Dementia and Psych MedsDementia and Psych Meds

Andrew S. Rosenzweig, MD, MPHAndrew S. Rosenzweig, MD, MPH

Medical Director, MedOptionsMedical Director, MedOptions

Assistant Clinical Professor, Brown UniversityAssistant Clinical Professor, Brown University

What Is A Geriatric Psychiatrist?What Is A Geriatric Psychiatrist?

A geriatric psychiatrist is a medical doctor with A geriatric psychiatrist is a medical doctor with special training in the diagnosis and treatment special training in the diagnosis and treatment of mental disorders that may occur in older of mental disorders that may occur in older adults. These disorders include, but are not adults. These disorders include, but are not limited to, dementia, depression, bipolar limited to, dementia, depression, bipolar disorder, anxiety and late-life schizophrenia.disorder, anxiety and late-life schizophrenia.

Demographics of the Elderly PopulationDemographics of the Elderly Population

By 2030, older adults will account for 20% of the By 2030, older adults will account for 20% of the population, up from 13% in 2000population, up from 13% in 2000

At age 85+, there are 241 women for every 100 menAt age 85+, there are 241 women for every 100 men

Mental disorders in older adults are under-reportedMental disorders in older adults are under-reported

The rate of suicide is highest among older adults The rate of suicide is highest among older adults compared to any other age groupcompared to any other age group

Most Common Psychiatric Disorders in Late LifeMost Common Psychiatric Disorders in Late Life

OutpatientOutpatient

DementiaDementia

DepressionDepression

Substance Abuse (alcohol)Substance Abuse (alcohol)

Psychotic DisordersPsychotic Disorders

Long-Term CareLong-Term Care

DementiaDementia

Other Organic Mental DisordersOther Organic Mental Disorders

Mood DisordersMood Disorders

MR-DDMR-DD

Psychotic DisordersPsychotic Disorders

Alzheimer’s Disease (AD): Alzheimer’s Disease (AD): More Than Just Memory LossMore Than Just Memory Loss

AD is a progressive, degenerative disease involving:AD is a progressive, degenerative disease involving:– Loss of memory and other cognitiveLoss of memory and other cognitive

functions functions– Decline in ability to perform activities Decline in ability to perform activities

of daily living of daily living– Changes in personality and behaviorChanges in personality and behavior– Increases in resource utilizationIncreases in resource utilization– Eventual nursing home placementEventual nursing home placement

“A Peculiar Disease of the Cerebral Cortex”

Alzheimer’s Original Case Report (1907)Alzheimer’s Original Case Report (1907)

The first case report of Alzheimer’s disease highlighted The first case report of Alzheimer’s disease highlighted the presence of psychosis and agitation in these the presence of psychosis and agitation in these patientspatients

““The first noticeable symptom of illness was suspiciousness The first noticeable symptom of illness was suspiciousness of her husband…believing that people were out to murder of her husband…believing that people were out to murder her”her”

““She screams that her doctor wants to cut her open; at times, She screams that her doctor wants to cut her open; at times, she seems to have auditory hallucinations”she seems to have auditory hallucinations”

Source: Alzheimer A. Source: Alzheimer A. Allegmeine Zeitschrift für PsychiatrieAllegmeine Zeitschrift für Psychiatrie. 1907;64:146-148.. 1907;64:146-148.

Behavioral and Psychological Behavioral and Psychological Symptoms of DementiaSymptoms of Dementia

PsychosisPsychosis DelusionsDelusions ParanoiaParanoia HallucinationsHallucinations

AgitationAgitation Aggression Aggression CombativenessCombativeness Hyperactivity Hyperactivity

(including (including wandering)wandering)

HypervocalizationHypervocalization DisinhibitionDisinhibition

Source: Finkel et al. Am J Geriatr Psychiatry. 1998;6:97-100.

