Dr. Janet P. McMillan, APRN-BCPsychiatric Nurse PractitionerHattiesburg, MS

Psychotropic Medications in Older Adults: Pearls and Pitfalls

› 1. Provide information on how the most commonly prescribed psychotropic medications affect the elderly.

› 2. Examine recent concerns about the use of psychotropic medications with older adults.

› 3. Describe implications for the advance practice nurse prescribing psychotropic medications the older adults.

Objectives

› Psychotropic medications are more prevalent among community dwelling older adults than any other age group. Community dwelling elder adults are 7 to 18 times more likely to use psychotropic drugs than are middle-aged adults.

› More than half of community dwelling older adults who are admitted to nursing homes receive psychotropic medications within two weeks of their admission.

› In fact, in a study of older adults with dementia in nursing homes and psychiatric care geriatric units, researchers found the 87% of patients were taking 1 psychotropic medication, 66% were taking 2, 36% were taking 3, and 11% were taking 4 or more psychotropic medications.

Understanding the Scope of the Problem

› It is well documented that older adults are highly vulnerable to the adverse effects of psychotropic medications. Those older than age 70 are 3 1/2 times more likely than younger individuals to be admitted to the hospital for adverse reactions associated with psychotropic medications.

› In short, psychotropic medications can induce or worsen hypotension and get put elderly patients at risk for falls and skeletal fractures, particularly when given in combination with other medications.

Adverse Affects in the Elderly

› Psychotropic medication is a broad term referring to medications that affect mental function, behavior, and experience.

› These medications are typically administered to older adults to manage symptoms of anxiety, depression, psychological distress, and/or insomnia.

› The 3 most commonly prescribed categories of medications include anxiolytic, antidepressant, and antipsychotic medications.

What Are Psychotropic Medications?

› Age-related changes such as altered absorption, altered distribution, changed hepatic metabolism, reduced renal excretion, and altered neurophysiology all affect the pharmacokinetics and pharmacodynamics of medications.

› Comorbid medical diagnoses and polypharmacy also affect pharmacokinetics and pharmacodynamics properties of soccer tropic medications putting older adults at risk for adverse drug reaction and interactions.

› These facts are well-known to prudent prescribed and should be taken into consideration.

Age-Related Changes

› Anxiolytic medications are most commonly prescribed for anxiety disorders or symptoms. The most common anxiolytic medications prescribed for older adults are the benzodiazepines.

› Older adults experience an increased magnitude of the common side effects of these drugs, particularly sedation and memory and psychomotor impairment.

› This is most likely due to the reduced rates of drug clearance and elimination in older adults. Some older adults experience paradoxical excitement from benzodiazepines.

Anxiolytic/Hypnotic Medications

› Long-term use (more than 30 days) of benzodiazepines are contraindicated in older adults due to the risk of cognitive decline, reduced physical coordination, and addiction; however, many older adults are prescribed benzodiazepines for months or even years.

› Many older adults are prescribed benzodiazepines as a sleep aid; however, this might actually worsen sleep patterns in older adults.

› About 10% of geriatric hospitalizations are related to the use of benzodiazepines.

Hazards of BZD Use in Older Adults

› Sedating antihistamine drugs should also be avoided, as they may be associated with delirium and other anti-cholinergic side effects.

› If prescribed, hypnotic drugs should be tapered to discontinue, if taken longer than two weeks.

Are Antihistamines OK?

› First of all be sure that the symptom you are treating is indeed anxiety.

› Recognizing and being able to differentiate anxiety from other underlying medical illnesses such as cardiac disorders, endocrine disorders withdrawal from alcohol, caffeine or nicotine can be difficult because patients may exhibit similar symptoms.

› Many elderly patients have undiagnosed depression, which can present with atypical symptoms similar to an anxiety disorder, or patients may have comorbid anxiety and depression.

What is the Alternative?

› If the patient has been taking benzodiazepines long-term, closely monitor them for cognitive and/or functional decline using screening tools such as the mini mental status exam.

› Fall risk should be assessed, as well as symptoms of increasing tolerance and/or dependence.

› If a problem is noted and discontinuation is indicated, work collaboratively with the family or an inpatient facility in a carefully titrated withdrawal program.

