Welcome%20to%20Seminar%20on%20Psychogeriatric%20Medications%20and%20their%20Effects%20on%20Behavior%20in%20the%20Long-Term%20Care%20(LTC)%20Meera%20Kaur,%20Ph.D,%20R.D.%20Assistant%20Professor%20and%20C[e-mail]

1
Welcome to SeminaronPsychogeriatric
Medications and their Effects on Behavior in the
Long-Term Care (LTC)Meera Kaur, Ph.D,
R.D.Assistant Professor and Clinical Dietitian
Department of Family Medicinekaur_at_cc.umanitoba.ca

1
2
Objectives of the Session
2

• To understand
• The common mental health issues in elderly
  residents of LTC facilities
• The drugs commonly used to manage mental health
  and behavioral issues
• Common side-effects
• The interactions with foods and other drugs
• The nutritional impacts and management

Meera Kaur, PhD, RD
3
Outline of the Session
3

• Introduction
• Prevalence of mental health issues in LTC
• Common psychiatric diagnosis in LTC
• Commonly used psychogeriatric medications
  Side-effects,
• Food / Drink interactions, Drug interactions
• Nutritional management
• Micronutrients and caffeine in LTC
• Adjunctive therapy
• Team approach
• Implications for the practitioner
• Case studies
• Summary

Meera Kaur, PhD, RD
4
Introduction...
4

• Elderly population in developed countries has
  rapidly increased
• In Canada, the number of seniors receiving care
  in LTC homes is rising
• 1986 203, 000
• 1996 240, 000
• 2021 18 of 6.7 million Canadian
• 2031 LTC bed will triple or quadruple
• Source Health Canada, 1999 and 2002

Meera Kaur, PhD, RD
5
Introduction
5

• Projected elderly population (1990-2050) in USA

Source US Department of Commerce, 1989
Meera Kaur, PhD, RD
6
Prevalence of Mental Health /Behavioral Issues in
LTC
6

• Eighty percent of the residents in LTC suffer
  from some kind of mental health issues or
  behavioral problems (Conn et al., 2001).
• The classic study of Rovner et al. (1990) Total
• nursing home included in the study 454
• Dementia 2/3rd (40 of demented residents had
  depression, delusion, delirium)
• Affective disorders 10
• Schizophrenia or another psychiatric illness
  2.4

Meera Kaur, PhD, RD
7
Common Psychiatric Diagnosis in LTC Settings
7

• Dementia
• Delirium
• Depression
• Disorders
• Mood
• Psychotic
• Dysthymic
• Adjustment
• Personality Change

Meera Kaur, PhD, RD
8
Factors Affecting Drug Metabolism in the Elderly
8

• Key point An elderly person is more susceptible
  to
• adverse drug reactions than younger one because
  of
• Decreased lean body mass
• Increased body fat
• Decreased serum albumin
• Changes in
• digestion/absorption, kidney and liver functions,
  drug receptor sensitivity and amount of
  neurotransmitters

Meera Kaur, PhD, RD
9
Dementia
9

• Key Points
• Most common mental disorder in LTC homes (gt50)
• Alzheimers disease is the most common cause
• Residents with dementia will demonstrate
• Cognitive impairment that affects their daily
  functioning
• Behavioral disturbances (apathy,
  agitation,depression etc.)
• Demented residents have increased susceptibility
  to side-effects from psychoactive drugs
• Management Multi-model

Meera Kaur, PhD, RD
10
Medications in Dementia
10

• Cholinesterase Inhibitors prescribed for the
  treatment of mild to moderate AD.
• Donepezil (Aricept)
• Galantamine (Reminyl)
• Memantine HCl (Exiba)
• Rivastigmine (Exelon)
• Herbal products
• Ginko Biloba
• Remember FX
• ,

Meera Kaur, PhD, RD
11
Cholinesterase Inhibitors
11

• Interaction with
• Foods/Herbal products
• St. John Wort
• Ginko Biloba
• Drugs
• Cytochrome P450 Anti-
• cholinergic cholinergic
• agent Tacrine, Luvox, TCA

• Common side-effects
• Nausea
• Vomiting
• Diarrhea
• Loss of appetite
• Weight loss

