PSYCH PART 2: ADHD, INSOMNIA, ACUTE AGITATION, ALZHEIMER

Question 1

3 hallmark symptom of ADHD

Answer 1

inattention, hyperactivity and impulsivity

Question 2

reasonable trial of stimulants?

Answer 2

3-4 weeks

Question 3

1st line agent for ADHD?

Answer 3

long acting stimulant

2nd line: short/intermediate acting, atomoxetine, guanfacine

Question 4

which agents are consider short, intermediate and long acting?

Answer 4

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

Question 5

when do you start pharmacotherapy in children with ADHD?

Answer 5

6 years or older

Question 6

which drug is amphetamine based and which is methyphenidate

Answer 6

amp (VAD) aderral, vvyvanse, dexedrine

methy: concerta, biphentin, ritalin, foquest

Question 7

ADHD drug adverse effects?

Answer 7

suppressed appetite, decreased weight and height,

increased BP/HR, insomnia, aggression, psychosis

Question 8

onset of stimulant vs non stimulant

Answer 8

stimulant: 1-3 weeks

non 4-8 weeks up to 12 weeks

Question 9

role of atomoxetine and adverse effects

Answer 9

second line if not tolerating stimulants/ not responding to

adverse: similar to stimulant but increased hepatoxicity and increased sedation

Question 10

role of clonidine

Answer 10

clonidine alone or in combination with stimulants is also effective in improving both ADHD and tic symptoms in patients with both condition

Question 11

can concerta be sprinkled into food

Answer 11

no, it is an osmotic controlled released oral delivery system (OROS)

agents that can be sprinkled and given with food: adderral, biphentin and foquest

Question 12

drug holiday for ADHD

Answer 12

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

Question 13

ADHD agents with lower abuse potential

Answer 13

concerta, and vyvanse

Question 14

MOA of guanfacine Intuniv XR and atomoxetine Strattera

Answer 14

guanfacine: Alpha₂-adrenergic Agonists

atomoxetine: Norepinephrine Reuptake Inhibitors

Question 15

transient insomnia and acute insomnia and chronic insomnia

Answer 15

transient <3 days

acute: <3 months
chronic: >3 nights/ week and >/ 3 months

Question 16

first line treatment for insomnia

Answer 16

CBT

Question 17

timeframe for non-prescription and prescription trial for insomnia

Answer 17

non prescription: <14 days

prescription: 7 days then reassess in 1 week

Question 18

which 3 BZD is indicated for insomnia in canada

which agent is best for elderly patient

Answer 18

(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

Question 19

what is one rare but notable side effects of zopiclone and zolpidem?

Answer 19

complex sleep behaviours have been reported in up to 3% of patients prescribed zopiclone and zolpidem (black boxed warning)

Question 20

AE of z like drugs ( zoplicone)

Answer 20

Bitter metallic taste,

“hangover”, dry mouth

rare complex sleep disorder

wait 12 hrs before operating vehicle

Question 21

DOC for insomnia during pregnancy

Answer 21

zopiclone

avoid BZD, zolpidem,

Question 22

role of doxepin

Answer 22

indicated for sleep insomnia maintenance

dose 3-6 mg ( lower than antidepressant dose)

minimal risk of tolerance and falls risk of cognitive impairment

Question 23

is BZD for insomnia safe during breast feeding

Answer 23

low dose of short acting BZD ( lorazepam) appears safe in breastfeeding

Question 24

explain different classification of dementia

alzheimer’s disease

vascular dementia

lewy body/parkinson’s dementia

Answer 24

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

Question 25

pharmacological recommendations for dementia:

AChEi

memantine

antipsychotics

antidepressants

trazodone

BZD

Answer 25

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

Question 26

compare AChEi therapy?

donepezil, galantamine and rivastigmine

indication, tolerability, clinical tips and side effects

Answer 26

see pic

Question 27

memantine MOA, and adverse effects

and caution

Answer 27

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

Question 28

when should AchEIs be d/c?

Answer 28

did not experience clinical benefit

AE

dose should be tapered before stopping the agent

Question 29

what is the role of gingko biloba?

what safety concern should we consider

Answer 29

increased blood flow and viscosity of blood

NO significant efficacy support

caution in patient taking anti platelet/ anticoagulants and NSAID -→ increased risk of bleeding

Question 30

Efficacy of cholinesterase inhibitor and memantine is measure by

Answer 30

Decline in MMSE less than 2

average improvement of ADAS-cog score was 2-3 points. 3 point change is considered clinically relevant

Question 31

when should you see improvement in cognitive symptoms?

when should we follow up after initiating therapy or increasing the dose?

Answer 31

early improvement 4-6 weeks

improvement 3-6 months

follow up in 2 weeks

Question 32

DOC for lewy body dementia

what should we avoid?

Answer 32

rivastigmine

avoid antipsychotics, if really required may used olanzapine or quetiapine

Question 33

DOC for vascular dementia?

Answer 33

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

Question 34

which antipsychotic have the best evidence for treatment dementia

Answer 34

risperidone and olanzapine

Question 35

antipsychotic have been shown to increased the risk of what compared to clinical trails

Answer 35

risk of stroke and death

Question 36

when should we initiate antipsychotic ?

Answer 36

severe behavioural symptoms, particularly with psychosis or risk of harm to self or others

Question 37

what is the role of trazodone in dementia

Answer 37

treat disrupted sleep/wake cycles and “sundowning” (worsening of behaviour as darkness falls).

Question 38

which dementia agent should we be cautious in patient with seizure and CVD

Answer 38

memantine

Question 39

when is BZD preferred over antipsychotic in treating delirium?

Answer 39

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

Question 40

which BZD IM option is available for treating delirium

Answer 40

midazolam and lorazepam

Question 41

can olanzapine and BZD be administered concomitantly

Answer 41

no, it can lead to cardiac and respiratory complications that can result in death

Question 42

what is “5 an ”2 combination of BZD and first gen antipsychotic

Answer 42

5 mg haloperidol and 2 mg of lorazepam ( both IM or IV)

Question 43

which agent has long history and experience with agitation?

Answer 43

IM haloperidol is standard of care

Question 44

most commonly used antipsychotic agent for delirium

Answer 44

olanzapine and risperidone

Question 45

how to treat delirium in patient with dementia

Answer 45

lowest doses of antipsychotic should be used for the shortest duration possible

risperidone treats agitation and other behavioural symptoms linked to alzehimers

Question 46

which agent may contribute to insomnia?

Answer 46

anticonvulsants, central adrenergic blockers, diuretics, selective serotonin reuptake inhibitors, steroids, stimulants.