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Mental Illness in Older Adults Flashcards

1
Q

Absorption in older adults

A

Drug absorption is reduced in older adults due to loss of mucosal intestinal surface, decrease in gastrointestinal blood flow and reduced gastric acidity.

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2
Q

Distribution in older adults.

A

Altered plasma protein concentrations, body fat and intracellular fluid content
Decreased muscle and tissue mass,[ reduced blood flow to tissues and organs.
Active drug uptake into tissues
Blood-brain barrier is less intact in older adults= increased drug concentration into the brain.

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3
Q

Metabolism in older adults

A

Reduction in total liver size
Reduction in liver blood flow (40-50% reduction between 25 and 65 years of age)
CYP-450 system inducers or inhibitors

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4
Q

Elimination in older adults

A

Decreased total kidney size and the number of functioning nephrons.
Decreased renal blood flow with increasing age=decline in glomerular filtration rate (GFR).
Decreased renal clearance is frequently aggravated by the effects of enlarged prostate or chronic urinary tract infection.

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5
Q

Pharmacodynamics in older adults.

A

Older adults have increased sensitive to anticholinergic drug effects. Examples:
Tricyclic antidepressants
Antihistamines
Urinary antimuscarinic agents
Antipsychotic drugs
Antiparkinsonian drugs withatropine-like activity
OTC hypnotics
Even in low doses, can increase risk of heatstroke by inhibiting diaphoresis.

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6
Q

Action of Atropine

A

Atropine Antagonizes Acetylcholine receptors.

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7
Q

Anticholinergic Mneumonic

A

“Red as a beet, Dry as a bone, Mad as a hatter, full as a flask”.
Symptoms:
Flushing, anhydrosis, Dry mucous membranes, mydriasis, Altered mental status, fever, urinary retention.

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8
Q

Delirium causes menumonic
(I watch Death)

A

Infection
Withdrawal
Acute Metabolic
Trauma
CNS pathology
Hypoxia
Deficiencies
Endocrinopathies
Acute Vascular
Toxins or drugs
Heavy Metals.

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9
Q

Mneumonic for life-threatening causes of Delirium
WWHHHHIMPS

A

Wernicke’s Encephalopathy
Withdrawal
Hypertensive crisis
Hypoperfusion/hypoxia of the brain
Hypolgycemia
Hyper/hypothermia
Intracranial process or infection
Metabolic/meningitis
Poisons
Status epilepticus

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10
Q

Deliriogenic medications (mneumonic)
ACUTE CHANGE IN MS

A

Antibiotics
Cardiac drugs
Urinary incontinence drugs
Theophylline
Ethanol
Corticosteroids
H2 Blockers
Antiparkinsonian drugs
Narcotics
Geriatric psychiatric drugs
ENT drugs
Insomnia Drugs
NSAIDs
Muscle relaxants
Seizure medications

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11
Q

Beers criteria Medication list

A

Recommendations for medications which are inappropriate and should be avoided in older adults
Recommendations are categorized as:
Strong: Benefits clearly outweigh harms, adverse events, and risks, or harms, adverse events, and risks clearly outweigh benefits
Weak: Benefits may not outweigh harms, adverse events, and risks
Insufficient: Evidence inadequate to determine net harms, adverse events, and risks
Use the recommendations with caution

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12
Q

Dementia(overview)

A

-Dementia consists of amnesia, aphasia, apraxia, agnosia, and changes in executive functioning
-Various potential causes and types of dementia
-Alzheimer’s disease most common type
-Risk increases with advanced aging
-Various hypotheses (e.g. amyloid cascade hypothesis)
-Loss of intellectual abilities that interfere with functioning
-At least one of these categories:
-impaired abstract thinking
-impaired judgment
-personality change
-cortical dysfunction

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13
Q

Alzheimer’s pathophysiology(get from book)

A
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14
Q

7 stages of Alzheimer’s disease

A

Stage 1
Normal health
Stage 2
Normal aged forgetfulness
Stage 3
Mild cognitive impairment
Stage 4
Mild Alzheimer’s Disease
Stage 5
Moderate Alzheimer’s Disease
Stage 6
Moderately Severe Alzheimer’s Disease
Stage 7
Severe Alzheimer’s Disease

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15
Q

Mild cognitive impairment Clinical presentation

A

One cognitive domains impaired
ADLs and IADLs intact
Loss of recent and remote memory
Difficulty with executive functioning
May lose valuables
Able to perform ADLs

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16
Q

Moderate Alzheimer’s Clinical Presentation

A

At least two cognitive domains impaired and impaired IADLs:
Increased memory loss
Significant confusion
Easily frustrated, agitated
Moderate to severe communication difficulties
Difficulty with basic ADLs
Agnosia
Apraxia
Poor judgment
Loss of impulse control
Perceptual disturbances
Increased personality and behavior problems

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17
Q

Agnosia

A

Inability to understand the import or significance of sensory stimuli.
Not explained by defect in sensory pathways or cerebral lesion.
May also refer to selective loss or disuse of knowledge of specific objects because of emotional circumstances (i.e. in schizophrenia, anxiety, depression).