Behaviors Reported in Agitation and AggressionBehaviors Reported in Agitation and Aggression

AgitationAgitation

PhysicalPhysical: pacing, inappropriate robing/disrobing, trying to get to a different place, handling : pacing, inappropriate robing/disrobing, trying to get to a different place, handling things inappropriately, restlessness, stereotypythings inappropriately, restlessness, stereotypy

VerbalVerbal: Complaining, requests for attention, negativism, : Complaining, requests for attention, negativism, repeated repeated questions/phrases, screamingquestions/phrases, screaming

AggressionAggression

PhysicalPhysical: hitting, kicking, pushing, scratching, tearing, : hitting, kicking, pushing, scratching, tearing, biting, spittingbiting, spitting

VerbalVerbal: threats, accusations, name-calling, obscenities: threats, accusations, name-calling, obscenities

Psychosis and Agitation:What We Know

Common in Alzheimer’s disease and Common in Alzheimer’s disease and other dementing illnessesother dementing illnesses

Major source of caregiver distressMajor source of caregiver distress

Contribute to Contribute to – Premature institutionalizationPremature institutionalization– Increased costIncreased cost

Sources: Drevets et al. Sources: Drevets et al. Biol PsychiatryBiol Psychiatry. 1989;25:39-48./Ellgring. 1989;25:39-48./Ellgring. NeurologyNeurology. 1999:52(suppl 3):S17-S20./Rabins PV. . 1999:52(suppl 3):S17-S20./Rabins PV. Int Int Psychogeriatr. Psychogeriatr. 1991;3:319-324.1991;3:319-324.

Prevalence of Symptoms of Prevalence of Symptoms of Psychosis and Agitation in DementiaPsychosis and Agitation in Dementia

Cache County Study of Memory in Aging (CCSMA)Cache County Study of Memory in Aging (CCSMA)

First US population study of behavioral disturbances in First US population study of behavioral disturbances in dementiadementia

Evaluated the prevalence and severity of mental and behavioral Evaluated the prevalence and severity of mental and behavioral disturbances in the elderlydisturbances in the elderly

5092 individuals were screened5092 individuals were screened

Participants with dementia (n=329) were compared to control Participants with dementia (n=329) were compared to control group without dementia (n=673)group without dementia (n=673)

Source: Lyketsos CG et al. Source: Lyketsos CG et al. Am J PsychiatryAm J Psychiatry. 2000;157:708-714.. 2000;157:708-714.

20

Prevalence of Symptoms of Prevalence of Symptoms of Psychosis and Agitation in DementiaPsychosis and Agitation in Dementia

NPI Item

Dementia(n=329)

%

No Dementia(n=673)

%

Apathy Depression Agitation/aggression Irritability DelusionsAnxietyAberrant motor behaviorHallucinationsDisinhibitionElation

27.423.723.720.418.517.014.313.79.10.9

3.17.02.84.52.45.60.40.60.90.3

Source: Adapted with permission from Lyketsos CG et al. Source: Adapted with permission from Lyketsos CG et al. Am J PsychiatryAm J Psychiatry. 2000;157:708-714. American Psychiatric Association.. 2000;157:708-714. American Psychiatric Association.

21

Sources: Rabins PV. Sources: Rabins PV. Int Psychogeriatr. Int Psychogeriatr. 1991;3:319-324./Stoppe et al. 1991;3:319-324./Stoppe et al. Drugs AgingDrugs Aging. 1999;14:41-54.. 1999;14:41-54.

Causes of Distress to Caregivers

Physical violencePhysical violence Catastrophic Catastrophic

reactionsreactions HittingHitting Making accusationsMaking accusations

SuspiciousnessSuspiciousness IncontinenceIncontinence Memory disturbanceMemory disturbance Inappropriate sexual Inappropriate sexual

behaviorbehavior

Disturbing symptomsDisturbing symptoms

Sources: Deutsch et al. Sources: Deutsch et al. Am J Psychiatry. Am J Psychiatry. 1991;148:1159-1163./Drevets. 1991;148:1159-1163./Drevets. Biol PsychiatryBiol Psychiatry. 1989;25:39-48.. 1989;25:39-48.

Delusions in Alzheimer’s DiseaseDelusions in Alzheimer’s Disease

Delusional thought content (eg, paranoia) is Delusional thought content (eg, paranoia) is common (studies suggest 34% to 50% incidence)common (studies suggest 34% to 50% incidence)

Common delusionsCommon delusions– Marital infidelityMarital infidelity– Patients, staff are Patients, staff are

trying to hurt metrying to hurt me– Staff, family members Staff, family members

are impersonatorsare impersonators– People are stealingPeople are stealing

my thingsmy things

– My house is not my homeMy house is not my home– Strangers living in my homeStrangers living in my home– Misidentification of peopleMisidentification of people– People on TV are realPeople on TV are real

Effect of Losses in Dementia Effect of Losses in Dementia

Normal Feelings Thoughts BehaviorsNormal Feelings Thoughts Behaviors

Dementia Feelings Short Circuit BehaviorsDementia Feelings Short Circuit Behaviors

