Pharm 549

Vascular changes in elderly associated with depression

"Vascualar depression" "White matter hyperintensities"

What are the highlighted drugs for on the delerium list

Anticholinergics Benzodiazepines Muscle relaxants opioids corticosteroids metoclopramide

A =

Appetite Wt gain or loss

S =

Suicidility

Which drugs cause the most ADE in elderly adults

Warfarin Insulin THese are the two ones that have a lot ore then anyone else Others are -Oral antiplatelet agents -Oral hypoglycemic agents -opoid analgesics -Digoxin -HEDIS -Beers criteria

SIGECAPS

-Sadness -Interest loss of pleasure or activities -Guilt or worthlessness -Energy -Concentration, or lack of -Appetite gain or loss -Psychomoter retarditaiton or agitation -Suicidility

Late life depression and medical comorbidities

-Higher rates of depression dx in... -History of MI, History of CHD, those undergoing cardiac catheterization, etc............ -Cancer dx = 4x increase in MDD dx within 2y -Poorer physical health outcomes in those with depression -Increased mortality in those with BrCa + MDD -Higher costs of care for those with dual diagnoses -92% higher total health care costs for CHF + MDD v. CHF alone

Bereavement controversy

-Included as a condition in DSM IV -Referred to as "bereavement exclusion" -MDD dx not given unless symptoms of grief persist for 2 months+

nutritional issues could also lead to diabetes

-Iron deficient anemia -Vitamin B12 deficiency

What are the inflammatory changes induce "Sickness behavior"

-Pro-inflammatory cytokines (TNF-alpha, IL-1 IL-6) -Mimic depressive or neurovegetative symptoms -↓ tryptophan and serotonin availability -↓mesocortical and mesolimbic dopamine systems -Stimulate HPA axis, and activate CRH

incidence of drug induced depression with methyldopa

3.6%

Which are the two that for a diagnosis you need to have a lest one of

1. Sadness 2. Loss of interest or pleasure the 5 other ones are minor symptoms, but you need to have for the diagnosis at least a positive for #1 or #2

Clondine incidence of inducing depression

1.5%

Life time prevalence of major depression in 60+

10.6 %

What if they are in an instituation

15-25%

what % of americans over the age of 50 have a mental health disorder

20%

what is the incidence of levitracetam induced depression

3-5%

Topiramate incidence of drug induced depression

3-9%

E =

Energy, loss of

reserpine incidence of drug induced depression in the elderluy

7%

hypoactive hypoalert ability ot follow commands

Able to follow simple commands; passively cooperates with requests

What are the high risk drugs for delirium

Benzo's Diphenhydraimine Dopamine agoinists Meperidine Muscle relaxants Neuroleptics Scopolamine

medication induced depression

Clonidine Methyldopa Reserpine Topirmate Vigabatin Levetiracetam Phenobarbital Phenytoin

C =

Concentration or lack there of

Delerium mnemonic is

D= drugs E=eyes or ears L= Low oxygen states I= infection R=retention I= ictal U = uncontrol pain M= metabolic (s) = subdural

Wht happenned in DSM 5

DSM 5 removed Bereavement Exclusion Providers encouraged to carefully consider presence of MDD in addition to Bereavement Increased diagnosis of MDD??

reserpine mechanism of action for elderly deression

Depletes neuronal NE, DA, 5HT

What could be a issue with endocrine system causing depression

Diabetes and hypothyroidism each can have symptoms that can resemble depression

abd how is your thinking ability

Difficulty focusing attention; disorganized; inappropriately silent; no clear speech

Hypoative-hypoalert level of alert

Drowsy, lethargic; may fall asleep between questions; is stuporous

D =

Drugs

E =

Eyes ears or emotions

Who should you share your advanced directives with

Medical decision maker • Alternate health care proxy • Physician - document in medical record • Hospital - document in medical record • Key family members and friends • Attorney (if applicable)