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18
Q

Apraxia

A

Inability to perform voluntary purposeful activity. Not explained by paralysis or other motor or sensory impairment.

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19
Q

Severe Alzheimer’s Clinical presentation

A

Limited memory
Limited communication
Increasing vulnerability and frailty
Loss of bowel and/or bladder control
Extremely limited ability to perform ADLs

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20
Q

Parkinson’s disease dementia pathophysiology

A

Reduction of dopamine secreting cells
Affects the motor circuits between brain and the basal ganglia
Loss of memory
Judgement and reasoning impaired

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21
Q

Parkinson’s treatment

A

Dopamine agonists (May be taken alone or with Levodopa)
Stimulate the brain but less effective than Levodopa
FDA approved: Parkinson’s Disease, Restless leg syndrome
Off label use: Rapid eye movement sleeping disorder, sleep related eating disorder
pramipexole (Mirapex)
ropinirole (Requip)
bromocriptine (Parlodel)

22
Q

Carbidopa/levodopa(sinemet)

A

Carbidopa/Levodopa (Sinemet)
FDA approved: Parkinsonism
Most effective drug for Parkinson’s Disease
Carbidopa usually given as a combo drug

23
Q

Off label use for Sinemet

A

Off label use: sleep related eating disorder and restless leg syndrome

24
Q

Dopamine Agonists

A

-(May be taken alone or with Levodopa)
Stimulate the brain but less effective than Levodopa
FDA approved: Parkinson’s Disease, Restless leg syndrome