Thoughts are impaired by Thoughts are impaired by losseslosses of: of:

memorymemory of coping with past situations of coping with past situations

judgmentjudgment to select among alternative actions to select among alternative actions

insightinsight needed to solve problems needed to solve problems

inhibitionsinhibitions and and impulse control impulse control needed to show restraintneeded to show restraint

Practical Recommendations: Decrease EscalationPractical Recommendations: Decrease Escalation

Approach in a calm mannerApproach in a calm manner

Use distraction: food, drink, musicUse distraction: food, drink, music

Maintain eye contact and comfortable postureMaintain eye contact and comfortable posture

Match verbal and non-verbal signalsMatch verbal and non-verbal signals

Identify and state the affect observed in the patientIdentify and state the affect observed in the patient

Identify what is triggering the behaviorIdentify what is triggering the behavior

Modify the environmentModify the environment

Target Symptoms for TreatmentTarget Symptoms for Treatment

Physical aggressionPhysical aggression

AgitationAgitation

Delusions/paranoiaDelusions/paranoia

HallucinationsHallucinations

Sleep/wake cycle Sleep/wake cycle changeschanges

Depression, Depression, withdrawalwithdrawal

Eating problemsEating problems

Verbal outburstsVerbal outbursts

PharmacotherapyPharmacotherapy

AnticonvulsantsAnticonvulsants

AntidepressantsAntidepressants

Beta-blockersBeta-blockers

BenzodiazepinesBenzodiazepines

Medications for treating target symptomsMedications for treating target symptoms Trazodone,Trazodone, buspironebuspirone

Acetylcholinesterase Acetylcholinesterase inhibitorsinhibitors

AntipsychoticsAntipsychotics

MemantineMemantine

AnticonvulsantsAnticonvulsants

Divalproex, carbamazepineDivalproex, carbamazepine

Open trials, case reports, and 4 controlled Open trials, case reports, and 4 controlled studiesstudies

May have specific utility for paroxysmal May have specific utility for paroxysmal and aggressive behavior dyscontrol in the and aggressive behavior dyscontrol in the absence of psychotic symptomsabsence of psychotic symptoms

Sources: Chambers et al.Sources: Chambers et al. IRCS Med Sci IRCS Med Sci. 1982;10:505-506./Lott AD et al. . 1982;10:505-506./Lott AD et al. J Neuropsychiatry Clin NeurosciJ Neuropsychiatry Clin Neurosci. . 1995;7:314-319./Mellow et al. 1995;7:314-319./Mellow et al. J Geriatr Psychiatry NeurolJ Geriatr Psychiatry Neurol. 1993;6:205-209./Tariot PN et al. . 1993;6:205-209./Tariot PN et al. J Am Geriatr SocJ Am Geriatr Soc. . 1994;42:1160-1166./Tariot et al. 1994;42:1160-1166./Tariot et al. Am J Psychiatry.Am J Psychiatry. 1998;155:54-61./ 1998;155:54-61./Tariot et al. J Clin Psychiatry 1999;60:684-9.

Divalproex:Divalproex: Dementia-Related AgitationDementia-Related Agitation

Efficacy data emerging Efficacy data emerging

Gastrointestinal intolerance and Gastrointestinal intolerance and excessive sedation may limit utility*excessive sedation may limit utility*

Hepatotoxicity and thrombocytopenia are Hepatotoxicity and thrombocytopenia are rare but serious potential side effects rare but serious potential side effects

Source: Lott et al. Source: Lott et al. J Neuropsychiatry Clin NeurosciJ Neuropsychiatry Clin Neurosci. 1995;7:314-319./Mellow et al. . 1995;7:314-319./Mellow et al. J Geriatr Psychiatry NeurolJ Geriatr Psychiatry Neurol. . 1993;6:205-209.1993;6:205-209.

*A placebo-controlled trial of divalproex for the treatment of behavioral disturbances in the elderly was recently halted due *A placebo-controlled trial of divalproex for the treatment of behavioral disturbances in the elderly was recently halted due to excessive somnolence and weight loss in the divalproex group (C. Spath, RPh, oral communication, January 2000). to excessive somnolence and weight loss in the divalproex group (C. Spath, RPh, oral communication, January 2000). As a result, a lower dose and more conservative titration schedule will be utilized in future trials.As a result, a lower dose and more conservative titration schedule will be utilized in future trials.

