Transcript Source: Health Canada, 2008

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
[email protected]
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
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Outline of the Session
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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
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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
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Introduction
• Projected elderly population (1990-2050) in USA
Projection of elderly population
65 to 84
85+
Total
60
40
20
50
20
40
20
30
20
20
20
10
20
00
20
90
0
19
Percent
80
Year
Source: US Department of Commerce, 1989
Meera Kaur, PhD, RD
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%
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Common Psychiatric Diagnosis in
LTC Settings
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Dementia
Delirium
Depression
Disorders
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Mood
Psychotic
Dysthymic
Adjustment
Personality Change
Meera Kaur, PhD, RD
Factors Affecting Drug
Metabolism in the Elderly
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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
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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
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Medications in Dementia
Cholinesterase Inhibitors: prescribed for the treatment
of mild to moderate AD.
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•
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Donepezil (Aricept)
Galantamine (Reminyl)
Memantine HCl (Exiba)
Rivastigmine (Exelon®)
Herbal products
• Ginko Biloba
• Remember FX
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Cholinesterase Inhibitors…
Common side-effects
Interaction with
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•
•
•
•
• Foods/Herbal products
Nausea
Vomiting
Diarrhea
Loss of appetite
Weight loss
– St. John Wort
– Ginko Biloba
• Drugs
– Cytochrome P450; Anti-
cholinergic & cholinergic
agent; Tacrine, Luvox, TCA
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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
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Cholinesterase Inhibitors
Memantine HCl (Exiba): With or without foods
• Side effects: anorexia,  wt., N/V, constipation,
flatulence,
diarrhea,
dehydration,
hallucinations, sleep disorder, BP
confusion,
Nutritional management:
• Nutrient-dense small frequent feeding with variety in
color and taste; yogurt or other foods with probiotics;
and, adequate hydration among others
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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
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Herbal Products: Ginko Biloba…
Meera Kaur, PhD, RD
Herbal Products…
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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: http://www.remember-fx.com/qa.htm
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Herbal Products
North American Ginseng
(Panax quinquefolius)
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Behavioral and Psychological
Symptoms of Dementia (BPSD)
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Agitation
Restlessness
Wandering
Mood disturbances
Delusions
Hallucinations
Rage and violence
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Catastrophic reaction
Phobias/fears
Shouting/screaming
Sleep disturbances
Sundowning
Apathy
Sexual disturbances
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Medications in BPSD...
• Commonly used medications in BPDS are
Antipsychotics.
Typical Antipsychotics (TA)
Atypical Antipsychotics (ATA)
,
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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)
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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)
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Typical Antipsychotics
Interactions with:
Foods, Herbal Products, Drinks: coffee, tea,
herbs, nutraceuticals
• Drugs: Cytochrome P450, alcohol
opioids, methyldopa
levodopa, TCA
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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)
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Atypical Antipsychotics ...
Common side-effects:
• Tradive Dyskinesia
• Akathisia
• Hyperglycemia
• Obesity
•  wt.,  appetite,  TG,  liver enzymes,  thirst
•  wt.,  appetite, anorexia,
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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
Meera Kaur, PhD, RD
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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,
modalities, Electroconvulsive therapy (ECT)
Meera Kaur, PhD, RD
Social
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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
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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
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SSRI
Interactions
• Foods, Herbal Products, Drinks
- St John Wort
- Tryptophan supplement
• Drugs
- Non selective MAO Inhibitors ( phenelzine)
- carbamazepine
- phenytoin
- nafcillin
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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
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TCA
Interactions
• Foods, Herbal Products, Drinks
- St John Wort
- Tryptophan supplement
- High fibre diet
• Drugs
- Medication specific
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Other Antidepressants...
Commonly used other antidepressants
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•
•
•
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Bupropion (Wellbutrin)
Venlafaxine
Duloxetine
Nefazodone
Monoamine Oxidase Inhibitor (MAO1)
Common Side effects
• Sedation
• Orthostatic  BP
• Anticholinergic effects
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Other Antidepressants
Interactions
• Foods, Herbal Products, Drinks
- St John Wort
- Tryptophan supplement
• Drugs
- Medication specific
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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
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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
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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
Meera Kaur, PhD, RD
Other Mood Disorders…
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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.
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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
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•
• 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
Meera Kaur, PhD, RD
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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
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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.)
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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?
Meera Kaur, PhD, RD
Nutrition Checklist (general)
• Are caffeine, alcohol, sugar
substituted for other foods?
or
fat
being
• 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?
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Role of Specific Nutrients
• Folate and Vitamin B12: Deficiency of folate and
vitamin B12 — 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).
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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).
Meera Kaur, PhD, RD
Adjunctive Therapies...
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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.
Meera Kaur, PhD, RD
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Adjunctive Therapies
Meera Kaur, PhD, RD
Team Approach
Meera Kaur, PhD, RD
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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
Meera Kaur, PhD, RD
49
Ms. B
50
• 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.
Meera Kaur, PhD, RD
My Mom
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• 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?
Meera Kaur, PhD, RD
Summary
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• 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.
Meera Kaur, PhD, RD
Selected References
53
• 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
Meera Kaur, PhD, RD
Acknowledgement
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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
Meera Kaur, PhD, RD
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Society, Friendship and Love...
Divinely bestowed upon men!
Oh! had I the wings of a dove…
How soon would I taste you
again……
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Thank you
for gracing the session!
Any question?
Meera Kaur, PhD, RD