G =

Guilt or worthlessness

What are the neurological changes in the elderly

Hippocampal volume decreases Frontostriatal dysfunction

I=

Ictal (i.e; post ictal states)

Levetiracetam mechanism for inducing depression

Increased GABA, and also increases suicidility

topiriamte MOA for depression

Increased GABA, attenuates glutamate

I =

Infection

Ziprasidone

Initial 5-10mg max of 40 Oral or IM It is more sedating han haloperidolk risk of cardiac arrhytmia heart failure and agranulocytosis Due to the above mentioned risk pretty much only used in the ICU as a last line option

I =

Interest/ pleasure or loss of

What is one way to think about geriatric syndrome

It is multiple etiological factors interacting with multiple pathogenetic pathway leading to a unifeid minifestation

With neurology is it depression or a medical cormibidity

Like the difficulity o distinguishing dementia, TBI, Seizures, CVA, parkinson from depression

L =

Low oxygen state (ami, stroke, PE)

M=

Metabolic

Does depression in elderly look like depression in the general population

No there is a decreased responsivness

Methyldopa mechanism in depression

Partial agonism of the NE receptor

P=

Psychomotor retardation or agitation

Clonidine mechansim

Reduces NE output cii Alpha 2 receptor

R =

Retention ( of urine or stool)

What is the neumonic or depressionn

SIGECAPS

S =

Sadness

Geriatric syndrome

The term "geriatric syndrome" is used to capture those clinical conditions in older persons that do not fit into discrete disease categories. Many of the most common conditions cared for by geriatricians, including delirium, falls, frailty, dizziness, syncope and urinary incontinence, are classified as geriatric syndromes. Nevertheless, the concept of the geriatric syndrome remains poorly defined.

Whata re the rates of dpression in community dwelling seniors

about 5%

motor activity in hypoactive-hypoalert

decreased amount of activity perform more slowly

on tests how to distinguish between deelirium and dementia

delirium course is fluctuating, its onset is acute or sub acture, and it occurs in the provess of a medical illness or a netabolic derangement. Whereras demetia is a slow and steady decline, with a chronic onset

Vigabatrin moa for inudcing depression

increased GABA

Pharm treatment for delirium Haloperidol

initial 0.25-0.5mg with a max of 3mg Oral, IM, IV risk of EPS increase is faily dose exceeds 3 mg This is the longest used one with the most large trials

Agitated delirium Risperidone

initial 0.25-0.5mg with a max of 3mg Oral, or IM Cones with slightly less risk of EPS then with haloperidaol aat low doses Only small studies but considered similiar to haloperidol

Quitapine

initial 12.5-25mg with a max of 50mg Oral Much more sedating then haloperidol, with risk of hypotension

Olanzapine

initial 2.5-5 mg with a max of 20mg Oral, Sublingual, or IM OLanzapine in more sedating the haloperidal only small trials and oral reute is less effective then haloperidol

Lorazapam in treatment of agitiated delirium

intital 0.25-.5 mg with a max of 2mg Oral, IM, IV More paradoxical excitation and respiratory depression than with haloperidol this is a second line agenst, it is used with your brother due to alcholo withdrawl or if patient has history of the neurolepti malignt syndrome

(S)

subdural

How ever the 50+ age group has a lower rate of depression then the younger folds

thats not even a question

U =

uncontrolled pain

You mean to tell me thata with all of the work that we did on the beers criteria its that low on the ADE list for elderly

yup

What is delerium

• A clinical syndrome characterized by a disturbance in level of awareness and reduced ability to direct, focus, sustain, and shift attention • A change in cognition (deficit in orientation, executive ability, language, visuoperception, learning, and memory) • The disturbance develops over a short period of time and tends to fluctuate in severity during the course of the day • Attributable to general medical condition • An independent risk factor for prolonged hospitalization and mortality in critically ill patients • "Brain failure"