BenzodiazepinesBenzodiazepines

Minimal efficacy dataMinimal efficacy data

SedatingSedating

Cause fallsCause falls

Further inhibit learning and memoryFurther inhibit learning and memory

Paradoxical disinhibitionParadoxical disinhibition

Commonly usedCommonly used– lorazepamlorazepam

– oxazepamoxazepam

Source: Coccaro.Source: Coccaro. Am J Psychiatry Am J Psychiatry. 1990;147:1640-1645.. 1990;147:1640-1645.

Acetylcholinesterase InhibitorsAcetylcholinesterase Inhibitors

Drugs used to treat Alzheimer’s disease act by inhibiting Drugs used to treat Alzheimer’s disease act by inhibiting acetylcholinesterase activityacetylcholinesterase activity

These drugs block the esterase-mediated metabolism of These drugs block the esterase-mediated metabolism of acetylcholine to choline and acetate. This results in:acetylcholine to choline and acetate. This results in:– Increased acetylcholine in the synaptic cleftIncreased acetylcholine in the synaptic cleft– Increased availability of acetylcholine for postsynaptic and Increased availability of acetylcholine for postsynaptic and

presynaptic nicotinic presynaptic nicotinic (and muscarinic) acetylcholine receptors(and muscarinic) acetylcholine receptors

Nordberg A, Svensson A-L. Drug Safety. 1998;19:465-480.

Memantine in ADMemantine in AD

FDA approved for moderate-to-severe ADFDA approved for moderate-to-severe AD

Studies show slowing of cognitive decline, stabilization or Studies show slowing of cognitive decline, stabilization or improvement over baseline for >6 monthsimprovement over baseline for >6 months

Slowing of decline in functional outcomesSlowing of decline in functional outcomes

Some behavioral symptom reduction (especially apathy, Some behavioral symptom reduction (especially apathy, anxious/depressive features)anxious/depressive features)

Antipsychotic Drug PrescriptionsAntipsychotic Drug Prescriptions

Source: IMS Health, NDTI. Plymouth Meeting, Pennsylvania. August 1999. Source: IMS Health, NDTI. Plymouth Meeting, Pennsylvania. August 1999.

24%

Total PrescriptionsTotal Prescriptions United States PopulationUnited States Population

OtherOther

ElderlyElderly13%

AntipsychoticAntipsychoticPrescriptions Prescriptions for the Elderlyfor the Elderly

Conventional AntipsychoticsConventional Antipsychotics

Extensive clinical experienceExtensive clinical experience

Modest efficacyModest efficacy

Side effects can hinder treatmentSide effects can hinder treatment

High risk of tardive dyskinesiaHigh risk of tardive dyskinesia

Commonly used in geriatricsCommonly used in geriatrics– HaloperidolHaloperidol

– ThioridazineThioridazine

Source: Tune et al. In: Davidson M, ed. Source: Tune et al. In: Davidson M, ed. Psychiatric Clinics of North America.Psychiatric Clinics of North America. Philadelphia, Penn: WB Saunders Philadelphia, Penn: WB Saunders Co. 1991:353-373.Co. 1991:353-373.

Conventional Antipsychotics:Conventional Antipsychotics: Side Effects Are PredictableSide Effects Are Predictable

Extrapyramidal symptomsExtrapyramidal symptoms

Anticholinergic effects Anticholinergic effects

Cognitive toxicityCognitive toxicity

SedationSedation

Orthostatic hypotension Orthostatic hypotension

Tardive dyskinesiaTardive dyskinesia

Source: Tune et al. In Davidson M, ed. Source: Tune et al. In Davidson M, ed. Psychiatric Clinics of North America.Psychiatric Clinics of North America. Philadelphia, Penn: WB Saunders Co. 1991:353- Philadelphia, Penn: WB Saunders Co. 1991:353-373.373.

Atypical Antipsychotics Atypical Antipsychotics

ClozapineClozapine

Olanzapine Olanzapine

Quetiapine Quetiapine

RisperidoneRisperidone

ZiprasidoneZiprasidone

Aripiprazole Aripiprazole

•• Most studied antipsychotic in the elderlyMost studied antipsychotic in the elderly

•• 3 pivotal placebo-controlled trials in dementia patients (N = 3 pivotal placebo-controlled trials in dementia patients (N =

1306)1306)

•• Side-effects equivalent to placebo in therapeuticSide-effects equivalent to placebo in therapeutic

dose rangedose range

•• Recommended dosing regimen in dementiaRecommended dosing regimen in dementia

–– Starting dose: 0.25 mg to 0.5 mg hsStarting dose: 0.25 mg to 0.5 mg hs

–– Target dose range: 0.5 mg to 1.5 mg hsTarget dose range: 0.5 mg to 1.5 mg hs

Aronson SM. Mental Disorders in the Elderly: New Therapeutic Aproaches 1998. De Deyn PP et al. Neurology 1999.

