Behavioral and Mental Health Management

• Behavioral and Mental Health Management

  • Dementia
  • Alzheimer's Disease
  • Anxiety
  • Agitation/Aggression
  • Depression
  • Sundowning Syndrome

   

  • Major changes in the conditions of daily life accompany the aging process and have an impact on health
  • Some changes are vascular causes (forgetting to take meds) others are caused by life changes (death of spouses) or economic stress (reduced income, increased expenses)
  • Reports show < 1300 of the 29000 psychiatrics in the US are certified in geriatrics
• Statistics

  • 54 million Americans that are > 65 yrs old
  • ~20% of those have a mental health disorder
  • Annual cost of treatment in US ~$200 billion annually
  • Baby Boomers (1946-1964)
  • Have higher risk of depression, anxiety and substance abuse than those born before WWII
• Where Do We Fit In?

  • This is where pharmacists can play a HUGE role
  • Drug-Drug interaction
  • Drug-Disease interactions
  • Catching s/sxs early
  • Special bond w/ pts
  • Expanded scope of practice/specialties
  • Fun Fact: there are only 4670 BCGP in the US
  • < 400 in CA!
• Dementia Pathophysiology -- Pathway

  • Increased deposits of amyloid beta (A-beta) peptide in cerebral cortex
  • Extracellular plaques and cerebral vascular lesions
  • Intraneuronal fibrillary tangles consisting of tau protein
  • Progressive loss of neurons (cholinergic neurons mostly)
  • Thinning of cortex

  
  

  Causes: Largely Unknown

  • Inflammatory process
  • Synaptic dysfunction
  • Hydration?
  • Genetic component ?
• Dementia Preventative Treatment Approaches

  • Cholinesterase inhibitors
  • NMDA antagonists -- to inhibit excitotoxicity
  • Statins -- off label
  • Believed to help w/ formation of plaques (atherosclerosis)
  • NSAIDs -- disappointing results
  • Increase risks (bleed and CV)
  • Antibody therapy -- did not perform well, but a start
  • Antioxidants -- disappointing results
• Confusion

  • Typically the beginning stages
  • Wandering
  • Unable to reason
  • Not able to follow storyline
  • Usually transient
  • NOT "the norm"
  • Causes can usually be found
• Confusion --> Dementia

  • Confusion becomes more pronounced
  • More routine
  • More advanced
  • Early diagnosis cannot reverse or cure
  • Treatment CAN slow progression (NOT guaranteed)
  • Greater chance to improve QOL of pt and caregivers
  • CAN give pt time to plan and prepare
• Dementia -- Causes

  • Alzheimer's is #1 cause of dementia (60-80%)
  • Vascular dementia is #2 (multi-infarct dementia)
  • Risks of dementia include:
  • Medications
  • Alcohol induced
  • Genetics
  • Hearing loss
  • Chronic conditions -- especially uncontrolled
• Dementia -- Differential Diagnosis

  • Reversible causes
  • Fever
  • Infection
  • Sodium imbalance
  • Magnesium imbalance
  • Vitamin deficiency
  • Drug interaction
  • Thyroid levels
  • Pain
  • Increases risk of confusion
• Dementia -- Types

  • Lewy Body Dementia
  • Decline in thinking, reasoning and independent function
  • Frontotemporal Dementia (FTD)
  • 2 types
  • One affects speaking, writing, and compression
  • One affects empathy judgement and conduct
  • Parkinson's dementia
  • Often experience hallucinations, delusions, and paranoid thoughts
• Treatment -- Acetylcholinesterase Inhibitors

  Donepezil (Aricpet)

  • Dose: 5-10mg nightly
  • Modest decline in deterioration
  • May delay nursing home placement
  • Consumer report stated improved testing, but not QOL
  • MOA: centrally active, reversible, and noncompetitive acetylcholinesterase inhibitor
  • SE:
  • N/D
  • For nausea -- dose in the evening
  • Dizziness
  • Insomnia
  • For insomnia -- dose in the morning
  • HA
  • Agitation
  • Transdermal patch available
• Treatment -- Acetylcholinesterase Inhibitors (cont.)

