Pharm2 - #02 - Geriatric Psychopharmacology

Front 1

What needs to be considered regarding renal fxn when giving meds to elderly?

Back 1

1. prolonged ½-lives
2. reduced clearance → reduced maintenance dosing

Front 2

What to consider regarding liver fxn when giving meds to elderly?

Back 2

Drugs metabolized more slowly (greatest changes are in Phase I rxns)

Front 3

Pharmacokinetic changes w/ aging:

Back 3

Reduced lean body mass
Reduced total and % body water
Decrease in serum albumin

Front 4

Pharmacodynamic changes w/ aging:

Back 4

More sensitive to some sedative hypnotics
Blunted homeostatic control mechanisms
Increasd incidence of orthostatic hypotension

Front 5

3 Commonly missed illnesses in elderly:

Back 5

Dementia, Delirium, Depression/anxiety

Front 6

Who gets amyloid plaques? Location?

Back 6

-specific for AD
-extracellular

Front 7

Who gets neurofibrillary tangles? Location?

Back 7

-present in many neurodegenerative diseases
-intraneuronal

Front 8

DSM-IV Definition of Dementia (Alzheimer’s Type):

Back 8

Development of multiple cognitive deficits manifested by both memory impairment + one of the following:

1. aphasia: loss of ability to speak or understand speech
2. apraxia: inability to willfully perform acts
3. agnosia: loss of ability to recognize objects, persons, sounds, shapes, or smells
4. disturbance in executive functioning (i.e. mental capacity to control and apply mental skills to problem-solving strategies)
5. significant impairment in social or occupational functioning
6. gradual onset and continuing decline
7. no alternate definition
8. deficits do not occur exclusively during the course of delirium

Front 9

Clinical presentation of Alzheimer’s Disease (mild stage):

Back 9

• MMSE score >/= 21
• Forgetfulness, difficulty learning new info
• Trouble planning meals, managing finances, taking meds on schedule
• Depression symptoms
• Ability to perform ADLs is maintained

Front 10

Clinical presentation of Alzheimer’s Disease (moderate stage):

Back 10

• MMSE score b/w 10-20
• Short- and long-term memory impairment
• Difficulty performing tasks
• Agitation, behavioral symptoms common
• Deficits in intellect and reasoning

Front 11

Clinical presentation of Alzheimer’s Disease (severe stage):

Back 11

• MMSE score less than 9
• May groan, scream, mumble, speak gibberish
• Behavioral symptoms are common
• Failure to recognize family or faces
• Troubles w/ all essential ADLs

Front 12

Evaluation for Alzheimer’s Disease:

Back 12

• History: changes; acute vs chronic
• IADL’s: independent, assist, dependent (use telephone, shopping, food preparation, housekeeping, laundry, transportation, finances, medication)
• ADL’s: independent, assist, dependent (bathing, dressing, toileting, transfers, continence, feeding)
• Detect: common changes from baseline
• new or exacerbation of illness: self /spouse
• death in family
• psycho-social, environmental, economic
• vision, hearing, constipation, fluid intake

Front 13

What is lost and thus causes dementia?

Back 13

-Synapses are lost and cause dementia (plaques do not cause it)
-Cholinergic loss is a major contributor to dementia (especially to memory loss)

Front 14

What type of neurons are shrunken in nromal aging and lost in AD?

Back 14

Glutamatergic

Front 15

Only FDA-approved Alzheimer’s Treatments**:

Back 15

•Donepezil (Aricept)
•Memantine (Namenda)
•Rivastigmine (Exelon)
•Galantamine (Razodyne)

Front 16

Prevalence of depression in community?

Prevalence of depression in nursing homes?

Back 16

1-4%

42-51%

Front 17

What symptoms are most common in a depressed elderly person (>65):

Back 17

Death thoughts, sleep problems, appetite, energy level
(in descending order)

-Elderly do NOT complain of depressive symptoms any more than younger groups!

Front 18

What fraction of acute post-MI pts are depressed?

Back 18

1/3

Front 19

**What is a strong independent predictor of negative outcome from sudden cardiac death in pts w/ CAD? What are the stats?**

Back 19

Depression!
3.5x at 6 months
6.64x at 18 months

Front 20

Depression is a risk factor for the following:

Back 20

•New onset cardiac disease
•Type 2 diabetes
•Predictor of mortality in some forms of cancer

Front 21

Depression in Neurological Illnesses:

Back 21

•Alzheimer’s 0 - 57%
•Parkinson’s 25 - 50%
•Post stroke 30 - 60% (within first 2 years after initial stroke)
•Huntington’s 50%

Front 22

What liver enzyme is involved in largest number of therapeutic drug metabolism rxns?