Falsetti AE. Am J Health-Syst Pharm 2000. Jeste DV et al. J Clin Psychiatry 1996. Snowdon J et al. Am J Geriatr Psychiatry 2002.

Risperidone In Dementia-Related Risperidone In Dementia-Related Psychosis And AgitationPsychosis And Agitation

Risperidone In DementiaRisperidone In Dementia

625 Patients With Dementia625 Patients With Dementia

•• Prospective, 12-week, multicenter,Prospective, 12-week, multicenter,

placebo-controlledplacebo-controlled

•• Randomized to (12 weeks)Randomized to (12 weeks)

–– Risperidone fixed dose (0.5 mg/d, 1 mg/d, 2 mg/d)Risperidone fixed dose (0.5 mg/d, 1 mg/d, 2 mg/d)

–– PlaceboPlacebo

•• Mean age 83 ± 8y; 68% femaleMean age 83 ± 8y; 68% female

•• Mean MMSE 6.6/30Mean MMSE 6.6/30

Katz IR et al. J Clin Psychiatry 1999.

Risperidone In Dementia: ResultsRisperidone In Dementia: Results

•• 1 mg and 2 mg doses efficacious on outcome measures 1 mg and 2 mg doses efficacious on outcome measures

(BEHAVE-AD, CMAI)(BEHAVE-AD, CMAI)

•• 2 mg dose resulted in higher rate of EPS2 mg dose resulted in higher rate of EPS

•• 1 mg dose side effect rate equivalent to placebo1 mg dose side effect rate equivalent to placebo

Katz IR et al. J Clin Psychiatry 1999.

LATE-LIFE DEPRESSIONLATE-LIFE DEPRESSIONLATE-LIFE DEPRESSIONLATE-LIFE DEPRESSION

Four Hallmarks:Four Hallmarks:

Depressed moodDepressed mood

AnhedoniaAnhedonia

Physical symptomsPhysical symptoms

Psychological symptomsPsychological symptoms

Four Hallmarks:Four Hallmarks:

Depressed moodDepressed mood

AnhedoniaAnhedonia

Physical symptomsPhysical symptoms

Psychological symptomsPsychological symptoms

DEPRESSED MOODDEPRESSED MOODHallmark 1Hallmark 1

DEPRESSED MOODDEPRESSED MOODHallmark 1Hallmark 1

Neither necessary, nor sufficientNeither necessary, nor sufficient

Can be misleadingCan be misleading

Beware of asking the question, “Are Beware of asking the question, “Are you depressed?”you depressed?”

Neither necessary, nor sufficientNeither necessary, nor sufficient

Can be misleadingCan be misleading

Beware of asking the question, “Are Beware of asking the question, “Are you depressed?”you depressed?”

ANHEDONIAANHEDONIA Hallmark 2Hallmark 2

ANHEDONIAANHEDONIA Hallmark 2Hallmark 2

Loss of interest or pleasureLoss of interest or pleasure

May be most important andMay be most important and

useful hallmarkuseful hallmark Ask, “What do you enjoy doing?”Ask, “What do you enjoy doing?”

Loss of interest or pleasureLoss of interest or pleasure

May be most important andMay be most important and

useful hallmarkuseful hallmark Ask, “What do you enjoy doing?”Ask, “What do you enjoy doing?”

PHYSICAL SYMPTOMSPHYSICAL SYMPTOMS Hallmark 3Hallmark 3

PHYSICAL SYMPTOMSPHYSICAL SYMPTOMS Hallmark 3Hallmark 3

Sleep disturbanceSleep disturbance

Appetite or weight changeAppetite or weight change

Low energy or fatigueLow energy or fatigue

Psychomotor changesPsychomotor changes

Sleep disturbanceSleep disturbance

Appetite or weight changeAppetite or weight change

Low energy or fatigueLow energy or fatigue

Psychomotor changesPsychomotor changes

PSYCHOLOGICAL SYMPTOMS PSYCHOLOGICAL SYMPTOMS Hallmark 4Hallmark 4

PSYCHOLOGICAL SYMPTOMS PSYCHOLOGICAL SYMPTOMS Hallmark 4Hallmark 4

Low self-esteem or guiltLow self-esteem or guilt

Poor concentrationPoor concentration

Suicidal ideation or persistentSuicidal ideation or persistent thoughts of deaththoughts of death