If A Benzodiazepine Medication is Needed…

› Tolerance: requiring higher doses to achieve the same effect

› Dependence: – taking the drug in larger amounts over a longer time than intended; – persistent desire or unsuccessful attempts to control use; – spending a great deal of time trying to obtain the medication, such as

going to multiple doctors.; and – impaired social functioning as a result of the substance.

› Discontinuation withdrawal symptoms will occur after use of more than 30 days and must be carefully monitored. Half-life will determine symptoms severity.

Tolerance Vs. Dependence

Half-Life (hours) Generic Name Trade Names5-10 Temazepam Restoril6-10 Oxazepam Serax10-14 Alprazolam Xanax22-54 Clonazepam Klonopin20-48 Diazepam Valium25-30 Flunitrazepam Rohypnol

Common Benzodiazepines

› Onset: 2-3 days for short-acting 5-7 days for long-acting

› Symptoms typically last 2-4 weeks, up to a few months

› Symptoms can be more intense at the beginning and end of reduction.

› Symptoms typically fluctuate

› Symptoms vary from mild to severe and may require hospitalization

Benzodiazepine Withdrawal

› Nonpharmacological interventions such as activity-based therapies (music, art, dance, drama), reality orientation, reminiscence, validation, and multi sensory stimulation should be explored to ameliorate symptoms of anxiety and insomnia prior to reliance on anxiolytic medications.

› Treatments for generalized anxiety disorder overlap greatly with those for depression.

› First line treatments include SSRIs, SNRIs, buspirone (BuSpar), pregabalin (Lyrica), and gabapentin (Neurontin).

Non-Pharmacological Management of Anxiety

› There is a place for the use of benzodiazepines in treating the patient with an anxiety disorder when prescribed responsibly.

› When initiating an SSRI or an SNRI, the serotonergic agents are often activating, difficult to tolerate early in dosing, and have a delayed onset of action.

› Therefore short-term use (2-4 weeks) of a benzodiazepine might be indicated for these patients to provide relief of anxiety symptoms.

› Antidepressant medications are prescribed for depressive disorders, anxiety disorders, and insomnia or depression with comorbid anxiety.

› SSRIs have become the preferred first-line treatment for depression in older adults due to the benign side effect profile, reduced anti-cholinergic and cardiovascular effects.

› However, older adults have increased sensitivity to adverse effects than the younger patients. Citalopram (Celexa), escitalopram (Lexapro), and sertraline (Zoloft) are generally well tolerated.

Antidepressant Medications

› Tricyclic antidepressants have a number of side effects that increase the elderly patients risk for falls including: – sedation, – psychomotor retardation, – postural hypotension, and – anti-cholinergic effects

› This risk is greatest during the first 90 days of treatment.

Tricyclic Antidepressants in the Elderly?

› Although there is a risk with prescribing antidepressant medications in the elderly, there is concern that depression in older adults often goes unrecognized.

› One study reported that the rate of undiagnosed depression in the elderly could be as high as 85%, with only 15% to 19% of older people receiving ample antidepressant medication.

There is a Caveat…

› Work closely with mental health professionals to identify elderly individuals with depressive symptoms.

› Understand that depression and older adults can be manifested through atypical symptoms of depression including: – anxiety, – difficulty with concentration and memory, – confusion, – slow movements, and – unexplained somatic complaints.

So What Can We Do?

› Work with patients and families to provide resources for: – psychoeducation, – family counseling, – home care, – grief/loss support groups, and – outpatient senior care programs.

› Complementary or alternative therapies such as prayer, massage, or aromatherapy can also be helpful.

Resources

› When prescribing antidepressant medications to older adults, be familiar with the side effect profile and the major drug to drug interactions.

› Some SSRIs and TCAs cause hyponatremia and increased risk of bleeding when combined with NSAIDs, aspirin, or warfarin.

› Bupropion (Wellbutrin) can increase the risk of seizures in a patient with a previous seizure disorder.

› Serious side effects of antidepressant medications include the risk for activation of mania in patients with bipolar disorder, serotonin syndrome, and suicidal ideation.

When Medications Are Needed…

› Antipsychotic medications, typically given for psychotic symptoms, are also frequently administered to manage disruptive behavior and older adults with cognitive impairment.

› Antipsychotic medications include both typical and atypical drugs.

