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Organization of inpatient care for Geriatric Mental Health Care
SHIV GAUTAMMD(psych), DPM, FAMS
Sr.Professor, HOD & Supdt.
Psychiatric Centre Jaipur
Addl.Principal SMS Medical College Jaipur
Aging Physiology• Individuals become more dissimilar as they
grow.
• Abrupt decline in any system is always due to disease and not to normal aging.
• Normal aging can be attenuated by modification of risk factors.
• In the absence of disease decline in homeostatic reserve causes no symptoms and imposes few restrictions in activities of daily living regardless of age.
Aging Pathology
• Multiple Pathology– Cataracts, deafness, degenerative joint
diseases, like osteoarthritis or osteoporosis, varicose veins are all conditions which are likely to develop slowly and to progress.
– Cancer, pernicious anaemia, thyrotoxicosis, myxoedema common due to deterioration of immune mechanisms.
– Obesity, diabetes, depression and dementia frequently seen
Under reporting of illness
• Callous Attitude Towards Health
• Attitude of the Relatives
Barriers to Obtaining Proper History
• Mental Confusion• Deafness• Concentration• Co-operation• Idiosyncrasis
Neuro-Psychiatric Disorders
• Cerebrovascular Diseases
• Depressive and other Psychiatric Disorders
• Cognitive Impairment and Dementia
• Neurodegenerative Disorders
• Infections of the Central Nervous System, Sleep Disorders and Coma.
Laboratory Evaluation and Other Investigations
• Routine Haematological Tests -Complete Blood cell count Platelets count
Prothrombin time Serum Electrolytes
Blood glucose level Renal Panel
Hepatic Panel
Routine Diagnostic Tests -• Lipid Profile, Blood sugar fasting, Electrocardiogram,
Chest radiograph, • Optional – EEG, CT Scan, MRI
Facilities for an inpatients Geriatric Mental Health Care
• Entrance with ramp and wheel chair
• Adequate OPD space with waiting facilities
• Consultation chambers for mental health team (Psychiatrists, Clinical Psychologist, Psychiatric Social worker)
• Nursing Station and Drug dispensing
• Inpatient wards with attendant facility
• Semi ICU• Lab investigations
facilities• Recreation room• Rehabilitation activities • Storage and
Documentation space
INTERDISCIPLINARY TEAMCONSULTATION-LIASION
• Medical internist Gynaecologist
• Ophthalmologist Orthopaedician
• Physiotherapist Dietician
• Yoga trainer
Age related changes in the Central Nervous System
Gross brain atrophy Ventricular enlargement Selective regional neuronal loss Remodeling of dendrite, axons &
synapses Appearance of intraneuronal
lipofuschin Selective regional decrease in
neurotransmitter & neuropeptides.
Contd...........
Selective modification of neurotransmitter metabolism
Possible dysregulation of gaseous neurotransmitter metabolism
Glucocorticoid neurotoxicity Changes in receptors Changes in neurotrophinsChanges in signal transduction
…contd.
Impairment of calcium homeostasis Possible changes in cell cycle regulations
(eg, cyclins) Possible changes in extra cellular matrix
proteins (eg. Laminin, proteoglycans) Possible regional decline in cerebral blood
flow Possible regional decline in metabolic rate Appearance of senile plaque &
neurofibrillary tangle
PHARMACODYNAMICS AND AGING
Neurotransmitter Pharmacodynamic changes with aging
Dopaminergic system
Dopamine D2 receptor in the striatum
Cholinergic system
Choline acetyl transferase
Cholinergic cell numbers
Contd...........
Adrenargic system
cAMP production in response to beta-agonists
Beta – adrenoceptor number
Beta – receptor affinity
Alpha 2 – adrenoceptor responsiveness
Gabaminergic system
Psychomotor performance in response to benzodiazepines
? Post – synaptic receptor response to GABA.
Contd...........
PHARMACOKINTIC CHANGES WITH AGING
Points to remember before prescribing medication in elderly
Magnitude of effect (clinical response) = Pharmacodynamics x Pharmacokinetics x biological variance
In elderly medical complication of pharmacotherapy alone constitute a highly significant treatable health problem.