Low self-esteem or guiltLow self-esteem or guilt

Poor concentrationPoor concentration

Suicidal ideation or persistentSuicidal ideation or persistent thoughts of deaththoughts of death

MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENT

Support Support

Psychotherapy Psychotherapy

PsychopharmacologyPsychopharmacology

Electroconvulsive therapyElectroconvulsive therapy

NON-SPECIFIC SUPPORTNON-SPECIFIC SUPPORT

Reflective listeningReflective listening– If I understand you correctly, you…If I understand you correctly, you…

Empathic communicationEmpathic communication– I can see you feel very sad…(reflection)I can see you feel very sad…(reflection)– I can understand…(legitimation)I can understand…(legitimation)

Specific offer of supportSpecific offer of support– I am here to help you…I am here to help you…

PartnershipPartnership– Let’s you and I together…Let’s you and I together…

RespectRespect– I am very impressed by…I am very impressed by…

PSYCHOTHERAPIESPSYCHOTHERAPIES

Cognitive-behavioral therapyCognitive-behavioral therapy– Negative thinking, expectations of self and worldNegative thinking, expectations of self and world

Interpersonal psychotherapyInterpersonal psychotherapy– Role changeRole change

Problem-solving therapy (pleasant activities)Problem-solving therapy (pleasant activities)

Life narrative reviewLife narrative review– Integrity vs. despair Integrity vs. despair

Grief counselingGrief counseling

PSYCHOTHERAPYPSYCHOTHERAPYPSYCHOTHERAPYPSYCHOTHERAPY EffectiveEffective

– Mild to moderate major depressionMild to moderate major depression– Adjunct to antidepressantsAdjunct to antidepressants– Chronic depressionChronic depression

Possibly effectivePossibly effective– Minor depressionMinor depression– For patients in life transitions or with personal For patients in life transitions or with personal

conflictsconflicts– Depression in long-term careDepression in long-term care– Depression in ADDepression in AD

EffectiveEffective– Mild to moderate major depressionMild to moderate major depression– Adjunct to antidepressantsAdjunct to antidepressants– Chronic depressionChronic depression

Possibly effectivePossibly effective– Minor depressionMinor depression– For patients in life transitions or with personal For patients in life transitions or with personal

conflictsconflicts– Depression in long-term careDepression in long-term care– Depression in ADDepression in AD

PHARMACOTHERAPYPHARMACOTHERAPYPHARMACOTHERAPYPHARMACOTHERAPY

Effective Effective – Major depressionMajor depression

– Chronic depression (dysthymia)Chronic depression (dysthymia)

Inconclusive evidence to date Inconclusive evidence to date – Minor depressionMinor depression– Depression of AD (7 RCT)Depression of AD (7 RCT)

Lyketsos, Am J Psych 2000Lyketsos, Am J Psych 2000

Effective Effective – Major depressionMajor depression

– Chronic depression (dysthymia)Chronic depression (dysthymia)

Inconclusive evidence to date Inconclusive evidence to date – Minor depressionMinor depression– Depression of AD (7 RCT)Depression of AD (7 RCT)

Lyketsos, Am J Psych 2000Lyketsos, Am J Psych 2000

TREATMENT GUIDELINESTREATMENT GUIDELINESTREATMENT GUIDELINESTREATMENT GUIDELINES

Titrate agent to achieve Titrate agent to achieve

therapeutic dose or remission therapeutic dose or remission

Full effect may take 4-6 weeksFull effect may take 4-6 weeks

Continue for 4-9 months after full remissionContinue for 4-9 months after full remission

Use maintenance medication for recurrent Use maintenance medication for recurrent depressionsdepressions

Titrate agent to achieve Titrate agent to achieve

therapeutic dose or remission therapeutic dose or remission

Full effect may take 4-6 weeksFull effect may take 4-6 weeks

Continue for 4-9 months after full remissionContinue for 4-9 months after full remission

Use maintenance medication for recurrent Use maintenance medication for recurrent depressionsdepressions

