeRestless leg syndrome
Depress the brainDepress the brain SedationSedation Slurred speech, aspirationSlurred speech, aspiration Confusion, deliriumConfusion, delirium Falls Falls
Anti-anxiety AgentsAnti-anxiety Agents
BuSpar (buspirone)BuSpar (buspirone) DizzinessDizziness Nausea Nausea Headache Headache Nervousness, excitementNervousness, excitement Lightheadedness Lightheadedness
Mood StabilizersMood Stabilizers
Bipolar disorderBipolar disorder Agitation, aggressionAgitation, aggression
Eskalith, Lithobid Eskalith, Lithobid Lithium carbonate-pills, tabletsLithium carbonate-pills, tablets Lithium citrate-liquidLithium citrate-liquid
AnticonvulsantsAnticonvulsants Depakote (valproate)Depakote (valproate) Tegretol (carbamazepine)Tegretol (carbamazepine) Lamictal (lamotrigine)Lamictal (lamotrigine)
Mood StabilizersMood Stabilizers LithiumLithium
Usual medication in bipolar disorderUsual medication in bipolar disorder Narrow safety indexNarrow safety index Therapeutic levelTherapeutic level
Overdose is a concernOverdose is a concern Look intoxicatedLook intoxicated
Sedation, comaSedation, coma Causes of overdoseCauses of overdose
Sweating, vomiting, diarrheaSweating, vomiting, diarrhea Excessive urinationExcessive urination
Goes along with excessive drinkingGoes along with excessive drinking Use of diureticsUse of diuretics
HCTZ, acetazolamideHCTZ, acetazolamide Tegretol (carbemazapine)Tegretol (carbemazapine)
Mood StabilizersMood Stabilizers LithiumLithium
Mild-moderate overdoseMild-moderate overdose N/V, diarrheaN/V, diarrhea DrowsinessDrowsiness Weak musclesWeak muscles Slurred speechSlurred speech Lack of coordinationLack of coordination
Severe overdoseSevere overdose GiddinessGiddiness AtaxiaAtaxia Blurred visionBlurred vision TinnitusTinnitus Large output of dilute urineLarge output of dilute urine
Mood StabilizersMood Stabilizers
Lithium Lithium Caffeine, theophyllineCaffeine, theophylline
Lower lithium levelLower lithium level NSAIDs, ACEIs, CCBsNSAIDs, ACEIs, CCBs
Worsen potential neurotoxicityWorsen potential neurotoxicity
Chronic problemsChronic problems Damages kidneyDamages kidney
Nephrogenic diabetes insipidusNephrogenic diabetes insipidus Damages thyroidDamages thyroid
Hypothyroidism Hypothyroidism
Mood StabilizersMood Stabilizers
Anticonvulsants Anticonvulsants Depakote (valproate)Depakote (valproate)
Slows down the brainSlows down the brain Therapeutic levelTherapeutic level
Oversedated, slurred speech, ataxiaOversedated, slurred speech, ataxia EpilepsyEpilepsy Migraine headacheMigraine headache Bipolar disorderBipolar disorder
Mood StabilizersMood Stabilizers Anti-convulsantsAnti-convulsants
Depakote (valproate)Depakote (valproate) SedationSedation Blood cell abnormalitiesBlood cell abnormalities
White blood cellsWhite blood cells Platelets Platelets
Hepatitis, pancreatitis Hepatitis, pancreatitis Nausea, vomiting, dyspepsiaNausea, vomiting, dyspepsia DizzinessDizziness Abdominal painAbdominal pain Weight gainWeight gain Rash Rash
Mood StabilizersMood Stabilizers
AnticonvulsantsAnticonvulsants Tegretol (carbamazapine)Tegretol (carbamazapine)
Therapeutic levelTherapeutic level Overdose results in sedation, slurred speech and Overdose results in sedation, slurred speech and
ataxiaataxia Low level may be due to medication itselfLow level may be due to medication itself
EpilepsyEpilepsy Trigeminal neuralgia, migraineTrigeminal neuralgia, migraine Bipolar disorderBipolar disorder
Mood StabilizersMood Stabilizers AnticonvulsantsAnticonvulsants
Tegretol (carbamazapine)Tegretol (carbamazapine) Many side effects are similar to DepakoteMany side effects are similar to Depakote
DizzinessDizziness DrowsyDrowsy Dry mouthDry mouth Nausea, vomitingNausea, vomiting Unsteady gaitUnsteady gait
Less commonLess common Hepatitis, pancreatitisHepatitis, pancreatitis Blood cellsBlood cells
Anemia Anemia White blood cellsWhite blood cells Platelets Platelets
Mood StabilizersMood Stabilizers
Anticonvulsants Anticonvulsants Lamictal (lamotrigine)Lamictal (lamotrigine)
RashRash Can be severe and even fatalCan be severe and even fatal
Under 1%Under 1% Various dosing schedulesVarious dosing schedules
A bit higher risk if also on DepakoteA bit higher risk if also on Depakote
OtherwiseOtherwise Sedating, dizziness, double vision, Sedating, dizziness, double vision,
headachesheadaches
Antipsychotics Antipsychotics Many agentsMany agents
OlderOlder Haldol (haloperidol), Haldol decanoateHaldol (haloperidol), Haldol decanoate
Newer Newer Risperdal (risperidone), Risperdal ConstaRisperdal (risperidone), Risperdal Consta
Invega (paliperidone), Invega SustennaInvega (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)
Antipsychotics Antipsychotics
PsychosisPsychosis Main functionMain function
Schizophrenia to deliriumSchizophrenia to delirium
