- cognitive decline accompanied by motor features of parkinsonism - Prominent visual hallucinations - avoid conventional antipsychotics: haloperidol, thioridazine, fluphenazine

Geriatrics: Agitation Flashcards by Marissa Hovey

Neuropsychiatric symptoms (NPS)

Mild:
- depression
- anxiety
- irritability
- apathy

Severe:
- Agitation
- aggression
- vocalizations
- hallucinations
- delusions
- disinhibition

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Delirium vs Dementia

Delirium -> acute onset
Dementia -> gradual onset

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Medical causes of agitation in dementia

Medication
Infection
CVA
Trauma
Pain

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Benefits of antipsychotics for NPS in dementia

very effective for hallucinations and delusions

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Risks of antipsychotics for NPS in dementia

Increased mortality in elderly patients with dementia-related psychosis

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Rank from most to least safe in geriatric patients: Haloperidol, Quetiapine, Olanzapine

Quetiapine > Olanzapine > Haloperidol

Quetiapine is “safer”, but still carries risks

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Treatment for delusions and hallucinations

Aripiprazole*
Olanzapine*
Quetiapine*
Risperidone*
Clozapine (rarely used-blood dyscrasias)
Ziprasidone
Perphenazine
Haloperidol (acute/hospice use)
Fluphenazine
Thioridazine (anti-Ch)

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Treatment for Parkinson’s Disease in geriatrics

visual hallucinations -> pharm treatment
significant emotional distress or dangerous / upsetting behavior

Quetiapine
Olanzapine
Pimavanserin (Nuplazid) $$$

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Aripiprazole dosing + pearls

2-5 mg/d initially
max 30 mg/d
2nd gen

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Olanzapine dosing + pearls

Hallucinations: 2.5-10mg/d
Parkinson’s: 2.5-5 mg/d
ADE: weight gain
2nd gen

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Quetiapine dosing + pearls

Hallucinations: 25-800 mg/d
Parkinson’s: 12.5-75 mg/d
ophthalmic exam recommended Q6 months
2nd gen

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Risperidone dosing + pearls

0.25 - 1 mg/d
dose-related EPS, IM not for acute treatment
do not exceed 6mg

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Lewy Body Dementia

cognitive decline accompanied by motor features of parkinsonism
Prominent visual hallucinations
avoid conventional antipsychotics: haloperidol, thioridazine, fluphenazine

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Depressive symptom management

Non-pharm: recreational programs, activity therapies

Meds:
- SSRIs (citalopram, escitalopram, fluoxetine, sertraline)
- SNRIs (desvenlafaxine, duloxetine, venlafaxine)
- Mirtazapine
- Trazadone
- Bupropion

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Meds not to use for depressive symptoms in geriatric patients

Paroxetine
Desipramine
Nortriptyline

Anticholinergic ADEs!

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Citalopram dosing + pearls

10-40mg
ADE: EPS, hyponatremia, GI upset, nausea, upper GI bleeds, suicide, insomnia

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Escitalopram dosing + pearls

5-20mg
ADE: EPS, hyponatremia, GI upset, nausea, upper GI bleeds, suicide, insomnia

Fluoxetine dosing + pearls

10-40mg
ADE: EPS, hyponatremia, GI upset, nausea, upper GI bleeds, suicide, insomnia
Long half-life
more insomnia

Sertraline dosing + pearls

25-100mg
ADE: EPS, hyponatremia, GI upset, nausea, upper GI bleeds, suicide, insomnia
Hypomania

Desvenlafaxine dosing + pearls

50mg
ADE: nausea, HTN, dry mouth, headaches, dizziness
indicated for depression only

Duloxetine dosing + pearls

20-60mg
ADE: nausea, dry mouth, dizziness, HTN, renal dose adjustments
indicated for depression + diabetic neuropathy

Venlafaxine dosing + pearls

25-100mg
ADE: HTN, QTc prolongation, EPS, withdrawal sx, hyponatremia, insomnia
useful in severe depression / anxiety

Bupropion dosing + pearls

75-225 mg
ADE: irritability, insomnia, can lower seizure threshold
more activating
lack of cardiac and sexual ADEs

Mirtazapine dosing + pearls

5.5-225 mg
ADE: sedation, hypotension, may increase appetite
useful for depression + insomnia or weight loss

insom-nom-nom-nomia

Trazodone dosing + pearls

25-150mg ADE: sedation, falls, hypotension When sedation is desirable

Apathy treatment

- methylphenidate - dextroamphetamine - modafanil

Manic-like behavioral sx treatment

Divalproex sodium * Carbamazepine Lamotrigine Lithium

Divalproex sodium dosing + pearls

250-2,000 mg/d ADE: nausea, GI upset, ataxia, sedation, hyponatremia CBC, platelet, LFT at baseline + Q6M Available in sprinkle cap Better tolerated than other mood stabilizers

Carbamazepine dosing + pearls

200-1,000 mg/d ADE: nausea, fatigue, ataxia, blurred vision poor tolerability in older adults

Lamotrigine dosing + pearls

25-200 mg/d ADE: Skin rash, SJS, dizziness, sedation, neutropenia, anemia increased ADE when used with divalproex

Lithium dosing + pearls

150-1,000 mg/d ADE: nausea, vomiting, tremor, confusion, leukocytosis, gait ataxia Poor tolerability in older adults narrow therapeutic window

Agitation / Aggression secondary to: Psychosis

Aripiprazole Olanzapine Quetiapine Risperidone

Agitation / Aggression secondary to: Depression

SSRIs

Agitation / Aggression secondary to: Anxiety

Buspirone (2-4 week trial) Trazodone

Agitation / Aggression that is unresponsive to 1st line therapy

Divalproex sodium Carbamazepine IM Olanzapine

Agitation / Aggression with sexual aggression

Aripiprazole Olanzapine Quetiapine Risperidone Divalproex sodium Conjugated equine estrogens Medroxyprogesterone injectable

Sundowning sx

Forgetful, confused, delirious, agitated, anxious, restless Insomnia w/ pacing, wandering, yelling, combativeness

Sundowning non-pharm treatment

Night lights check ins

Sundowning acute pharmacologic treatment

Trazodone 1st gen APS 2nd gen APS (do not use quetiapine in insomnia without sundowning or hallucinations)

Sundowning long term pharm treatment

Trazodone Melatonin 2nd gen APS 1st gen APS

Insomnia acute treatment

Trazodone Melatonin BZDs Mirtazapine

Insomnia long term treatment

trazodone melatonin