Title: 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%20Clinical%20Dietitian%20Department%20of%20Family%20Medicine%20kaur@cc.umanitoba.ca
1Welcome 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
2Objectives 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
3Outline 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
4Introduction...
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
5Introduction
5
- Projected elderly population (1990-2050) in USA
-
Source US Department of Commerce, 1989
Meera Kaur, PhD, RD
6Prevalence 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
7Common Psychiatric Diagnosis in LTC Settings
7
- Dementia
- Delirium
- Depression
- Disorders
- Mood
- Psychotic
- Dysthymic
- Adjustment
- Personality Change
Meera Kaur, PhD, RD
8Factors 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
9Dementia
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
11Cholinesterase 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
12Cholinesterase 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
13Cholinesterase 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
14Herbal 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
15Herbal Products Ginko Biloba
15
Meera Kaur, PhD, RD
16Herbal 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
17Herbal ProductsNorth American Ginseng (Panax
quinquefolius)
17
Meera Kaur, PhD, RD
18Behavioral 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
21Typical 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
22Typical Antipsychotics
22
- Interactions with
- Foods, Herbal Products, Drinks coffee, tea,
herbs, nutraceuticals - Drugs Cytochrome P450, alcohol
- opioids, methyldopa
- levodopa, TCA
Meera Kaur, PhD, RD
23Atypical 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
24Atypical Antipsychotics ...
24
- Common side-effects
- Tradive Dyskinesia
- Akathisia
- Hyperglycemia
- Obesity
- ? wt., ? appetite, ? TG, ? liver enzymes, ?
thirst - ? wt., ? appetite, anorexia,
-
Meera Kaur, PhD, RD
25Atypical 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
26Depression
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
29SSRI
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
31TCA
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
33Other Antidepressants
33
- Interactions
- Foods, Herbal Products, Drinks
- - St John Wort
- - Tryptophan supplement
- Drugs
- - Medication specific
Meera Kaur, PhD, RD
34Monoamine 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
35Sedatives...
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
36Herbal 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
37Other 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
38Other 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
3939
- 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
40Nutritional 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
41Nutritional 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
42Nutrition 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
43Nutrition 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
44Role 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
45Caffeine 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
46Adjunctive 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
47Adjunctive Therapies
47
Meera Kaur, PhD, RD
48Team Approach
48
Meera Kaur, PhD, RD
49Implications 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
50Ms. 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
51My 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
52Summary
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
53Selected 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
54Acknowledgement
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
5555
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
56Thank you for gracing the session!Any
question?
56
Meera Kaur, PhD, RD