Behavioral problems in dementiaBehavioral problems in dementia No evidence that they workNo evidence that they work
Everyone has some story…Everyone has some story…
Bipolar disorderBipolar disorder Newer indication with novel agentsNewer indication with novel agents
Antipsychotics Antipsychotics
Main side effectsMain side effects Motor problemsMotor problems
Extra-pyramidal side effectsExtra-pyramidal side effects Blood sugar and cholesterolBlood sugar and cholesterol
Metabolic syndromeMetabolic syndrome Risks in dementiaRisks in dementia
Increased mortality riskIncreased mortality risk Others Others
Antipsychotics Antipsychotics
Movement problemsMovement problems DystoniaDystonia
Sustained muscle contractionSustained muscle contraction Wry neckWry neck
Rare in the elderlyRare in the elderly Problem of young peopleProblem of young people
Easily treated if newEasily treated if new Benedryl (diphenhydramine), Cogentin Benedryl (diphenhydramine), Cogentin
(benztropine)(benztropine) Harder to treat tardive dystoniaHarder to treat tardive dystonia
Botulinum toxin IMBotulinum toxin IM
Antipsychotics Antipsychotics
Movement problemsMovement problems AkathisiaAkathisia
Cannot sit stillCannot sit still Very uncomfortableVery uncomfortable
Especially in the legsEspecially in the legs Rule out Restless Leg Syndrome, anxietyRule out Restless Leg Syndrome, anxiety
TreatmentTreatment Beta blockersBeta blockers BenzodizepinesBenzodizepines
Antipsychotics Antipsychotics Movement problemMovement problem
ParkinsonismParkinsonism Drug-induced Parkinsonism (DIP)Drug-induced Parkinsonism (DIP)
More likely in older patientsMore likely in older patients Tremor, stiff, slowTremor, stiff, slow Both sides at onceBoth sides at once
Stop medication or lower doseStop medication or lower dose Seroquel, Abilify, ClozarilSeroquel, Abilify, Clozaril
Takes weeks at leastTakes weeks at least May not improve May not improve
Parkinson’s medications don’t work too wellParkinson’s medications don’t work too well May cause worse psychosisMay cause worse psychosis
Antipsychotics Antipsychotics
Movement problemsMovement problems Tardive dyskinesiaTardive dyskinesia
Repetitive non-purposeful movementRepetitive non-purposeful movement Mouth, head, limbs, trunkMouth, head, limbs, trunk
Usually takes yearsUsually takes years Common in persons with schizophreniaCommon in persons with schizophrenia Less time, less drug with the elderlyLess time, less drug with the elderly
No treatmentNo treatment RecognitionRecognition Stop medicationStop medication Change agentsChange agents
Antipsychotics Antipsychotics
Blood sugar and cholesterolBlood sugar and cholesterol May be partially due to weight gainMay be partially due to weight gain
Induce or worsen diabetesInduce or worsen diabetes Induce or worsen elevated cholesterolInduce or worsen elevated cholesterol Fasting blood glucose and lipids Fasting blood glucose and lipids
recommendedrecommended All can cause these symptomsAll can cause these symptoms
Zyprexa and Clozaril most likelyZyprexa and Clozaril most likely
Antipsychotics Antipsychotics
Risks with dementiaRisks with dementia FDA warningFDA warning
Increased mortality risk Increased mortality risk Almost double the rate of a sugar pillAlmost double the rate of a sugar pill
Sedation, Parkinsonism, tardive Sedation, Parkinsonism, tardive dyskinesiadyskinesia Aspiration pneumoniaAspiration pneumonia
Cardiac conductionCardiac conduction Strokes, especiallyStrokes, especially
Antipsychotics Antipsychotics OtherOther
SedationSedation Low blood pressure upon standingLow blood pressure upon standing
Especially SeroquelEspecially Seroquel Prone to fallsProne to falls
Cardiac conductionCardiac conduction Especially GeodonEspecially Geodon Prone to heart attack, strokeProne to heart attack, stroke
Low WBC countLow WBC count Clozapine Clozapine Prone to infectionProne to infection Requires weekly CBCsRequires weekly CBCs
Neuroleptic malignancy syndromeNeuroleptic malignancy syndrome Rare Rare
EmergencyEmergency Very rigid, high fever, confusionVery rigid, high fever, confusion
Sleep AgentsSleep Agents
HypnoticsHypnotics Only for sleepOnly for sleep
Benzodiazepine-likeBenzodiazepine-like Ambien (zolpidem)Ambien (zolpidem) Sonata (zaleplon) Sonata (zaleplon)
Melatonin mediatorMelatonin mediator Rozerem (ramelteon)Rozerem (ramelteon)
AntidepressantsAntidepressants Desyrel (trazodone)Desyrel (trazodone) Elavil (amitriptyline)Elavil (amitriptyline) Remeron (mirtazapine)Remeron (mirtazapine)
Sleep AgentsSleep Agents
Ambien and SonataAmbien and Sonata Short term useShort term use
Daytime drowsinessDaytime drowsiness DiarrheaDiarrhea Dizziness Dizziness
Longer useLonger use Drugged feelingDrugged feeling DizzinessDizziness
Abnormal thinking, behavior changes, complex Abnormal thinking, behavior changes, complex behaviorsbehaviors
Rare Rare Driving, eating, e.g. Driving, eating, e.g.
