PSYCH PART 2: ADHD, INSOMNIA, ACUTE AGITATION, ALZHEIMER Flashcards
3 hallmark symptom of ADHD
inattention, hyperactivity and impulsivity
reasonable trial of stimulants?
3-4 weeks
1st line agent for ADHD?
long acting stimulant
2nd line: short/intermediate acting, atomoxetine, guanfacine
which agents are consider short, intermediate and long acting?
SHORT-ACTING: (RITALIN, DEXEDRINE)
INTERMEDIATEACTING: (RITALIN SR, DEXEDRINE SPANSULES) may last up to 8 hours.
LONG-ACTING: (CONCERTA, BIPHENTIN, ADDERALL XR, VYVANSE) are dosed once-daily
when do you start pharmacotherapy in children with ADHD?
6 years or older
which drug is amphetamine based and which is methyphenidate
amp (VAD) aderral, vvyvanse, dexedrine
methy: concerta, biphentin, ritalin, foquest
ADHD drug adverse effects?
suppressed appetite, decreased weight and height,
increased BP/HR, insomnia, aggression, psychosis
onset of stimulant vs non stimulant
stimulant: 1-3 weeks
non 4-8 weeks up to 12 weeks
role of atomoxetine and adverse effects
second line if not tolerating stimulants/ not responding to
adverse: similar to stimulant but increased hepatoxicity and increased sedation
role of clonidine
clonidine alone or in combination with stimulants is also effective in improving both ADHD and tic symptoms in patients with both condition
can concerta be sprinkled into food
no, it is an osmotic controlled released oral delivery system (OROS)
agents that can be sprinkled and given with food: adderral, biphentin and foquest
drug holiday for ADHD
symptoms may dissipate as patients enter adolescence. Weaning the medication for a 2- to 3-week period once a year (usually in the summer months) may provide an opportunity to reassess ADHD-related behaviours and to confirm whether the stimulant is still required for the next school term
ADHD agents with lower abuse potential
concerta, and vyvanse
MOA of guanfacine Intuniv XR and atomoxetine Strattera
guanfacine: Alpha2-adrenergic Agonists
atomoxetine: Norepinephrine Reuptake Inhibitors
transient insomnia and acute insomnia and chronic insomnia
transient <3 days
acute: <3 months
chronic: >3 nights/ week and >/ 3 months
first line treatment for insomnia
CBT
timeframe for non-prescription and prescription trial for insomnia
non prescription: <14 days
prescription: 7 days then reassess in 1 week
which 3 BZD is indicated for insomnia in canada
which agent is best for elderly patient
(flurazepam, nitrazepam, temazepam, triazolam): TTNF
Temazepam is usually a suitable all-purpose hypnotic with a half-life sufficient to cover the sleep period without causing hangover effects. Flurazepam and nitrazepam are not recommended due to their longer half-lives; they accumulate with repeated dosing and are associated with more next-day effects than shorter-acting agents
agent preferred for older patient: temazepam, lorazepam and oxazepam ( off label used
what is one rare but notable side effects of zopiclone and zolpidem?
complex sleep behaviours have been reported in up to 3% of patients prescribed zopiclone and zolpidem (black boxed warning)
AE of z like drugs ( zoplicone)
Bitter metallic taste,
“hangover”, dry mouth
rare complex sleep disorder
wait 12 hrs before operating vehicle
DOC for insomnia during pregnancy
zopiclone
avoid BZD, zolpidem,
role of doxepin
indicated for sleep insomnia maintenance
dose 3-6 mg ( lower than antidepressant dose)
minimal risk of tolerance and falls risk of cognitive impairment
is BZD for insomnia safe during breast feeding
low dose of short acting BZD ( lorazepam) appears safe in breastfeeding
explain different classification of dementia
alzheimer’s disease
vascular dementia
lewy body/parkinson’s dementia
alzheimer’s disease: gradual and progressive, neurofibrillary tangles + beta amyloid plaques= decrease ACh and increase glutamate
vascular: more sudden as a result of stoke or CV events., acute and or/chronic reduction of blood flow
levy body/parkinson: gradual and progressive, lewy bodies in nerve cells, hallucinations and motor impairment common
pharmacological recommendations for dementia:
AChEi
memantine
antipsychotics
antidepressants
trazodone
BZD
AChEi : first line, slow progression
memantine: alternative to AChEi (adjunct)
antipsychotics: used for hallucination and psychosis, avoid in lewy body/parkinson dementia
antidepressants : used if depression present
trazodone: manage agitation, sundown or disturbed sleep/wake cycles
BZD: conflicting data
compare AChEi therapy?