  Rivastigmine (Exelon)

  • Doses:
  • Oral: 1.5 - 6 mg twice daily w/ food
  • Patch: 4.6, 9.5, 13.3 mg/24hr
  • MOA: reversible selective cholinesterase inhibitor that interacts preferentially w/ acetylcholinesterase G1
  • SE:
  • N/V/D
  • Dizziness
  • Arrythmias
  • Loss of appetite
  • Weight loss
  • Transdermal patch available
• Treatment -- Acetylcholinesterase Inhibitors (cont.)

  Galantamine (Razadyne)

  • Doses:
  • IR: 4-12 mg twice daily
  • ER: start 8mg daily, then increase to 16-24mg
  • MOA: reversible, competitive acetylcholinesterase inhibitor that also acts on nicotinic acetylcholine receptors
  • SE:
  • N/V/D
  • Arrhythmias
  • Confusion
  • HA
  • Dizziness
  • Studies are usually for short duration
  • CAUTION w/ antimuscarinic for overactive bladder
• Treatment -- NMDA Blockers

  Memantine (Namenda)

  • Dose:
  • IR: 5-10 mg twice daily
  • XR: 28mg daily
  • Start at 7mg daily and titrate weekly
  • MOA: low to moderate affinity NMDA receptor antagonist that binds to NMDA receptor-operated cations channels
  • Prevents glutamatergic overstimulation at NMDA receptor
  • SE:
  • V/D
  • Dizziness
  • Constipation
  • HA
  • Confusion
  • Must be renally adjusted
• Treatment -- AChEi/NMDA Combo

  Memantine/Donepezil (Namzaric)

  • Dosing based on starting doses of separate agents
  • Cannot start someone on these cold
  • SE:
  • HA
  • Dizziness
  • Anorexia
  • N/V/D
  • Ecchymosis
  • DC slowly -- abrupt continuation may worsen cognitive function
• Treatment -- Unconventional

  • Vitamin E
  • Doses > 150 IU
  • Carry risk -- not much strength
  • Ginkgo biloba
  • Used for memory
  • Benefit not shown in dementia
  • Can increase bleeding risk
  • A-phosphatidylserine
  • L-carnitine
  • Huperzine A
  • Derived from Chinese club moss
  • Evidence strength was low, lots of DDI's
• Treatment -- Controversial

  Aducanaumab (Aduhelm)

  • MOA: monoclonal antibody directed against aggregated soluble and insoluble forms of amyloid beta
  • Provided accelerated approval 6/7/2021
  • "investigators found "atypical collaboration" btwn the company and the FDA"
  • Expert outside advisers expressed concerns over effectiveness of drug
  • Exceedingly expensive ($56000/yr)
  • The frequency of side effects, particularly amyloid-related imaging abnormalities (ARIAs) shed doubt on place in therapy
  • Casts doubts on new drug -- Lecanemab (Leqembi)
• Anxiety

  • Affects 10-20% of the elderly populaiton
  • Strong link btwn anxiety and memory
  • Amnesia
  • Flashbacks
• Anxiety -- Contributors

  • Extreme stress/trauma
  • Grief
  • Alcohol and caffeine
  • Medications
  • Alzheimer's and dementia
  • Fear -- FFF (forgetting, falling, finances)
  • Abandonment
  • Being dependent
  • Being victimized
  • Death
• Anxiety -- Presentations

  • Excessive worry
  • Fear
  • Hoarding/collecting
  • Depression
  • Avoidance
  • Inhaler usage**
  • Refusal/obsession w/ routine activities
  • Poor sleep
  • Physical:
  • Tense
  • Increase HR
  • Shallow breathing
  • Nausea
  • Sweating
  • Shaking
  • Fatigue
• Phobias

