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2. Geriatric Psychiatry + Neuroanatomy > Geriatric Psychopharmacology > Flashcards

Geriatric Psychopharmacology Flashcards

1
Q

list the 3 cholinesterase inhibitors

A

donepezil

rivastigmine

galantamine

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2
Q

what are the approved AD pharmacotherapies in canada

A

memantine

cholinesterase inhibitors

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3
Q

how effective are the cholinesterase inhibitors for mild to moderate AD

A

modestly effective

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4
Q

how do cholinesterase inhibitors work

A

stop the breakdown of acetylcholine in the synaptic cleft

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5
Q

how does donepezil work

A

NON competitive

reversible

longlasting

once a day morning dose of 5-10 mg

generally well tolerated and easy to use

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6
Q

how does rivastigmine work

A

non competitive

pseudo-irreversible

comes as a patch or capsules (BID dosing)

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7
Q

how is rivastigmine metabolized

A

almost totally INDEPENDENT of the hepatic CYP system

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8
Q

how does galantamine ER work

A

BOTH a cholinesterase inhibtor and NICOTINIC receptor modulation

COMPETITIVE inhibition

once daily dosing

side effect profile is similar to donepezil but may be better for anxiety

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9
Q

patients treated with cholinesterase inhibitors showed less decline on what areas of function

A

overall cognition

memory

naming

executive functions

ADLs

**galantamine reduces caregiver time by ONE HOUR per day in mild to moderate AD

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10
Q

list dementias that can be treated with cholinesterase inhibitors

A

mild to moderate AD

moderate to severe AD

dementia with lewy bodies

parkinsons disease dementia

vascular/mixed dementia

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11
Q

list 3 situations in which you would NOT prescribe a cholinesterase inhibitor

A

normal aging

MCI

fronto-temporal dementia (i.e bvFTD, semantic dementia, progressive nonfluent aphasia)

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12
Q

what % of those started on a cholinesterase inhibitor will improve noticeably

A

20%

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13
Q

what % of those started on a cholinesterase inhibitor will stay the samw

A

50%

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14
Q

what % of those started on a cholinesterase inhibitor will continue to worsen

A

20%

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15
Q

what % of those started on a cholinesterase inhibitor will be intolerant of the med

A

10-15%

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16
Q

list the side effects of cholinesterase inhibitors

A

GI ***

bradycardia

muscle cramps

sleep disturbance

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17
Q

what is one way to deal with GI SEs of cholinesterase inhibitors

A

change to Exelon patch

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18
Q

what should you do if a patient on a cholinesterase inhibitor is declining

A

consider alternative med when patient declining, there is caregiver dissatisfaction or there is medication intolerance

can SWITCH cholinesterase inhibitors or ADD MEMANTINE (better to add rather than switch to memenatine monotherapy)

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19
Q

what is the role of glutamate in AD

A

INCREASED activity at glutamate synapses

leads to TONIC MILD ACTIVATION at NMDA receptors

leads to neuronal death following CHRONIC INSULT and cognitive deficit due to decrease in SIGNAL TO NOISE ratio

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20
Q

how does memantine work

A

voltage dependent

low to moderate affinity

UNcompetitive NMDA receptor antagonist

acts SELECTIVELY at NMDA receptors

NO significant affinity for other receptors

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21
Q

how is memantine metabolized

A

undergoes LITTLE metabolism

majority is excreted UNCHANGED via the KIDNEYS (75-90%) with long half life (60-80 hours)

no role for cyp system

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22
Q

what behaviours improved with addition of memantine

A

agitation/aggression

irritability/lability

apathy/indifference

appetite/eating changes

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23
Q

when should you use memantine

A

moderate to severe AD–> MMSE typically under 16, needs regular prompting for basic ADLs

combined therapy with cholinesterase inhibitors preferred

useful for reducing agitation

consider in MILD AD if INTOLERANT of all cholinesterase inhibitors or they are contraindicated

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24
Q

do you have to adjust memantine in renal or hepatic impairment

A

not for hepatic

yes for renal (half of typical maintenance dose)

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25
Q

does memantine have significant drug interactions

A

no, minimal

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26
Q

list side effects of memantine

A

minimal

can have some dizziness, maybe confusion at week 4/change in bowel patterns/overactivation

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27
Q

how do you stage AD

A

by MMSE:

above 22–> mild

18-22–> mild to moderate

13-17–> moderate

8-16–> moderate to severe

less than 8–> severe

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28
Q

is trial discontinuation recommended for AD meds

A

no

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29
Q

why is it tricky to prescribe meds in geriatrics

A
  1. polypharmacy–> higher risk of interactions
  2. changes in physiology–> higher risk of SEs
  3. comorbidities–> higher risk of SEs
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30
Q

how does age impact sensitivity to benzos

A

the elderly have increased sensitivity to the CNS effects of benzos

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31
Q

why are older people at higher risk of bleeding (including as SE from meds)