donepezil, galantamine and rivastigmine
indication, tolerability, clinical tips and side effects
see pic
memantine MOA, and adverse effects
and caution
Blocks NMDA receptors (may also provide behaviour benefits+slowing decline)
AE: dizziness, drowsiness, confusion, INCREASED BP
caution: pt with seizures and CVD
DO NOT combine with angle closure glaucoma, SSS, left bundle branch block, bradycardia
when should AchEIs be d/c?
did not experience clinical benefit
AE
dose should be tapered before stopping the agent
what is the role of gingko biloba?
what safety concern should we consider
increased blood flow and viscosity of blood
NO significant efficacy support
caution in patient taking anti platelet/ anticoagulants and NSAID -→ increased risk of bleeding
Efficacy of cholinesterase inhibitor and memantine is measure by
Decline in MMSE less than 2
average improvement of ADAS-cog score was 2-3 points. 3 point change is considered clinically relevant
when should you see improvement in cognitive symptoms?
when should we follow up after initiating therapy or increasing the dose?
early improvement 4-6 weeks
improvement 3-6 months
follow up in 2 weeks
DOC for lewy body dementia
what should we avoid?
rivastigmine
avoid antipsychotics, if really required may used olanzapine or quetiapine
DOC for vascular dementia?
No drugs are clearly effective in vascular dementia. Cholinesterase inhibitors or memantine are treatment options only for patients with vascular dementia if they have a mixed component of Alzheimer disease, Parkinson disease dementia or dementia with Lewy bodies
which antipsychotic have the best evidence for treatment dementia
risperidone and olanzapine
antipsychotic have been shown to increased the risk of what compared to clinical trails
risk of stroke and death
when should we initiate antipsychotic ?
severe behavioural symptoms, particularly with psychosis or risk of harm to self or others
what is the role of trazodone in dementia
treat disrupted sleep/wake cycles and “sundowning” (worsening of behaviour as darkness falls).
which dementia agent should we be cautious in patient with seizure and CVD
memantine
when is BZD preferred over antipsychotic in treating delirium?
BZD preferred for CNS stimulant intoxication, BZD withdrawal and alcohol withdrawal
antipsychotic preferred for agitation with a known psychiatric disorder or CNS depressant intoxication, not preferred if delirium is not due to BZD withdrawal, alcohol withdrawal or sleep deprivation
which BZD IM option is available for treating delirium
midazolam and lorazepam
can olanzapine and BZD be administered concomitantly
no, it can lead to cardiac and respiratory complications that can result in death
what is “5 an ”2 combination of BZD and first gen antipsychotic
5 mg haloperidol and 2 mg of lorazepam ( both IM or IV)
which agent has long history and experience with agitation?
IM haloperidol is standard of care
most commonly used antipsychotic agent for delirium
olanzapine and risperidone
how to treat delirium in patient with dementia
lowest doses of antipsychotic should be used for the shortest duration possible
risperidone treats agitation and other behavioural symptoms linked to alzehimers
which agent may contribute to insomnia?
anticonvulsants, central adrenergic blockers, diuretics, selective serotonin reuptake inhibitors, steroids, stimulants.