  • Phobias are EXTREMELY common
  • Social phobias
  • Embarrassment --> names, places, recipes
  • Shame --> appearances
  • Overwhelmed by crowds and excitement
  • Signs and Symptoms -- phsyical sxs
  • Blushing
  • Heavy sweating
  • Trembling
  • Nausea
  • Difficulty talking
• Generalized Anxiety

  • Constant worries
  • Little to no precipitating factors
  • Dwell on concerns regarding
  • Health
  • Money
  • Family
  • Disasters
  • Usually are aware, they worry too much but can't help it
  • Signs and Symptoms
  • Difficulty concentrating, sleeping, and relaxing
  • Startle easily
  • Fatigue
  • Chest pains
  • HA
  • Dizzy
  • Lightheaded
• Non-Pharmacologic Treatment -- DO THIS!

  • Talk therapy
  • Rearranging
  • Acknowledging what is worrying pt and address when able
  • Family, friend, spiritual support
  • Meditation, deep breathing
  • Exercise
  • Consistency
• Non-Pharmacologic -- AVOID THIS!

  • Caffeine
  • Alcohol
  • Nicotine
  • Over-eating
  • Herbal supplements
  • Overstimulation*
• Pharmacologic Treatment -- Anxiolytic [Benzodiazepines]

  • Beers Criteria association
  • Table 2: all BZD increase risk of cognitive impairment, delirium, falls, fractures, and MVA in older adults
  • Table 3
  • Avoid in w/ or at high risk for delirium -- increase/worsening delirium
  • Dementia or cognitive decrease -- increase CNS effects
  • Hx fall/fracture
  • NOT preferred in elderly, but if you must, remember: LOT
  • Lorazepam (Ativan)
  • Dose: 1-2 mg PO in 2-3 divided doses
  • Max: 2mg/day for initial dosing
  • Max: 3mg/day
• Pharmacologic Treatment -- Anxiolytic [Benzodiazepines] (cont.)

  • Lorazepam (Ativan)
  • Dose: 1-2 mg PO in 2-3 divided doses
  • Max: 2mg/day for initial dosing
  • Max: 3mg/day
  • Oxazepam (Serax)
  • Dose: 10mg PO 3-4 times daily
  • May increase (cautiously) to 15mg 3-4 times daily
  • Temazepam (Restoril)
  • Dose: 7.5-15 mg PO nightly
  • Side effects:
  • Dizziness
  • Confusion
  • Depression
  • HA
  • Dyspepsia
  • Syncope
  • Illogical thinking*
  • Vision changes
  • Falls*
  • Increased risk of overdose when combined w/ opioids
  • Table 5
• Pharmacological Treatment -- Other Agents

  Buspirone (Buspar)

  • Dose: 7.5mg twice daily
  • May increase every 2-3 days in 2.5mg increments
  • Max 30mg twice daily
  • Great for antidepressant augmentation

   

  Antidepressants

  • Escitalopram (Lexapro)
  • Table 3: Hx falls and fracture
  • Citalopram (Celexa)
  • Table 4: exac/cause SIADH or hypoNa
  • Sertraline (Zoloft)
  • Table 5: CNS agents, warfarin

   

  Side Effects

  • Nausea
  • Dizziness
  • Confusion*
  • Depression
  • Headache
  • Syncope
  • Illogical thinking*
  • Falls*
• Controversy -- Benzo

  Benzodiazepines: shorter-acting ones are NOT safer than long-acting ones

   

  The Good

  • Best anxiolytics
  • Options for short half life
  • Tolerated well
  • Low cost, generics

   

  The Bad

  • Can increase
  • Confusion
  • Aggression
  • Paradoxical anxiety
  • Dependence

   

  The Ugly

  • Regulation
  • Reports of increased risk of deaths
• Agitation

  • General term encompassing
  • Combativeness
  • Shouting
  • Hyperactivity
  • Disinhibition
  • Troublesome for pt and caregivers alike
• Agitation Treatment

  • Non-pharmacologic
  • Redirection
  • Family support
  • Patience
  • Antipsychotics
  • Beer's Criteria association
  • Table 2: increase risk of CVA, cognitive, decline, and mortality in dementia
  • Table 3: h/o delirium, dementia of cognitive impairment, falls and fracture, Parkinson's (except Quetiapine)
  •  Table 4: may exacerbate/cause SIADH or hypoNa
  • Table 5: CNS agents, warfarin
• Agitation Treatment (cont.)