Sleep AgentsSleep Agents RozeremRozerem
DizzinessDizziness Daytime drowsinessDaytime drowsiness Fatigue Fatigue Nausea, diarrheaNausea, diarrhea
TrazodoneTrazodone Drowsiness, insomnia, fatigueDrowsiness, insomnia, fatigue AgitationAgitation Dry mouthDry mouth Constipation Constipation Headache Headache Drop in blood pressure upon standingDrop in blood pressure upon standing Priapism Priapism
Dementia MedicationsDementia Medications
All are capable of modestly slowing All are capable of modestly slowing functional declinefunctional decline Use both classes together Use both classes together
Cholinesterase inhibitorsCholinesterase inhibitors Aricept (donepezil)Aricept (donepezil) Exelon (rivastigmine)Exelon (rivastigmine) Razadyne (galantamine)Razadyne (galantamine)
NMDA antagonistsNMDA antagonists Namenda (memantine)Namenda (memantine)
Dementia MedicationsDementia Medications
Cholinesterase inhibitorsCholinesterase inhibitors CommonCommon
Diarrhea, nausea and vomiting, loss of appetiteDiarrhea, nausea and vomiting, loss of appetite Weight lossWeight loss
Insomnia, sleepinessInsomnia, sleepiness Muscle crampsMuscle cramps
Less commonLess common Nightmares Nightmares Agitation Agitation Frequent urinationFrequent urination BruisingBruising
Dementia MedicationsDementia Medications
NamendaNamenda Well-toleratedWell-tolerated
No side effect occurred in 5% and double No side effect occurred in 5% and double the placebo rate in controlled trialsthe placebo rate in controlled trials
DizzinessDizziness Headache Headache ConfusionConfusion Constipation Constipation
The Falling ManThe Falling Man
What to do?What to do? FallsFalls
Parkinson’s disease gaitParkinson’s disease gait Parkinson’s disease orthostasisParkinson’s disease orthostasis Parkinson’s disease medicationsParkinson’s disease medications
Plus could be contributing to the psychosisPlus could be contributing to the psychosis Trazodone orthostasisTrazodone orthostasis Dehydration, poor nutritionDehydration, poor nutrition HypothyroidismHypothyroidism Zoloft hyponatremiaZoloft hyponatremia Apraxia from cognitive decline/dementiaApraxia from cognitive decline/dementia
The Falling ManThe Falling Man OrthostasisOrthostasis
Per standing, sitting blood pressure readingsPer standing, sitting blood pressure readings Low blood pressure upon standingLow blood pressure upon standing Dizzy, fallDizzy, fall
Dementia changes Dementia changes Should be more insidiousShould be more insidious
Parkinson’s medicationsParkinson’s medications Not changed in doseNot changed in dose
Hypothyroidism, dehydration, nutrition, Zoloft, UTIHypothyroidism, dehydration, nutrition, Zoloft, UTI All ruled out by lab testsAll ruled out by lab tests
Multiple influencesMultiple influences Orthostasis from Parkinson’s disease, trazodone, SeroquelOrthostasis from Parkinson’s disease, trazodone, Seroquel
Seroquel pushed the risk of orthostasis over the topSeroquel pushed the risk of orthostasis over the top Must stop Seroquel?Must stop Seroquel?
Could stop trazodoneCould stop trazodone Still psychoticStill psychotic
Abilify or ClozarilAbilify or Clozaril
Questions?Questions?