A

greater INHIBITION of vitamin K dependent clotting factors –> increased risk of bleeding

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32
Q

why are the elderly at greater risk of hypotension due to meds

A

increased sensitivity to negative inotropic and vasodilator + diminished baroreceptor sensitivity

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33
Q

is there a criteria to judge potentially inappropriate medication use in older adults

A

Beers criteria

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34
Q

why do Beers criteria recommend avoiding antipsychotics in the elderly

A

increased risk of CVA

greater risk of cognitive decline and mortality in persons with dementia

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35
Q

why do the Beers criteria recommend avoiding benzos in the elderly

A

all increase risk of cognitive impairment, delirium, falls, fractures, and MVAs in older adults

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36
Q

in which cases would you consider benzos in the elderly per the Beers criteria

A

seizure disorders

REM sleep behaviour disorders

benzo or etoh withdrawal

severe GAD

perioperational anesthesia

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37
Q

do the Beers criteria recommend benztropine for treating EPS in the elderly

A

no–> say there are better agents

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38
Q

why do the Beers criteria recommend avoiding Z drugs

A

adverse events similar to benzos in the elderly

increased ER visits and hospitalizations

increase MVAs

minimal improvement in sleep latency and duration

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39
Q

list medications that may cause SIADH or hyponatremia (esp in the elderly)

A

antipsychotics

carbamanzepine

diuretics

mirtazapine

oxcarbazapine

SNRIs

SSRIs

TCAs

tramadol

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40
Q

list medications that should be avoided in older adults with, or who are at high risk for, delirium (i.e are deliriogenic)

A

anticholinergics

antipsychotics

benzos

corticosteroids

H2 receptor antagonists (i.e cimetidine, famotidine, ranitidine, nizatidine)

meperidine

Z drugs

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41
Q

name a non-psych class of meds that should be avoided in parkinsons disease

A

antiemetics like metoclopramide as they are dopamine receptor antagonists with potential to worsen parkinsons symptoms

42
Q

which dopamine receptor antagonists appear to be less likely to precipitate worsening of parkinsons disease

A

pimavanserin

clozapine

*quetiapine has low quality evidence

43
Q

are there significant changes to absorption of medications with age

A

no, change with age is negligible (i.e gastric pH, GI motility, intestinal permeability, drug transporters, GI blood flow)

44
Q

what are the two factors that determine distribution of drugs

A

protein binding and volume of distribution

45
Q

how does protein binding change with age

A

decreased albumin–> decreased protein binding

leads to MORE FREE DRUG in geri populations

46
Q

how does volume of distribution change with age

A

INCREASED BODY FAT –> increased volume of distribution for LIPOPHILIC drugs i.e depot antipsychotics

DECREASED BODY WATER–> volume of distribution is decreased for HYDROPHILIC drugs (i.e lithium)

47
Q

how does liver metabolism change with age

A

hepatic volume and blood flow are decreased and thus CYP enzyme system is DECREASED (this is phase I metabolism)

phase II metabolism is NOT similarly affected

48
Q

how does renal excretion change with age

A

decreases/is slower –> drug interactions with CYP system can compound this problem

49
Q

list 4 psych meds that need to be adjusted for renal clearance in older adults

A

duloxetine

gabapentin

keppra

pregabalin

50
Q

in older adults, what meds should you NOT combine with:

opioids

A

benzos

gabapentin, pregabalin

*risks of overdose/sedation related events

51
Q

in older adults, what meds should you NOT combine with:

lithium

A

loop diuretics

ACEIs

due to risk of Li toxicity

52
Q

why should you make sure to minimize anticholinergic med burden in the elderly

A

risk of cognitive decline

53
Q

which has higher risk of GI bleed–> NSAIDs or SSRIs

A

NSAIDs–> but combo of SSRI + NSAID increases the risk by about double

54
Q

what are the big SEs of cognitive enhancers (cholinesterase inhibitors)

A

GI–> vomiting and nausea

(also falls, syncope, dizziness/confusion, bradycardia etc)

55
Q

what are the 3 classes of psychotropic medications that are most implicated in higher risk of falls in the elderly

A

sedative/hypnotics

antidepressants

antipsychotics

*these have higher risk than antihypertensives, beta blockers, NSAIDs, narcotics, etc

56
Q

who is more likely to fall–men or women

A

female gender is risk factor for falls

57
Q

how does the risk for falls change overtime in older people on TCAs

A

DECREASES over time

58
Q

how does the risk for falls change overtime in older people on SSRIs

A

INCREASES over time

59
Q

what makes SSRIs particularly risky for falls

A

implicated in decreasing bone density by about 3-6% thus also increasing risk for fracture with falls