Adverse reaction to drugs of all types is seven times higher in those aged 70 to 79 years, than in those 20 to 29 years old.
Non compliance with therapy is a major problem for psychiatric patients, and this dilemma is exacerbated with age.
Age related health problems combines with physiological changes to increase the probability of adverse effect from medication which in turn increase the likelihood of non compliance.
Complexities of medication regimens are further complicated by communication difficulties arising from impaired hearing, cognitive impairment, language & cultural difficulties.
Psychopharmacological Treatment of Geriatric Disorders
The psychiatrist of an 87 year old patient suffering from
heart disease, arthritis and depression must ask a number
of questions to himself.
Q. What is the best treatment - Pharmacotherapy?
Psychotherapy? E.C.T.?
Q. If pharmacotherapy, what is the most appropriate drug?
Q. Balancing the adverse effect and efficacy. What is the
best dosage?
Q. How soon will the patient’s symptom decrease?
Q. If the drug is effective. How long will the treatment last?
Q. If the drug is ineffective how long should the wait before
changing the treatment?
GERIATRIC MANIA
Risk of Mania decline in late life, nonetheless mania
and hypomania affect 5-10% of psychiatric patients.Established mood stabilizers
Lithium salts
Valproate
Carbamazepine
Calcium channel blockers
E.C.T.
Putative Mood stabilizes"
L. Thyroxine
Phosphatidyl choline
Progesterone
Clozapine, Olanzapine Magnesium salt
Newer Anticonvulsants Lamotrigine, Gabapentin Topiramate, Tigabine
Omega 3 fatty acid
Antidepressants in old age depression
• Cumulative incidence of depression in people aged upto 70 years is 26.95% for men & 42.5% for women, still most of the drug trials exclude elderly subjects.
• In addition, most of the drug trials also exclude subjects with medical comorbidity, which is a rule rather than exception. Hence the results of drug trials done in young adults can't be generalized to elderly.
…Antidepressants in old age depression contd.
• Prior to 1995, there were occasional studies which evaluated the use of antidepressants in elderly. But fortunately in the last 10 years many studies have evaluated the use of antidepressants in the elderly.
• These studies can be broadly classified as:
• Noncomparative studies• comparative studies using either placebo or
another antidepressant or both and • meta-analyses of the above studies.
Antidepressant Drugs and Dosages Preferred for Use in the Elderly
Geriatric dosage(mg per day)
Side EffectsDrugs
Startingdosage
Maintenancedosage
Sedation Agitation Anticholinergiceffects
Orthostatichypotension
Tricyclic antidepressants
Desipramine 25 50 to 150 Low Low Low Low
Nortriptyline 10 to 25 40 to 75 Moderate Low Low
Selective serotonin reuptake inhibtiors
Citalopram 20 20 to 40 Low Low - -
Fluvoxamine 50 50 to 200 Low Low - -
Paroxetine 10 20 to 30 Low Low - -
Sertraline 25 to 50 50 to 150 Low Low - -
Miscellaneous
Bupropion 100 100 to 400 - Moderate - Low
Nefazodone 100 100 to 600 Moderate -- Low Low
Trazodone 25 to 50 50 to 300 High - Low Moderate
Venlafaxine 75 75 to 350 Low Low Low Low
Cardiovascular
Renal
Diabetes
Hepatic ?
Hematological
Thyroid
Arthritis
Infectious disorders
Metabolic
Disorders Lithium CBZ VPA
Anticonvulsants in Depression with medical comorbidity
Psychotic agitation in the elderly with mania
Initial treatment Haloperidol 0.25 to 0.5 mg IM or PO After one hour, administer lorazepam 0.5mg IM or PO
Stabilization
Repeat alternating doses every hour until calm
Monitor carefully to avoid over sedation
Alternative regimen if extra pyramidal symptoms develop
Atypical antipsychitic riseperidone (0.5mg), or olanzapine (2.5 - 5 mg)
Avoid chlorpromazine and thioridazine due to their anticholinergic and hypotensive side effects.
Chronic medication
Daily dose of medication is determined by adding the total dose of each medication required to calm the patient and dividing it equally throughout the day.
