Geriatric Psychopharmacology Flashcards by Alana Meikle

list the 3 cholinesterase inhibitors

donepezil

rivastigmine

galantamine

How well did you know this?

Not at all

Perfectly

what are the approved AD pharmacotherapies in canada

memantine

cholinesterase inhibitors

How well did you know this?

Not at all

Perfectly

how effective are the cholinesterase inhibitors for mild to moderate AD

modestly effective

How well did you know this?

Not at all

Perfectly

how do cholinesterase inhibitors work

stop the breakdown of acetylcholine in the synaptic cleft

How well did you know this?

Not at all

Perfectly

how does donepezil work

NON competitive

reversible

longlasting

once a day morning dose of 5-10 mg

generally well tolerated and easy to use

How well did you know this?

Not at all

Perfectly

how does rivastigmine work

non competitive

pseudo-irreversible

comes as a patch or capsules (BID dosing)

How well did you know this?

Not at all

Perfectly

how is rivastigmine metabolized

almost totally INDEPENDENT of the hepatic CYP system

How well did you know this?

Not at all

Perfectly

how does galantamine ER work

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

How well did you know this?

Not at all

Perfectly

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

overall cognition

memory

naming

executive functions

ADLs

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

How well did you know this?

Not at all

Perfectly

list dementias that can be treated with cholinesterase inhibitors

mild to moderate AD

moderate to severe AD

dementia with lewy bodies

parkinsons disease dementia

vascular/mixed dementia

How well did you know this?

Not at all

Perfectly

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

normal aging

MCI

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

How well did you know this?

Not at all

Perfectly

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

20%

How well did you know this?

Not at all

Perfectly

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

50%

How well did you know this?

Not at all

Perfectly

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

20%

How well did you know this?

Not at all

Perfectly

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

10-15%

How well did you know this?

Not at all

Perfectly

list the side effects of cholinesterase inhibitors

GI ***

bradycardia

muscle cramps

sleep disturbance

How well did you know this?

Not at all

Perfectly

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

change to Exelon patch

How well did you know this?

Not at all

Perfectly

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

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)

How well did you know this?

Not at all

Perfectly

what is the role of glutamate in AD

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

How well did you know this?

Not at all

Perfectly

how does memantine work

voltage dependent

low to moderate affinity

UNcompetitive NMDA receptor antagonist

acts SELECTIVELY at NMDA receptors

NO significant affinity for other receptors

How well did you know this?

Not at all

Perfectly

how is memantine metabolized

undergoes LITTLE metabolism

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

no role for cyp system

How well did you know this?

Not at all

Perfectly

what behaviours improved with addition of memantine

agitation/aggression

irritability/lability

apathy/indifference

appetite/eating changes

How well did you know this?

Not at all

Perfectly

when should you use memantine

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

How well did you know this?

Not at all

Perfectly

do you have to adjust memantine in renal or hepatic impairment

not for hepatic

yes for renal (half of typical maintenance dose)

How well did you know this?

Not at all

Perfectly

does memantine have significant drug interactions

no, minimal

list side effects of memantine

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

how do you stage AD

by MMSE: above 22--> mild 18-22--> mild to moderate 13-17--> moderate 8-16--> moderate to severe less than 8--> severe

is trial discontinuation recommended for AD meds

why is it tricky to prescribe meds in geriatrics

1. polypharmacy--> higher risk of interactions 2. changes in physiology--> higher risk of SEs 3. comorbidities--> higher risk of SEs

how does age impact sensitivity to benzos

the elderly have increased sensitivity to the CNS effects of benzos

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

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

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

increased sensitivity to negative inotropic and vasodilator + diminished baroreceptor sensitivity

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

Beers criteria

why do Beers criteria recommend avoiding antipsychotics in the elderly

increased risk of CVA greater risk of cognitive decline and mortality in persons with dementia

why do the Beers criteria recommend avoiding benzos in the elderly

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

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

seizure disorders REM sleep behaviour disorders benzo or etoh withdrawal severe GAD perioperational anesthesia

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

no--> say there are better agents

why do the Beers criteria recommend avoiding Z drugs

adverse events similar to benzos in the elderly increased ER visits and hospitalizations increase MVAs minimal improvement in sleep latency and duration

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

antipsychotics carbamanzepine diuretics mirtazapine oxcarbazapine SNRIs SSRIs TCAs tramadol