60
Q

is risk of stroke higher with atypical or typical APs

A

higher with atypical

and also higher if have dementia

61
Q

list SSRIs and others that can cause QTc prolongation

A

citalopram

escitalopram

fluoxetine

mirtazapine

paroxetine

sertraline

trazodone

venlafaxine

62
Q

what street drug prolongs QTc

A

cocaine

63
Q

why should be careful with benztropine in the elderly

A

anticholinergic

64
Q

list 5 risk factors for SIADH

A

older age

female gender

concomitant use of diuretics

low body weight

lower baseline serum sodium

65
Q

list 3 major drug classes identified as potential precipitants of lithium toxicity

A

renal sodium wasting diuretics

ACEI

NSAIDs

66
Q

what lithium level do more geri psych people aim for

A

0.4-0.6mmol/L

no good studies

67
Q

do the risks of dystonia or akathesia change in the elderly

A

no–> dystonia is unlikely in the elderly and akathesia has same risk as general population (20-40%)

68
Q

how does the risk of parkinsonism as side effect change with age

A

above 50% to as high as 76% in age above 60

69
Q

how does the risk of tardive dyskinesia change with age

A

higher risk than in younger adults–depends on population (ie higher risk in institutionalized settings)

70
Q

what kind of medication is pramipexole

A

dopamine receptor AGONIST

71
Q

what type of medication in memantine

A

NMDA receptor ANTagonist

72
Q

what kind of medication is galantamine

A

cholinesterase inhibitor

73
Q

what kind of medication is donepezil

A

cholineserase inhibitor

74
Q

what kind of medication is bromocriptine

A

dopamine agonist

75
Q

what kind of medication is ropirinol

A

dopamine agonist

76
Q

what kind of medication is rivastigmine

A

cholinesterase inhibitor

77
Q

what kind of medication is amantadine

A

dopamine agonist

78
Q

3 indications for bromocriptine

A
  1. NMS (off label)
  2. hyperprolactinemia
  3. parkinsons
79
Q

5 side effects of bromocriptine

A
  1. NVD
  2. pulmonary fibrosis
  3. pleural effusion
  4. hypotension
  5. psychosis
80
Q

what other receptors dow bromocriptine bind to other than domapine

A

serotonin

alpha/beta adrenergic

81
Q

what is an indication for ropinirole

A

restless legs

(rarely, augmentation in TR depression)

82
Q

side effects of ropinirole

A

NVD

orthostatic hypotension

headache

dizziness

arrythmia

sleep attacks

psychosis

83
Q

indication for pramipexole

A

parkinsons

(rarely, augmentation in TR depression)

84
Q

side effects of pramipexole

A

NVD

orthostatic hypotension

headache

dizziness

arrythmia

sleep attacks

psychosis

85
Q

which of the dopamine agonists binds D3 more than D2

A

ropinirole + pramipexole

86
Q

how does pramipexole affect sleep

A

improves sleep architecture

*also is neuroprotective and has antidepressant effects

87
Q

4 indications for amantadine

A
  1. parkinsons
  2. restless legs
  3. TBI
  4. EPS

(rarely in severe cocaine withdrawal)

88
Q

which of the dopamine agonists can be used to treat restless legs

A

ropinirole

amantadine

89
Q

which of the dopamine agonists can be used to treat cocaine withdrawal

A

amantadine

*rare, withdrawal must be severe

90
Q

which dopamine agonist should you not discontinue abruptly

A

amantadine

91
Q

what other receptors does amantadine work on other than dopamine

A

NMDA antagonist

anticholinergic

92
Q

what medication is an alternative to benztropine if they cant tolerate a strong anticholinergic like benztropine

A

amantadine

93
Q

what dopamine agonist must you use renal dosing with

A

amantadine

94
Q

side effects of amantadine

A

dizziness

nausea

insomnia

irritability

psychosis

hypotension

livedo reticularis

95
Q

indications for memantine

A

moderate to severe AD
+/- vascular

*not indicated for other dementias

96
Q

which has fewer GI side effects, donepezil or rivastigmine

A

donepezil

97
Q

which of the cholinesterase inhibitors is best for parkinsons

A

rivastigmine

98
Q

which of the cholinesterase inhibitor is best for vascular dementia

A

donepezil

99
Q

which cholinesterase inhibitors can reduce AH/VH in parkinsons dementia/LBD

A

all of them

100
Q

where in the brain do cholinesterase inhibitors increase acetylcholine

A

in the hippocampus and the cortex

101
Q

list side effects of the cholinesterase inhibitors

A

NVD

weight loss

bradycardia

syncope

fatigue

insomnia

nightmares

muscle cramps

2. Geriatric Psychiatry + Neuroanatomy (14 decks)

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