Meera Kaur, PhD, RD
12
Cholinesterase Inhibitors.
12

• Donepezil (Aricept) May be taken with or without
  foods
• Side effects anorexia, ? wt., dehydration,
  N/V, pain, GI bleeding, bloating, diarrhea,
  insomnia, fatigue, muscle cramp,? or ?BP,
  headache, dizziness, syncope, tremor, ataxia,
  depression, blurred vision, ? urination
• Galantamine (Reminyl ER) With breakfast or food
• Side effects Same as above ? dyspepsia,
  flatulence, difficulty swallowing, chest pain,
  seizures, falling, ? blood K, ?BP, UTI,
  fainting

Meera Kaur, PhD, RD
13
Cholinesterase Inhibitors
13

• Memantine HCl (Exiba) With or without foods
• Side effects anorexia, ? wt., N/V,
  constipation, flatulence, diarrhea, dehydration,
  confusion, hallucinations, sleep disorder, ?BP
• Nutritional management
• Nutrient-dense small frequent feeding with
  variety in color and taste yogurt or other
  foods with probiotics and, adequate hydration
  among others

Meera Kaur, PhD, RD
14
Herbal Products
14

• Ginko Biloba Edible portion is leaf (available
  as gummies, tablets, capsules, strips, lozenges,
  powders or liquids). The dose is also measured in
  drops, teaspoons or tablespoons.
• Side effect Spontaneous bleeding
• Food interaction St. John Wort, Garlic
• Drug/supplements interaction Antiplatelet,
  ASA, NSAID, Heloperidol, fish oil, Vitamin E
• Source Health Canada, 2008

Meera Kaur, PhD, RD
15
Herbal Products Ginko Biloba
15
Meera Kaur, PhD, RD
16
Herbal Products
16

• Remember FX Purified natural product obtained
  from roots of North American ginseng. Used for
  improving mental performance.
• Side effect Spontaneous bleeding
• Food interaction St John wort, Garlic
• Drug interaction Blood thinner Coumadin
  (warfarin), MAOIs
• Source http//www.remember-fx.com/qa.htm

Meera Kaur, PhD, RD
17
Herbal ProductsNorth American Ginseng (Panax
quinquefolius)
17
Meera Kaur, PhD, RD
18
Behavioral and Psychological Symptoms of Dementia
(BPSD)
18

• Agitation
• Restlessness
• Wandering
• Mood disturbances
• Delusions
• Hallucinations
• Rage and violence

• Catastrophic reaction
• Phobias/fears
• Shouting/screaming
• Sleep disturbances
• Sundowning
• Apathy
• Sexual disturbances

Meera Kaur, PhD, RD
19
Medications in BPSD...
19

• Commonly used medications in BPDS are
  Antipsychotics.
• Typical Antipsychotics (TA)
• Atypical Antipsychotics (ATA)
• ,

Meera Kaur, PhD, RD
20
Typical Antipsychotics ...
20

• Typical Antipsychotics (TA) Prescribed for
• Psychotic syndrome (delusions, hallucinations
  etc.) that occurs in depression, mania,
  schizophrenia, paranoid disorders, delirium and
  dementia
• Agitation and aggression due to dementing illness
• Examples
• Haloperidol (haldol)
• Loxapine (Loxapac)
• Zuclopenthixol (Clopixol)
• ,

Meera Kaur, PhD, RD
21
Typical Antipsychotics ...
21

• Common side-effects
• Anticholinergic effects dry mouth, constipation,
  blurred vision, tachycardia, urinary retention,
  sweating, delirium, disorientation, confusion,
  cognitive disorder
• Extrapyramidal symptoms (EPS) dystonias,
  parkinsonism, akathesia, tradive dyskinesia,
  sedation, ?appetite, ? wt., ?BP, ratinopathy,
  skin rash, pigmentation, jaundice, neuroleptic
  malignant syndrome (? temperature, muscular
  rigidity, ?CPK, altered consciousness)

Meera Kaur, PhD, RD
22
Typical Antipsychotics
22

• Interactions with
• Foods, Herbal Products, Drinks coffee, tea,
  herbs, nutraceuticals
• Drugs Cytochrome P450, alcohol
• opioids, methyldopa
• levodopa, TCA

Meera Kaur, PhD, RD
23
Atypical Antipsychotics
23

• Atypical Antipsychotics (ATA) Prescribed as
  alternatives for typical antipsychotics, because
  they have lower rates of EPS than TA. In older
  residents with deliriumParkinsons disease, ATA
  are preferred over TA
• Example
• Risperidine (Risperdal)
• Olanzopine (Zyprexa)
• Quetiapine (seroquel)
• Clozapine (Clozaril)