25
Off label use for dopamine agonists
Off label use: Rapid eye movement sleeping disorder, sleep related eating disorder pramipexole (Mirapex) ropinirole (Requip) bromocriptine (Parlodel)
26
MAO inhibitors in Parkinson's
Prevents the breakdown of dopamine Modestly increases nigrostriatal dopamine Selegiline (Eldepryl)
27
Anticholinergic agents in Parkinson's
Reduces tremors associated with Parkinson’s Disease Trihexyphenidyl (Artane) Benztropine (Cogentin)
28
Amantadine in Alzheimer's
May temporarily relieve mild motor symptoms
29
COMT inhibitors (Catechol-O-Methyl-Transferase)
Prolongs the effects of Levodopa
30
Cholinergic Deficiency in Dementia
Another hypothesis to dementia Researchers have linked cholinergic disfunction with memory problems Improving cholinergic transmission as treatment for people with Alzheimer’s Disease may improve memory functioning
31
Cholinesterase inhibitors
Most widely used class of drugs used for Alzheimer’s Disease. Inhibit acetylcholine destruction by blocking enzyme acetylcholinesterase (AChE), relate to clinical manifestations of AD Researchers have linked cholinergic disfunction with memory problems Cognitive enhancer: It may improve memory and slow cognitive decline Can improve cognitive function in patients diagnosed with: Alzheimer’s Disease Vascular dementia Diffuse Lewy body disease
32
Donepizil(Aricept)
Once a day dosing (5 mg-10mg qhs); may be give BID if needed. Higher doses 10 mg-23mg qhs helpful for moderate to severe disease First line treatment (Can be used in all stages) Reversible, long acting, selective inhibitor of AChE Inhibits AChE in pre & post synaptic cholinergic neurons breakdown More Ach becomes available Slows down deterioration in cognitive functions Better side effect profile Mostly GI side effects: nausea, diarrhea, increase risk of GI bleeding GI effects transient Need treatment for 6 to 24 months to see maintained cognition NSAID’s should be avoided
33
Rivastigmine(Exelon)
-Mild to Moderate Alzheimer’s dementia: Rivastigmine (Exelon) transdermal patch 4.6mg daily to 9.5mg daily -Rivastigmine (Exelon) cap 3mg-6mg po bid -Short half life- 1.5 hours -Titrate slowly * 1.5mg BID for 2 weeks; 3mg BID for 2 weeks; 6mg BID (maximum) -Intermediate acting selective for AChE -Inhibits butyrylcholinesterase (BuChE) -Increases cholinergic synaptic transmission by inhibiting acetylcholinesterase in the synaptic cleft -Leads to increased concentrations of acetylcholine in the brain -Not metabolized by cytochrome P-450. -Must be taken with food to reduce GI side effects (nausea, vomiting and weight loss) -More GI side effects than Donepezil
34
Galantamine (Razadyne, Reminyl)
Mild to moderate Alzheimer’s dementia Formulation: oral, ER and solution 4mg BID for 4 weeks, if tolerated, then 8mg BID for 4 weeks, if tolerated (12mg BID max dose) (half life 6-8 hours) Peaks in one hour Dual mechanism of action: Binds to and inactivates AChE inhibition is matched with positive allosteric modulation (PAM)      Stimulates pre-synaptic muscarinic receptors to release more Ach Produces more cholinergic side effects (GI symptoms) Take with food Metabolized by cytochrome P-450 May interact with other drugs metabolized by this system
35
Memantin(namenda)
N-Methyl-d-aspartate (NMDA) Antagonist Dosing: 10mg po bid (Moderate to Severe Alzheimer’s Dementia) Long half-life (60-80 hours) Antagonist that regulates the activity of glutamate in the brain. Reduces abnormal activation of glutamate neurotransmission It may improve cognitive function and slow rate of decline May be given in combination with cholinesterase inhibitors Most of the agent is excreted unchanged. Protects cells against excess glutamate by binding to the NMDA receptors. Glutamate receptors are overactive with AD. Increased NDMA stimulation can cause neuronal death. Used to treat individuals during the moderate/severe stages of Alzheimer's disease.
36
Treating Psychiatric and behavioral symptoms in Dementia
The presence of non-dementia related psychosis or mania should be the only indication for prescribing first- and second-generation antipsychotic medications. Usually the patient has a long history of severe, persistent mental illness Always evaluate as to whether confounding comorbid conditions or risk factors exist. Explain to patients and family members the pros and cons of using these medicines before beginning and during therapy. These drugs should not be used routinely with dementia patients, unless the person is in severe distress or there is a marked risk of harm.
37
Why are antipsychotics not recommended in psychiatric and behavioral symptoms in dementia
Antipsychotics not recommended, no FDA approval Cardiovascular effects and increased mortality Black box warning/Beers Criteria (increased sudden death)
38
First line treatment in behavioral and psychiatric symptoms in dementia
First-line treatment of agitation and aggression in dementia include SSRIs/SNRI
39
Second line treatment in behavioral and psychiatric symptoms in dementia
Second-line may include valproic acid, beta blockers, gabapentin, pregabalin
40
Antipsychotics to avoid or use with caution in Elderly
Conventional: Haloperidol (Haldol) Adverse effects: EPS and TD Anticholinergic effects Sedation and potential for falls Atypical: Olanzapine (Zyprexa) Has threefold increase in risk of cerebrovascular accidents (CVAs) in aged patients with dementia. Atypical: Risperidone (Risperdal) Least sedating of the atypical antipsychotics Used in lower dosages Fewer extrapyramidal effects, orthostatic hypotension, sedation, or tardive dyskinesia Atypical: Quetiapine (Seroquel) Used for psychotic symptoms with those who have Parkinson’s disease
41
Patient/Caregiver teaching in treatment of dementias:
Take with food – can cause upset stomach Swallow capsules whole Liquid solution available: Exelon/Reminyl Drink plenty of non-caffeine liquids 8 glasses unless instructed differently by primary care provider Do not take double dose or extra doses May cause drowsiness Avoid the use of alcohol
42
Risk factors for suicide in elderly adults
Depression White American Male Alcohol abuse Living alone Recent death of spouse Physical illness Somatic complaints
43
Recommended drugs for depression in older adults
SSRI’s and SNRI’s Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Venlafexine (Effexor)
44
Factors that contribute to Substance use disorder in older adults:
Substance use disorder earlier in life Genetics Major life changes (death, loneliness, bereavement) Disengagement Deterioration of health Overprescribing practices
45
Alcohol abuse in older adults:
Alcohol abuse is prevalent in 10% to 15% of older adults Symptoms may include: Erratic changes in affect, mood, behavior Malnutrition Bladder/bowel incontinence Gait disturbances Reoccurring falls/injuries
46
Assessing for prescription medication dependence(benzodiazepenes)
Benzodiazepines very similar to alcohol May use screening tools Clinical Institute Withdrawal Assessment Clinical Opiate Withdrawal Scale -substitute prescription meds for alcohol Be aware of repeatedly losing prescriptions/pills
47
Assessing for prescription medication dependence(opioids)
Prescriptions from multiple physicians Congruency: does the complaint and clinical presentation? Above average knowledge about meds S/S withdrawals
48
Substance use dependence interventions
Assess all meds and develop a safe detox plan Low stimuli environment/seizure precautions Meds to minimize withdrawal Nutritional support Multidisciplinary approach- treatment options (Narcotics Anonymous, individual/group/family therapy)
49
Non-prescription medication misuse assessment:
-Assess patient’s nonprescription medication history -Don’t forget assess use of natural medications and herbals -Stress the importance of consulting physician and/or pharmacist before taking nonprescription drugs -Evaluate clients’ understanding of the effects of nonprescription drugs
50
Patient/Caregiver teaching for safe medication use:
Know the name, amount, type, frequency, purpose, and side effects of each prescription and nonprescription meds Bring all meds or a list to every visit Never borrow or share meds (diversion) Assess client’s ability to self-administer (vision, judgment, memory etc.) Simplify regimen as much as possible Use a single pharmacy
51
Psychopharmacology considerations in older adults
-Start low and go slow, but get to the goal. -Watch tendency to undertreat -Be careful of drug to drug interactions -Always monitor renal and hepatic function -Polypharmacy is a geriatric syndrome.

PMHNP (15 decks)

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