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?