Meera Kaur, PhD, RD
24
Atypical Antipsychotics ...
24

• Common side-effects
• Tradive Dyskinesia
• Akathisia
• Hyperglycemia
• Obesity
• ? wt., ? appetite, ? TG, ? liver enzymes, ?
  thirst
• ? wt., ? appetite, anorexia,

Meera Kaur, PhD, RD
25
Atypical Antipsychotics
25

• Interactions with
• Foods, Herbal Products, Drinks coffee, tea,
  herbs, nutraceuticals, grapefruit juice
• Drugs Cytochrome P450, SSRI,
• fluvoxamine, barbiturates,
• phenytoin, antifungal, arythromycin
• Smoking is an induction to CP450 system,
• which induces drug metabolism decreases
• the drug efficacy

Meera Kaur, PhD, RD
26
Depression
26

• Key Points
• Common mental health problem in LTC (15)
• The causative agents in depression are
  biological, psychological and social (Final
  Common Pathway)
• Residents with dementia may exhibit
• Depressed mood, loss of interest/pleasure,
  suicidal ideation
• Changes in weight or appetite, insomnia,
  hypersomnia
• Treatment Medication, Psychotherapy, Social
  modalities, Electroconvulsive therapy (ECT)

Meera Kaur, PhD, RD
27
Medications in Depression
27

• Selective Serotonin Reuptake Inhibitors (SSRI)
  Prescribed for mild to moderately severe
  depression. Used if TCA is contraindicated or not
  tolerated
• Trycyclic Antidepressants (TCA) Prescribed for
  severe depression with melancholic features.
• Other Antidepressants

Meera Kaur, PhD, RD
28
SSRI...
28

• Commonly used SSRIs
• Citalopram (Celexa)
• Fluoxetine (Prozac)
• Escitalopam (Cipralex)
• Fluvoxamine (Luvox)
• Common Side effects
• Taste change, Anorexia,
• ? or ? wt., N/V,
• Diarrhea, Constipation,
• Dry mouth, sexual Dysfunction

Meera Kaur, PhD, RD
29
SSRI
29

• Interactions
• Foods, Herbal Products, Drinks
• - St John Wort
• - Tryptophan supplement
• Drugs
• - Non selective MAO Inhibitors ( phenelzine)
  - carbamazepine
• - phenytoin
• - nafcillin

Meera Kaur, PhD, RD
30
TCA...
30

• Commonly used TCAs
• Desipramine (Norpramin)
• Nortriptyne (Aventyl)
• These two TCAs are the most
• appropriate for older residents.
• Common Side effects
• Sedation
• Orthostatic ? BP
• Anticholinergic effects

Meera Kaur, PhD, RD
31
TCA
31

• Interactions
• Foods, Herbal Products, Drinks
• - St John Wort
• - Tryptophan supplement
• - High fibre diet
• Drugs
• - Medication specific

Meera Kaur, PhD, RD
32
Other Antidepressants...
32

• Commonly used other antidepressants
• Bupropion (Wellbutrin)
• Venlafaxine
• Duloxetine
• Nefazodone
• Monoamine Oxidase Inhibitor (MAO1)
• Common Side effects
• Sedation
• Orthostatic ? BP
• Anticholinergic effects

Meera Kaur, PhD, RD
33
Other Antidepressants
33

• Interactions
• Foods, Herbal Products, Drinks
• - St John Wort
• - Tryptophan supplement
• Drugs
• - Medication specific

Meera Kaur, PhD, RD
34
Monoamine Oxidase Inhibitors
34

• Interactions
• Foods, Herbal Products, Drinks Aged or matured
  cheese( e.g.,Cheddar, Blue, Swiss) Aged or
  fermented meats and fish (e.g., pepperoni, corned
  beef, pickled herring, etc.)Meat, Brewers yeast
  and yeast extracts, (e.g., Bovril,Marmite, Oxo
  etc.) Broad bean pods
• Drugs SSRI, Cold Medications

Meera Kaur, PhD, RD
35
Sedatives...
35

• Commonly used sedatives
• Benzodiazepines (Clonazepam, Lorazepam)
• Common Side effects
• Amnesia, Drowsiness
• Interactions
• Foods, Herbal Products, Drinks
• St John Wort, Alcohol, Kava
• Drugs
• Other Sedatives

Meera Kaur, PhD, RD
36
Herbal Sedatives
36

• Commonly used herbal sedatives
• Ashwagandha
• Valerian
• Marijuana
• Common Side effects Drowsiness, CNS depression
• Interactions
• Foods, Herbal Products, Drinks
• Alcohol, Chillies
• Drugs
• Other Sedatives, ?-Blocker, Phenytoin

Meera Kaur, PhD, RD
37
Other Mood Disorders
37

• Bipolar Disorders best managed by
• Psychotherapy and family-focused treatment (FFT)
• Pharmacotherapy is less effective without FFT
• Mania Commonly used drugs are
• Lithium carbonate
• Side-effect tremor (resting, intentional)
  myoclonus, dehydration, salt depletion
• Food interaction caffeine
• Drug interaction NSAID, thiazide and K sparing
  diuretics.