Adjunctive antipsychotic medicationRisperidone
Daily divided doses of .5 to 3mg
Monitor patient carefully for orthostatic hypotension and EPS as dose is increased
Olanzapine
Daily doses of 2.5 to 10 mg /day’
Transient elevation in liver enzyme have been reported
Risepeidone plus olanzapine
Observe for increased agitation or other manic symptom because of breakthrough mania with risperidone.
Clozapine
Reserved for patients who are intolerant of risperidone and olanzapine,
Daily doses start at 12.5mg, increase to 50mg
If history of seizure disorder should be maintained on an anticonvulsant
Monitor for orthostatic hypotension and weekly complete blood count to assess for evidence of bone marrow toxicity
ATYPICAL ANTIPSYCHOTICS IN THE ELDERLY
Drug Metabolite t½ (h) CLR and T½changes in
elderly
CYP enzyme involved inmetabolism (potential
drug interactions)
Geriatricdoses mgper day
Clozapine Norclozapine, clozapineN- oxide (very limitedactivity)
4-12 CLRdecreased
CYP1A2, CYP2D6,CYP3A4 (theophylline,digoxin, warfarin)
50
Risperidone 9 hydroxy risperidone(active)
20 CLRdecreasedt½ prolonged
CYP2D6 (inhibitor drugssuch as quinidine) 2
Olanzapine 10-N-glucoranide, N-demethyl-olanzapine(inactive)
30 CLRdecreasedt½ prolonged
CYP2D6 (inhibitor drugssuch as quinidine) 10
Quetiapine Multiple (mainmetabolite is asulphoxide, usuallyinactive)
6' CLRdecreasedt½ prolonged
CYP3A4 (phenytoin,Thioridazine)
200
COMMON ANTIPSYCHOTIC DRUG INTERACTION IN THE ELDERLY
Combination Effect
TCAs and conventionalantipsychotics
Raises blood antidepressantconcentrations
SSRIs and clozapine Raises blood clozapine concentrations
Risperidone and clozapine Raises blood clozapine concentration
Smoking Lower blood antipsychotic concentration
Cimetidine Lower blood antipsychotic concentration
Anticholinergic drugs Additive memory and delirious effects
Anticonvulsant, antihypertensiveand sedative drugs
Additive sedative and delirious effects
Expert consensus guidelines
SPECIAL ISSUE IN USING ANTIPSYCHOTICS IN THE ELDERLY
Formulatory decision should be based on cost when drug of comparable efficacy are available.
It is especially important to consider safety and tolerability along with efficacy and cost.
Avoid low and mid-potency conventional antipsychotics as well as clozapine & ziprasidone in elderly patients who have corrected QTc interval prolongation.
…Expert consensus guidelinesDISEASE DRUG INTERACTION
Avoid low & mid potency conventional antipsychotics, clozapine and olanzapine in patients who have diabetes mellitus, dyslipedimia and or obesity.
Avoid ziprasidone, low and mid potency conventional antipsychotics and clozapine in patients who have a prolonged QTc interval or congestive heart failure.
Quetiapine is the first line recommendation for a patient with Parkinson’s disease , also consider low dose olanazapine or clozapine for patients with Parkinsons
Avoid high dose of risperidone in patients with Parkinson’s disease
Management of Cognitive symptoms-Dementia
• Cholinesterase inhibitors-mild to moderate dementia (Cummings et al., 2004).– Prescription only for-
• probable Alzheimer’s disease• duration of illness > 6months• MMSE > 10
– 3 phase response evaluation-• Early (2 wk)-assess tolerance & side effects• Late (3 mth)-assess cognition• Continued (6 mth)- assess disease state
…Management of Cognitive symptoms contd.
– Stop treatment if-
• Early evaluation-poor tolerance or compliance
• Deterioration continues at pretreatment rate
after 3-6 month of medication
• On maintenance doses, accelerated
deterioration
Drugs useful for reducing the signs of dementia
Drug Dose
Donepezil 5-10 mg daily
Rivastigmine 1.5-6 mg b.i.d.
Galantamine 4-12 mg b.i.d.
Memantine 5-20 mg daily
Recommended