Geriatrics: Agitation Flashcards
Neuropsychiatric symptoms (NPS)
Mild:
- depression
- anxiety
- irritability
- apathy
Severe:
- Agitation
- aggression
- vocalizations
- hallucinations
- delusions
- disinhibition
Delirium vs Dementia
Delirium -> acute onset
Dementia -> gradual onset
Medical causes of agitation in dementia
Medication
Infection
CVA
Trauma
Pain
Benefits of antipsychotics for NPS in dementia
very effective for hallucinations and delusions
Risks of antipsychotics for NPS in dementia
Increased mortality in elderly patients with dementia-related psychosis
Rank from most to least safe in geriatric patients: Haloperidol, Quetiapine, Olanzapine
Quetiapine > Olanzapine > Haloperidol
Quetiapine is “safer”, but still carries risks
Treatment for delusions and hallucinations
Aripiprazole*
Olanzapine*
Quetiapine*
Risperidone*
Clozapine (rarely used-blood dyscrasias)
Ziprasidone
Perphenazine
Haloperidol (acute/hospice use)
Fluphenazine
Thioridazine (anti-Ch)
Treatment for Parkinson’s Disease in geriatrics
- visual hallucinations -> pharm treatment
- significant emotional distress or dangerous / upsetting behavior
Quetiapine
Olanzapine
Pimavanserin (Nuplazid) $$$
Aripiprazole dosing + pearls
2-5 mg/d initially
max 30 mg/d
2nd gen
Olanzapine dosing + pearls
Hallucinations: 2.5-10mg/d
Parkinson’s: 2.5-5 mg/d
ADE: weight gain
2nd gen
Quetiapine dosing + pearls
Hallucinations: 25-800 mg/d
Parkinson’s: 12.5-75 mg/d
ophthalmic exam recommended Q6 months
2nd gen
Risperidone dosing + pearls
0.25 - 1 mg/d
dose-related EPS, IM not for acute treatment
do not exceed 6mg
Lewy Body Dementia
- cognitive decline accompanied by motor features of parkinsonism
- Prominent visual hallucinations
- avoid conventional antipsychotics: haloperidol, thioridazine, fluphenazine
Depressive symptom management
Non-pharm: recreational programs, activity therapies
Meds:
- SSRIs (citalopram, escitalopram, fluoxetine, sertraline)
- SNRIs (desvenlafaxine, duloxetine, venlafaxine)
- Mirtazapine
- Trazadone
- Bupropion
Meds not to use for depressive symptoms in geriatric patients
Paroxetine
Desipramine
Nortriptyline
Anticholinergic ADEs!
Citalopram dosing + pearls
10-40mg
ADE: EPS, hyponatremia, GI upset, nausea, upper GI bleeds, suicide, insomnia
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