Meera Kaur, PhD, RD
38
Other Mood Disorders (Mania)
38

• Carbamazepine (antiepileptic) Little data on
  use in late life
• Antipsychotics We have already discussed. Slide
  20, 21,22, 23, 24 and 25
• Valporic acid
• Side-effect sedation rashes dehydration, salt
  depletion ?platelet counts, liver toxicity
• Food interaction caffeine
• Drug interaction alcohol, ASA, warfarin

Meera Kaur, PhD, RD
39
39

• Mental health status of residents in LTC homes
  plays a great role in food acceptance or
  tolerance, and thus poises challenges to the LTC
  dietitians
• Psychogeriatric drugs further add to the
  challenges

Meera Kaur, PhD, RD
40
Nutritional Management...
40

• Key points Thorough understanding of the-
• current health status of the resident (physical,
  mental, social)
• current medication and their side effects
• drug-drug and drug-nutrient interaction
• age-related changes in
• sensory attributes
• GI system/ functions
• endocrine system
• changes in over all metabolism

Meera Kaur, PhD, RD
41
Nutritional Management
41

• Principles
• Achievements/management of satisfactory body
  weight and over all health through
• adequate intake of nutrients both in quantity and
  quality
• possible physical activities/exercise
• Dietary management (whenever possible) of
  drug-related complications (constipation,
  dehydration, liver functions, kidney functions,
  BP, blood lipid profile etc.)

Meera Kaur, PhD, RD
42
Nutrition Checklist (general)...
42

• Has there been a loss of more that 10 usual
  weight in the past 6 months?
• Is the diet being limited in some way that may
  result in missing nutrients and energy?
• Is fibre being completely avoided?
• Are milk or milk products being avoided?

Meera Kaur, PhD, RD
43
Nutrition Checklist (general)
43

• Are caffeine, alcohol, sugar or fat being
  substituted for other foods?
• Is the resident on texture modified diet?
• Is a non-prescribed diet being followed?
• Are meals or snacks being skipped, or is food
  consumption less than usual?

Meera Kaur, PhD, RD
44
Role of Specific Nutrients
44

• Folate and Vitamin B12 Deficiency of folate and
  vitamin B12 overt or latent is mainly a
  problem for the elderly and a challenge to health
  care professionals.
• Combination of oral cobalamin (1 mg/day) and
  folate (5 mg/day) for 2 months improved the
  clinical state of mildly/moderately demented
  residents with elevated homocysteine level
  (Nilsson et al., 2001).

Meera Kaur, PhD, RD
45
Caffeine in Long-Term Care
45

• Literature related to role of caffeine in the
  elderly population is limited. However,
  researches have shown that
• People who consume caffeine regularly, build
  tolerance to its diuretic effects
• Caffeine may interact with the medication used to
  treat
• Schizophrenia, anxiety and panic disorder
  (Benzodiazepines), bipolar disorder, mania
  (Lithium), insomnia and sundowning (TCA,
  haloperidol, benzodiazepines).

Meera Kaur, PhD, RD
46
Adjunctive Therapies...
46

• The overall vision of Adjunctive Therapies is a
  well-rounded and diverse program of treatment, as
  different people tend to respond to different
  treatment modalities. These are
• Art Therapy, Dance Movement Therapy, Psychodrama,
  Poetry Therapy, Recreational Therapy, Pet
  Therapy, and Psychosocial Education.

Meera Kaur, PhD, RD
47
Adjunctive Therapies
47
Meera Kaur, PhD, RD
48
Team Approach
48
Meera Kaur, PhD, RD
49
Implications for the Practitioners
49

• Dietary intervention for the restoration of
  general health and nutritional status
• Dietary management of drug-related complications
• Food rich in natural stimulants and protectants
  may be considered for the management of GI
  functions and over all health
• Whenever possible and applicable, LAB containing
  yogurt may be included in the diet of residents
  to improve liver function and promote gut health
• Team approach and adjunctive therapy help provide
  optimal nutrition support

Meera Kaur, PhD, RD
50
Ms. B
50

• An 84-year old women with advanced dementia was
  bedridden and severely apathetic. She neither fed
  herself, nor responded to staff attempting to
  feed her. After IV rehydration, family was asked
  to consent for tube feeding (TF). Family was
  concerned about TF. A trial of psychostimulent
  (methylphenidate) was successful in treating the
  apathy enough so that she was able to be fed, and
  she ultimately lived for another two years
  without requiring TF.
• Implications Treating the underlying causes such
  as apathy, depression etc. is crucial.
  Stimulation and rewarding activities are helpful
  for dietary intervention.