Antipsychotic Medications

› Typical antipsychotic medications have serious side effects that can affect quality of life, including tardive dyskinesia, acute extrapyramidal side effects, and neuroleptic malignant syndrome.

› Tardive dyskinesia involves abnormal muscle movements in the face, eyes, mouth, tongue, and limbs and can develop in 30% to 50% of patients, even at low drug dosages for short periods of time. It can last for several years and, in some cases, is irreversible even after the medication has been discontinued.

Older Adults Have Greater Risk…

› EPS include drug-induced parkinsonism, akinesia, dystonia, and akathisia. Parkinsonism and akathisia consist of lack of or slowed movement, depressed affect, salivation, expressionless face, tremor, and shuffling gait.

› Dystonia is characterized by muscle rigidity, contracted neck and eye muscles, and jaw and muscle soreness. Dystonic reactions are less common in older adults for reasons that remain uncertain.

› Akathisia is characterized by pacing and restlessness. Between 50% and 75% of all patients taking typical antipsychotic drugs experience EPS; however, elderly patients are at higher risk for drug induced parkinsonism and EPS than are younger patients.

Abnormal Involuntary Movements

› Neuroleptic malignant syndrome involves high fever, rigidity, altered consciousness, and autonomic system instability including unstable hypertension, tachycardia, sweating, pallor.

› NMS can be potentially fatal if not recognized and treated.

› Conditions such as neurological illness, dehydration, malnutrition, exhaustion, agitation, and organic brain disease are considered risk factors that make older adults more vulnerable to the development of neuroleptic malignant syndrome.

Life-Threatening Side Effects

› Older adults are also more susceptible to the anticholinergic and cardiovascular effects of typical antipsychotic drugs.

› These include dry mouth, constipation, blurred vision, urinary retention, hypotension, and cardiac conduction delay (specifically Q-T prolongation).

Anticholinergic Effects

› Atypical antipsychotic medications generally produce fewer of the adverse effects commonly associated with the typical antipsychotic medications.

› However black box warnings regarding the use of these medications with older adults due to the cardiac and cerebrovascular, mortality risks associated with their use in patients with dementia should be considered.

Atypicals are Slightly Better…

› Other serious side effects include adverse cardiovascular events, extrapyramidal symptoms somnolence, upper respiratory infections, edema, urinary tract infections, and fever.

› Although there is some controversy about the results of the CATIE-AD study, these drugs are not approved for use in patients with dementia.

No FDA Approved Medications for AD

› Nonpharmacological strategies for patients experiencing psychosis to minimize agitation and disruptive behavior include:– Sensory enhancement (music therapy and aromatherapy)– Socialization (reminiscence, simulated presence therapy)– Social support and contact (talking with the person, video or audio

types of family members, pet therapy)– Engaging activities (stimulation, activity and engagement)– Relief from discomfort (pain, hearing or vision problems, positioning,

and addressing activity of daily living needs).

So What are Some Safe Options?

› When prescribed, the patient should be monitored for oversedation, orthostatic hypotension, unsteadiness, and extraparyramidal symptoms.

› Use of the AIMS (abnormal involuntary movements scale) is recommended before treatment at baseline, at four weeks, eight weeks, and every six months thereafter.

› They should be prescribed only when necessary, reviewed regularly for continued need, and discontinued as soon as possible.

When Antipsychotics are Needed…

› The introduction of psychotropic medications in older adults should be done with caution…

› Start low (1/2 to 1/3 of the usual dose) and go slow.

› Documentation regarding the reasons for prescribing and continuing psychotropic medications should be a part of the patient's ongoing clinical record.

Proceed With Caution…

› Documentation should also be present indicating that other potential causes of disruptive behavior, such as delirium, pain, fatigue, hunger, incontinence, and infection, have been explored.

› Close monitoring for side effects and documentation of both pharmacological and nonpharmacological interventions, including their effectiveness, is essential.

Cover All the Bases

› Always investigate new symptoms to determine the root cause. It could be a manifestation of a serious problem or an adverse drug reaction.

› Determine if a medication is really needed. Sometimes a non-pharmacologic approach will work.

› Prescribe the lowest effective dose for the shortest period of time.

› Review medications at each visit and don’t forget herbals, vitamins, and other supplements.

Pearls for Geriatric Prescribing