ANTIDEPRESSANTSANTIDEPRESSANTSANTIDEPRESSANTSANTIDEPRESSANTS

TRICYCLICSTRICYCLICS SSRIsSSRIs

citalopram (Celexa)citalopram (Celexa) fluoxetine (Prozac)fluoxetine (Prozac) paroxetine (Paxil)paroxetine (Paxil) sertraline (Zoloft)sertraline (Zoloft)

OTHER NEW AGENTSOTHER NEW AGENTS bupropion (Wellbutrin) - DA/NEbupropion (Wellbutrin) - DA/NE mirtazapine (Remeron) - NE/5HTmirtazapine (Remeron) - NE/5HT nefazodone (Serzone) - SRI/5HTnefazodone (Serzone) - SRI/5HT venlafaxine (Effexor) - SRI/NRIvenlafaxine (Effexor) - SRI/NRI

TRICYCLICSTRICYCLICS SSRIsSSRIs

citalopram (Celexa)citalopram (Celexa) fluoxetine (Prozac)fluoxetine (Prozac) paroxetine (Paxil)paroxetine (Paxil) sertraline (Zoloft)sertraline (Zoloft)

OTHER NEW AGENTSOTHER NEW AGENTS bupropion (Wellbutrin) - DA/NEbupropion (Wellbutrin) - DA/NE mirtazapine (Remeron) - NE/5HTmirtazapine (Remeron) - NE/5HT nefazodone (Serzone) - SRI/5HTnefazodone (Serzone) - SRI/5HT venlafaxine (Effexor) - SRI/NRIvenlafaxine (Effexor) - SRI/NRI

ADVANTAGES OF SSRIs ADVANTAGES OF SSRIs ANDAND OTHER NEW AGENTSOTHER NEW AGENTS

ADVANTAGES OF SSRIs ADVANTAGES OF SSRIs ANDAND OTHER NEW AGENTSOTHER NEW AGENTS

Fewer side effectsFewer side effects Safety profile Safety profile Increased patient satisfaction Increased patient satisfaction Improved adherence to therapyImproved adherence to therapy Cost savingsCost savings

Fewer side effectsFewer side effects Safety profile Safety profile Increased patient satisfaction Increased patient satisfaction Improved adherence to therapyImproved adherence to therapy Cost savingsCost savings

CHOOSING AMONG SSRIs CHOOSING AMONG SSRIs AND AND OTHER NEW AGENTSOTHER NEW AGENTS

CHOOSING AMONG SSRIs CHOOSING AMONG SSRIs AND AND OTHER NEW AGENTSOTHER NEW AGENTS

Evaluate:Evaluate:

half-lifehalf-life

drug interactionsdrug interactions

side effectsside effects

Evaluate:Evaluate:

half-lifehalf-life

drug interactionsdrug interactions

side effectsside effects

HALF-LIFEHALF-LIFEHALF-LIFEHALF-LIFE

LongLong (longer than 1 day) (longer than 1 day) fluoxetine (Prozac)fluoxetine (Prozac)

ShortShort other SSRIs (once a day)other SSRIs (once a day) Effexor XR (once a day)Effexor XR (once a day) Wellbutrin SR (1-2x/day)Wellbutrin SR (1-2x/day) other new agents (2x/day)other new agents (2x/day)

LongLong (longer than 1 day) (longer than 1 day) fluoxetine (Prozac)fluoxetine (Prozac)

ShortShort other SSRIs (once a day)other SSRIs (once a day) Effexor XR (once a day)Effexor XR (once a day) Wellbutrin SR (1-2x/day)Wellbutrin SR (1-2x/day) other new agents (2x/day)other new agents (2x/day)

DRUG INTERACTIONSDRUG INTERACTIONSDRUG INTERACTIONSDRUG INTERACTIONS

Obtain medication historyObtain medication history

Be aware that all drugs canBe aware that all drugs can

affect the action and serumaffect the action and serum

levels of other drugs levels of other drugs

Monitor the clinical effects andMonitor the clinical effects and

serum levels of all medicationsserum levels of all medications

Obtain medication historyObtain medication history

Be aware that all drugs canBe aware that all drugs can

affect the action and serumaffect the action and serum

levels of other drugs levels of other drugs

Monitor the clinical effects andMonitor the clinical effects and

serum levels of all medicationsserum levels of all medications

SIDE EFFECTS SIDE EFFECTS (SSRIs)(SSRIs)

SIDE EFFECTS SIDE EFFECTS (SSRIs)(SSRIs)