What does an advanced directive do

• A legal document • Outlines type(s) and/or quantity of care desired • Used onlyif patient is incapacitated • Allows person to express values and desires related to end-of-life care • Person may change his or her mind at any time

predisposing factors for delirium

• Age • Male sex • Cognitive status • Functional status • Sensory impairment • Decreased oral intake • Medications • Multiple psychoactive agents • Polypharmacy • Alcohol abuse

common problems with assessing patients in the emergency department

• Atypical presentation • Altered laboratory values • Comorbities • Polypharmacy • Communication • Aphasia • Deafness or hearing impairment • Altered mental status • Delirium • Dementia

What is the average course and prognosis of delerium

• Average duration 3-20 days; can be longer • Hours to months to resolve • Full recovery lags behind normalization of laboratory and test results • Some patients may never fully recover • Associated with higher mortality

Who should you choose for a medical decision maker

• Family member • Friend • Lawyer • Someone from the person's faith community (e.g., pastor, rabbi)

In a hosptial with the elderly you want to prevent the following

• Functional decline • Falls • Delirium • Tethers • (Nosocomial) Infection • Malnutrition • Pressure ulcers • Venous thromboembolism • Adverse drug reactions

What are the leading cuases of delirium in hospital

• Hip fracture 28-61% • Surgery 15-53% • Medical pts 3-29%

how prevalent is delirium at certain medical places

• ICU 20-80% • Hospice 29% • Community (85+) 14% • At hospital admission 10-31% • LTC facility 1-60%

Problems that hte elderly can have in an emergancy department

• Lack of privacy • Lying on stretchers • Hard, slippery floors • Lack of windows • Harsh lighting • NOISE

When do you have a polst

• Life expectancy less than a year. • If one wishes for Do Not Attempt Resuscitation (allow natural death). • Anyone wishing to limit medical intervention. Anyone entering hospice care.

examples of advance care planning documents

• Living will • Durable power of attorney for health care • Do not resuscitate (DNR) order • Organ and tissue donation

other names for delirium

• Mental Status Change • Acute confusional state • Neurologic impairment • ICU psychosis • Septic encephalopathy • Acute brain failure • Toxic metabolic state • CNS toxicity • Cerebral insufficiency • Organic brain syndrome

Precations with antipsychotic medications

• QT prolongation • Polymorphic ventricular tachycardia • Extrapyramidal symptoms/acute dystonia • Neuroleptic malignant syndrome • Hypotension, if hypovolemia is present • Anticholinergic effects • May lower seizure threshold • Black box warning for dementia patients

POLST is a

• Serves as current physician orders for end-of-life care for the seriously ill. • Easily recognizable portableform that travels with the patient, including: home, assisted-living facilities, and hospitals. • Is NOT an Advanced Directive. It helps complement an Advanced Directive but is a separate document. • POLST is a signed order written in agreement between boththe patient and either a Physician, PhysicianAssistant, or Advanced Registered Nurse Practitioner

Coexisting medical conditions

• Severe illness • Multiple comorbidities • Chronic renal or hepatic disease • History of stroke • Neurologic disease • Metabolic derangements • Fracture or trauma • Terminal illness • Infection with HIV

What are some structural solutions for this

• Soundproof curtains • Hearing assistance • Removal of noise distractors • Reclining chairs or padded stretchers • Clocks, calendars, names of staff posted • Non-skid floor surfaces, hand rails • Bedside commodes • Visual aids • Sky or ceiling lights

How o treat delirium

• Treat or reverse underlying medical cause(s) • Thorough review of medications • Non-pharmacologic approaches • Pharmacologic agents • Haloperidol • Atypical antipsychotics • Benzodiazepines (?)

Geriatric syndromes

•Swallowing problems •Malnutrition •Bladder problems •Sleep difficulties Delirium •Dementia •Vision impairment •Hearing impairment •Dizziness •Fainting •Gait problems •Falls •Osteoporosis •Pressure ulcers