Back 22

CYP3A4

Front 23

What liver enzymes are highly involved in metabolism of SSRIs? (2)

Back 23

2D6 and 3A4

Front 24

What percentage of depressed elderly patients respond to antidepressants?

Back 24

60-85%

Front 25

What is an alternative therapy to medication for depressed elderly patients?

Back 25

ECT = elctro-convulsive therapy

(5-15% of non-responders to meds may respond to ECT)

Front 26

Benefits of ECT:

Back 26

Fewer CV and GI side effects
More favorable outcomes in general

Front 27

What is the “gold standard” in treatment of severe depression in the elderly?**

Back 27

ECT!**

Front 28

What kind of a condition is delirium?

Back 28

A medical condition* that presents w/ acute or subacute cognitive and behavioral changes

Front 29

Define: delirium

Back 29

=an acute disorder of attention and cognition

Front 30

DSM-IV criteria for delirium:

Back 30

• Disturbance of consciousness (ie, reduced clarity of awareness of environment) with reduced ability to focus, sustain, or shift attention
• A change in cognition (such as memory deficit, disorientation, language disturbance) or development of a perceptual disturbance that is not better accounted for by preexisting, established or resolving dementia
• The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day
•There is evidence from H&P that the disturbance is due to:
1.General medical condition
2.Substance intoxication delirium

Front 31

What types of patients experience high rates of delirium?

Back 31

ICU patients: 30-70%
Post-op patients: 50%

Front 32

What is the most frequent hospital complication in elderly patients?

Back 32

Delirium

Front 33

Mneumonic for causes of dementia:

Back 33

“I WATCH DEATH”

infection, withdrawl, acute metabolic, trauma, CNS pathology, hypoxia, deficiencies, endocrinopaties, acute vascular, toxins and drugs, heavy metals

Front 34

How is delirium assessed in ICU setting?

Back 34

(1) Acute change and fluctuation in mental status and behavior AND (2) Inattention AND EITHER (3) Disorganized thinking OR (4) Altered consciousness

Front 35

3 types of delirium:

Back 35

1. hyperactive/agitated
2. hypoactive (often missed)
3. mixed

Front 36

Compare delirium to dementia:

Back 36

1. Delirium: rapid onset, primary defect in attention*, fluctuates during course of day, visual hallucinations are common, often cannot attend to MMSE or clock draw
2. Dementia: insidious onset, primary defect in short term memory, attention often normal, does not fluctuate during the day, visual hallucinations less common, can attend to MMSE or clock draw, but cannot perform well

Front 37

What classes of drugs most commonly cause delirium? Why is this?

Back 37

Drugs w/ anti-cholinergic activity**: Cimetidine/Ranitidine**

-steroids, TCAs, neuroleptics, furosemide, captopril, warfarin

Front 38

Pathophysiology of delirium:

Back 38

Impaired cerebral oxidative metabolism and multiple neurotransmitter abnormalities**

Front 39

What is the Acetylcholine Hypothesis?

Back 39

•ACh is the critical neurotransmitter in pathogenesis of delirium
•Anti-cholinergic meds cause acute confusional states
•Impaired cholinergic transmission – susceptible to AD
•Reciprocal relationship exists b/w cholinergic and dopaminergic activities (delirium → excess of dopaminergic activity)

Front 40

What drug is the most frequently used in management of delirium?**

Back 40

Haloperidol**, because of it’s safety, efficacy and multiple routes of administration that are possible.

Front 41

S/Es of Haloperidol:

Back 41

Sedation
Hypotension
EPS
Prolonged QT → torsades de pointes

Front 42

What does it mean to take an inclusive approach to treating severe depression?**

Back 42

Treat it regardless of the understanding of reasons of depression**

Front 43

When is diagnostic screening for Alzheimer’s disease a must?**

Back 43

-any pt >65 where a spouse, family member, or caregiver is voicing concern over a patient’s cognition or functional status**

Front 44

Delirium is primarily characterized by:**

Back 44

Attentional difficulty**