  • Risperidone (Risperdal) 0.5-2 mg daily
  • Quetiapine (Seroquel) 50-150 mg daily
  • Olanzapine (Zyprexa) 5-7.5 mg daily
  • Table 3: h/o syncope
  • Table 7
  • Aripiprazole (Abilify) 2.5-12.5 mg daily
  • Haloperidol (Haldol) 0.25-0.5 mg daily
• Depression

  • Question: is depression normal for the elderly? NO, never
  • Causes:
  • Death
  • Health problems
  • Decreased phsyical functioning
  • Financial difficulties
  • Signs and Symptoms
  • Sleep disturbances
  • Changes in appetite --> wt changes
  • Fatigue/lethargy
  • Hopelessness/worthlessness
  • Loss of interest
  • Physical pain
  • Irritable/low annoyance threshold
  • Thoughts of death/suicide
  • Difficulty concentrating
  • Inability to make decisions
• Depression Treatment

  • SSRIs
  • Citalopram (Celexa) 20mg daily (max)
  • Escitalopram (Lexapro) 5-10mg daily
  • Sertraline (Zoloft)
  • Fluvoxamine (Luvox)
  • Table 3, 4, 5
  • Paroxetine (Paxil)
  • Table 7
  • SNRIs
  • Venlafaxine (Effexor)
  • Discontinued for: sleep, GI, anxiety, HA, wt loss
  • Table 3, 4, 5
  • TCA's
  • Mirtazapine (Remeron)
  • Table 4: may exacerbate/cause SIADH or hypoNa
  • Nortriptyline
  • Table 2, 3, 4, 5, 7
  • Despiramine
  • Table 2, 3, 4, 5, 7
• Depression -- How Can We Help?

  • Differential diagnosis is key… but difficult
  • Dementia vs. depression?
  •  most older adults will go to their PCP for treatment of depression
  • PCPs have limited time and competing priorities
  • Only 1 in 5 older adults treated for depression by PCP will improve
  • Get a good history
  • Talk to caregivers
  • Document progression
  • Is there a cause? A specific incidence that triggered the worsening?
  • Are there any other potential causes?
• Sundowning Syndrome

  • Can be seen in up to 25% of elderly pts
  • Up to 66% of those w/ Alzheimer's
  • Common clinical phenomenon manifested by the emergence or increment of neuropsychiatric symptoms in the late afternoon, evening or at night
  • DSM V
  • What's it look like?
  • Happens at night, as darkness falls
  • Increased from baseline
  • Confusion, anxiety, agitation
  • Pacing, wandering
  • Difficulty redirecting
  • Yelling
  • Causes: NOT known
  • Mental exhaustion
  • Circadian dysregulation
  • Shadows
  • Decreased SCN in brains of dementia pts
  • Decreased melatonin
• Sundowning Syndrome -- Pharmacologic Treatment

  • Melatonin 3-5mg
  • Dosed WAY before bedtime, NOT AT bedtime
  • Anxiolytics
  • Sleeping agents
  • Dalmane, Restoril
  • Ambien, Sonata
  • Antipsychotics
  • Used more for aggression and agitation
  • NOT approved but done
  • Acetylcholinesterase Inhibitor
  • Donepezil -- single study
  • Pain management
  • Look for wear-off effects
  • Problems
  • Paradoxical excitement
  • Increased risk of falls
• Sundowning Syndrome -- Non-Pharmacologic Treatment

  • Light therapy in the morning
  • Light boxes -- used in the morning
  • Calming tactics
  • Behavior modification
  • Sleep hygiene
  • Rearrange daily activities*** CAUTION
  • Phsyical activity
  • Consistency
  • Patience