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

anticholinergics antipsychotics benzos corticosteroids H2 receptor antagonists (i.e cimetidine, famotidine, ranitidine, nizatidine) meperidine Z drugs

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

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

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

pimavanserin clozapine *quetiapine has low quality evidence

are there significant changes to absorption of medications with age

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

what are the two factors that determine distribution of drugs

protein binding and volume of distribution

how does protein binding change with age

decreased albumin--> decreased protein binding leads to MORE FREE DRUG in geri populations

how does volume of distribution change with age

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)

how does liver metabolism change with age

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

how does renal excretion change with age

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

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

duloxetine gabapentin keppra pregabalin

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

benzos gabapentin, pregabalin *risks of overdose/sedation related events

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

loop diuretics ACEIs due to risk of Li toxicity

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

risk of cognitive decline

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

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

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

GI--> vomiting and nausea (also falls, syncope, dizziness/confusion, bradycardia etc)

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

sedative/hypnotics antidepressants antipsychotics *these have higher risk than antihypertensives, beta blockers, NSAIDs, narcotics, etc

who is more likely to fall--men or women

female gender is risk factor for falls

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

DECREASES over time

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

INCREASES over time

what makes SSRIs particularly risky for falls

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

is risk of stroke higher with atypical or typical APs

higher with atypical and also higher if have dementia

list SSRIs and others that can cause QTc prolongation

citalopram escitalopram fluoxetine mirtazapine paroxetine sertraline trazodone venlafaxine

what street drug prolongs QTc

cocaine

why should be careful with benztropine in the elderly

anticholinergic

list 5 risk factors for SIADH

older age female gender concomitant use of diuretics low body weight lower baseline serum sodium

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

renal sodium wasting diuretics ACEI NSAIDs

what lithium level do more geri psych people aim for

0.4-0.6mmol/L no good studies

do the risks of dystonia or akathesia change in the elderly

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

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

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

how does the risk of tardive dyskinesia change with age

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

what kind of medication is pramipexole

dopamine receptor AGONIST

what type of medication in memantine

NMDA receptor ANTagonist

what kind of medication is galantamine

cholinesterase inhibitor

what kind of medication is donepezil

cholineserase inhibitor

what kind of medication is bromocriptine

dopamine agonist

what kind of medication is ropirinol

dopamine agonist

what kind of medication is rivastigmine

cholinesterase inhibitor

what kind of medication is amantadine

dopamine agonist

3 indications for bromocriptine

1. NMS (off label) 2. hyperprolactinemia 3. parkinsons

5 side effects of bromocriptine

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

what other receptors dow bromocriptine bind to other than domapine

serotonin alpha/beta adrenergic

what is an indication for ropinirole

restless legs (rarely, augmentation in TR depression)

side effects of ropinirole

NVD orthostatic hypotension headache dizziness arrythmia sleep attacks psychosis

indication for pramipexole

parkinsons (rarely, augmentation in TR depression)

side effects of pramipexole

NVD orthostatic hypotension headache dizziness arrythmia sleep attacks psychosis

which of the dopamine agonists binds D3 more than D2

ropinirole + pramipexole

how does pramipexole affect sleep

improves sleep architecture *also is neuroprotective and has antidepressant effects

4 indications for amantadine

1. parkinsons 2. restless legs 3. TBI 4. EPS (rarely in severe cocaine withdrawal)

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

ropinirole amantadine

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

amantadine *rare, withdrawal must be severe

which dopamine agonist should you not discontinue abruptly

amantadine

what other receptors does amantadine work on other than dopamine

NMDA antagonist anticholinergic

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

amantadine

what dopamine agonist must you use renal dosing with

amantadine

side effects of amantadine

dizziness nausea insomnia irritability psychosis hypotension livedo reticularis

indications for memantine

moderate to severe AD +/- vascular *not indicated for other dementias

which has fewer GI side effects, donepezil or rivastigmine

donepezil

which of the cholinesterase inhibitors is best for parkinsons

rivastigmine

which of the cholinesterase inhibitor is best for vascular dementia

donepezil

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

all of them

where in the brain do cholinesterase inhibitors increase acetylcholine

in the hippocampus and the cortex

list side effects of the cholinesterase inhibitors

NVD weight loss bradycardia syncope fatigue insomnia nightmares muscle cramps