Agitation/insomniaAgitation/insomnia

GI distressGI distress

Sexual dysfunctionSexual dysfunction

Agitation/insomniaAgitation/insomnia

GI distressGI distress

Sexual dysfunctionSexual dysfunction

MANAGING SIDE EFFECTSMANAGING SIDE EFFECTSMANAGING SIDE EFFECTSMANAGING SIDE EFFECTS

SedationSedation– Give medication HSGive medication HS

GI distressGI distress– Give medication after mealsGive medication after meals

Anticholinergic effectsAnticholinergic effects– Bulk in diet, lemon dropsBulk in diet, lemon drops

Postural hypotensionPostural hypotension– Hydration, change position slowly, Hydration, change position slowly,

support hosesupport hose

2.2

8.4

16.1

21.1 21.0

15.8

11.19.6

8.5 8.16.0

3.7

1.2 1.6

0.0

5.0

10.0

15.0

20.0

25.0

Illicit Drug or AlcoholIllicit Drug or AlcoholDependence or Abuse, by Age: 2003Dependence or Abuse, by Age: 2003

Percent Dependent or Abusing in Past Year

Age in Years

12-13 14-15 16-17 18-20 21-25 26-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+

Age 50+

4228

5872

90

100.0

20.0

40.0

60.0

80.0

100.0

Alcohol and Illicit Drug Dependence or Alcohol and Illicit Drug Dependence or Abuse, as a Percentage of Total Substance Abuse, as a Percentage of Total Substance

Dependence or Abuse, by Age: 2003Dependence or Abuse, by Age: 2003

Age12 to 25

Age26 to 49

Age 50+

Percent of Substance Dependence/Abuse

Alcohol Only

Illicit Drug

Alcohol and Drug Treatment Admissions: Alcohol and Drug Treatment Admissions: Age 50+, 1992-2002Age 50+, 1992-2002

75 75 71 68 68 69 73 74 76 7580

20 2328 29 31

3642

4957

63

74

0102030405060708090

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Admissions in Thousands

Alcohol Only

Drugs

Key Themes in Late-Life Alcohol Key Themes in Late-Life Alcohol AddictionAddiction

Significant underdiagnosisSignificant underdiagnosis

Ageism, shame, misperceptionsAgeism, shame, misperceptions

Increased vulnerability to negative effects of ETOHIncreased vulnerability to negative effects of ETOH

Increased sensitivity and toleranceIncreased sensitivity and tolerance

ComorbiditiesComorbidities

Increased risk of hypertension, arrhythmia, mi, cardiomyopathyIncreased risk of hypertension, arrhythmia, mi, cardiomyopathy

Hemorrhagic StrokeHemorrhagic Stroke

CirrhosisCirrhosis

GI bleedingGI bleeding

Decreased bone densityDecreased bone density

MalnutritionMalnutrition

Depression, anxietyDepression, anxiety

Risk FactorsRisk Factors

GenderGender

Marital StatusMarital Status

Bereavement and other lossesBereavement and other losses

Lessening of Role ResponsibilitiesLessening of Role Responsibilities

Family historyFamily history

Health care settingsHealth care settings

DepressionDepression

Adverse Effects of Late-life DrinkingAdverse Effects of Late-life Drinking

Decreased quality of lifeDecreased quality of life

Family burdenFamily burden

Medication interactionsMedication interactions

TraumaTrauma

Increased suicide risk (10.6 fold increase with 1-2 Increased suicide risk (10.6 fold increase with 1-2 drinks/day)drinks/day)

Adverse medical outcomesAdverse medical outcomes

Effective Treatment StrategiesEffective Treatment Strategies

Prevention/educationPrevention/education

Brief adviceBrief advice

Brief interventionsBrief interventions

Referral managementReferral management

Specialized treatmentsSpecialized treatments

Examples of treatmentsExamples of treatments

Telephone disease management (TDM)Telephone disease management (TDM)

Cognitive Behavioral Therapy (CBT)Cognitive Behavioral Therapy (CBT)

Twelve step programsTwelve step programs

Motivational interviewingMotivational interviewing

Family involvement/social supportFamily involvement/social support

Examples of treatments (cont)Examples of treatments (cont)

Specialty addiction servicesSpecialty addiction services

Pharmacotherapy:Pharmacotherapy: NaltrexoneNaltrexone AcamprosateAcamprosate AntabuseAntabuse Others (SSRI’s, topiramate, ondansetron)Others (SSRI’s, topiramate, ondansetron)