Meera Kaur, PhD, RD
51
My Mom
51

• 70 year old widow, vegetarian. Since last 8
  months she is suffering from episodes of copious
  diarrhea followed by constipation. She has
  developed resistance to many medications. She is
  diabetic (NIDDM) with?BP and on medications. Poor
  GI functions. Can not tolerate most of the foods,
  especially vegetables and fruits (cooked or raw).
  Oral Intake is always poor. My brother phoned me
  describing her chronic illness and asked for
  dietary advise. What I did? I Discussed with her
  doctor. We put her on a synbiotic capsule
  (one/day) for 40 days. Then I suggested to add
  plain yogurt (1-2 tsp) in most of the foods that
  she can eat (rice, barley, lentil, milk, stew,
  soup etc). Did it work?

Meera Kaur, PhD, RD
52
Summary
52

• The prevalence of mental health issues in LTC
  facilities is at least 80. Psychogeriatric
  medication (P M) is essential while caring for
  LTC residents with mental health issues, but
  clearly it is a double-edged sword.
• Elderly people are at high risk of having
  side-effects of drugs, and their interactions
  with foods, drinks, other drugs, which affect
  their behavior.
• P M adds challenges to the dietitians while
  striving to provide optimal nutrition support to
  residents at LTC settings.
• Understanding the common psychogeriatric drugs,
  their action and interaction should help
  dietitian plan and implement optimal nutrition
  support for LTC residents.
• Team approach and adjunctive therapy are
  important to implement nutrition care plan
  successfully in LTC residents, specially those
  residents who are on P M.

Meera Kaur, PhD, RD
53
Selected References
53

• Canadian Coalition for Seniors Mental Health
  (www.ccsmh). National guidelines for seniorss
  mental health. 2006
• Conn, D., Herrmann, N.,Kaye, K., Schogt, DRB
  (Eds). Practical Psychiatry in the Long-Term Care
  Facility. Hogrefe and Huber Publishers. 2001
• Conn Et al., National guidelines for seniorss
  mental health. Ca. J Geri. 9, supp (2)S36-S71,
  2006
• Mallet, L., Spinewine, Huang A. The challenge of
  managing drug interactions in elderly. The
  Lancet, 370185-91, 2007.
• Maughan, RJ., Griffin, J. Caffeine ingestion and
  fluid balance a review. J Human Nutr. Diet.
  16411-420, 2003
• Pronsky, ZM, Food Medication Interactions.
  Birchrunville, PA, 2004
• Simmons, DH. Caffeine and its effects on persons
  with mental disorders. Arch. Psy. Nur, X (2),
  1996
• Watson, E. Depression and other Mood Disorders
  (seminar). Seven Oak General Hospital. May 15,
  2008

Meera Kaur, PhD, RD
54
Acknowledgement
54

• I gratefully appreciate
• The Dietitians of Canada, 2008 Conference
  Committee for giving me the opportunity to
  speak in this session
• The Gerontology Network for hosting the session
  and Healthcare Food Services for sponsoring the
  session.
• Dr. E. Watson, MB., BCh., FRCPC., Dr. M. Shane,
  FRCPC.,Ms. M. Lam, RD., Ms. L. Bohn, MSc., RD.,
  Seven Oaks General Hospital Ms. J. Helps, RD.,
  Deer Lodge Centre Ms. C. Eisenbraun, RD., Ms.
  J. Crawford RD., Ms. V. Bright, RD., Dietitians
  of Canada Ms. W. Smith-Windsor, RD., Ms. C.
  Tuan, RD., Selkirk Mental Health Centre for their
  valuable information while preparing the speech

Meera Kaur, PhD, RD
55
55

Society, Friendship and Love... Divinely
bestowed upon men! Oh! had I the wings of a
dove How soon would I taste you again
Meera Kaur, PhD, RD
56
Thank you for gracing the session!Any
question?
56
Meera Kaur, PhD, RD