Hillside Centre (Acute Tertiary Mental Health Hospital IHA) Carol - - PowerPoint PPT Presentation

Antipsychotics Detect, Select, Effect (P.I.E.C.E.S. 6th Ed)

CLeAR Webinar

February 14, 2014

Paula Diaz (Pharm) Carol Ward MD

Carol Ward Tertiary Mental Health IHA

Hillside Centre

(Acute Tertiary Mental Health Hospital IHA)

Carol Ward Tertiary Mental Health IHA

Call for Less Antipsychotics in Residential Care (CLeAR)

BC Patient Safety & Quality Council

Aim :

Achieve a reduction of 50% in the inappropriate use of antipsychotics in participating facilities across the province through evidence-based management of BPSD for seniors living in residential care by Dec. 31, 2014

Carol Ward Tertiary Mental Health IHA

Objectives

 Develop an understanding of the use of antipsychotics in the treatment of specific mental health disorders ( Detect)  Recognize the different classes of antipsychotics (typical and atypical) ( Select)  Review side-effects and related monitoring ( Effect)

Carol Ward Tertiary Mental Health IHA

Quick Facts: Mental Illness & Addiction in Canada

(3rd Ed)

Mental illness is a serious disturbance in thoughts, feelings and perceptions that is severe enough to affect day to day functioning.  Chances of having a mental illness in your lifetime 1 in 5

Carol Ward Tertiary Mental Health IHA

Quick Facts: Mental Illness & Addiction in Canada

(3rd Ed)

 At any given time percentage of Canadians who have mental illness: 10.4%  Lifetime

 Major Depression 8%  Bipolar disorder 1%  Schizophrenia 1%  Anxiety disorder 12%

Carol Ward Tertiary Mental Health IHA

Psychiatric Disorders in Late Life

‘Mental illness does not discriminate; no

• ne across the age span is immune to

its effects’

(Mental Health Commission of Canada- Seniors Guidelines)

www.mentalhealthcommission.ca/ seniorsguidelines

Dignity Support Address Stigma

Carol Ward Tertiary Mental Health IHA

Psychiatric Disorders in Late-Life (MHCC)

 Grow old with recurrent, persistent or chronic mental illness  Develop late-onset mental illness  Behavioural and Psychological Symptoms of Dementia (BPSD) associated with Major and Minor Neurocognitive Disorders (MCI/ Dementia)  Chronic medical conditions with known neuropsychiatric symptoms (ie. Parkinson’s Disease, stroke, COPD)

Carol Ward Tertiary Mental Health IHA

Prevalence of psychiatric disorders am ong

• lder adults in LTC- a system atic review

 Dementia 58% (12-91% )  BPSD in Dementia 78% (38-92% )  Major Depressive Disorder 10% (5-25% )  Clinically significant depressive symptoms 29% (14-82% )  Other (Anxiety (3-10% ),Schizophrenia (~ 6% ),Bipolar Disorder (~ 3% ) less well studied)

(Seitz D. et al, 2010)

Carol Ward Tertiary Mental Health IHA

Mental Health I ssues in the Nursing Hom e

(Conn D. The Canadian Review of Alzheimer’s Disease 2007; 9(1): 12-17.)

 80% -90% of NH residents suffer from a mental disorder  > 66% suffer from dementia  15% -25% have symptoms of major depression  77% have some degree of aggression or agitation  56% have delusions  33% have hallucinations

Carol Ward Tertiary Mental Health IHA

Definition of Psychotropic Medication

 Psycho = the mind (Greek)  Trop = a turning capable of turning the mind Any medication capable of affecting the mind, emotions and behaviour.

(aka: psychodynamic, psychoactive, psychotherapeutic)

Carol Ward Tertiary Mental Health IHA

Five Classes of Psychotropics

• 1. Antidepressants
• 2. Antipsychotics
• 3. Anxiolytics
• 4. Mood Stabilizers
• 5. Cognitive Enhancers

Carol Ward Tertiary Mental Health IHA

Antipsychotics

 discovery of Chlorpromazine in 1952 – surgical anesthetic (‘calming effect’)  discovered psychoactive effects – ’great reduction in restraint, seclusion and sedation of agitated patients’  lead to research in other psychotropics  Clozapine – first atypical

Carol Ward Tertiary Mental Health IHA

Antipsychotics

 classified based on chemical class and neuroreceptor affinity profiles

 antipsychotic activity  absence of deep coma or anesthesia in large doses  absence of physical or psychic dependence

 term ‘tranquilizer and neuroleptic’ are

• utmoded

Carol Ward Tertiary Mental Health IHA

Select (P.I.E.C.E.S.)

What class of antipsychotic is it?

Atypical

Risperidone Olanzapine Quetiapine Clozapine Paliperidone Aripiprazole Ziprasidone Asenapine Lurasidone

Traditional

Haloperidol Loxapine Chlorpromazine Perphenazine

Carol Ward Tertiary Mental Health IHA

DETECT

When should antipsychotics be considered?

Carol Ward Tertiary Mental Health IHA

Detect Antipsychotics may be used for:

 Specific treatment of a mental health disorder (DSM V). For example:

 Schizophrenia and related Psychotic Disorders  Bipolar Disorder  Major Depression – psychotic and/ or refractory

Carol Ward Tertiary Mental Health IHA

Detect con’t Antipsychotics may be used for:

 Supportive treatment. For example:

 Delirium

Carol Ward Tertiary Mental Health IHA

Detect con’t Antipsychotics may be used for:

 Treatment of a specific Behavioural and Psychological Symptoms of Dementia (BPSD): For example

 Delusions  Hallucinations  Physical/ verbal aggression  Manic-like  Sexually inappropriate behaviour

Carol Ward Tertiary Mental Health IHA

Reference

Best Practice Guide for Accommodating and Managing Behavioural and Psychological Symptoms of Dementia in Residential Care

A Client Centered Interdisciplinary Approach

B.C. Ministry of Health 2012

Carol Ward Tertiary Mental Health IHA

w w w .bcbpsd.ca

Algorithm Coming soon!

Carol Ward Tertiary Mental Health IHA

Part I: Interdisciplinary Decisional and Practice Support for BPSD:

• Assessment (green)
• Problem Solving (yellow)
• Care Planning (blue)

The Algorithm is m eant to be used from the top dow n:

Antifeau & Drance

Part 2 : Reassessm ent w ith GP or NP for BPSD

 Re-assessment with medical lens  Pharmacological considerations: behaviour that is dangerous, distressing, disturbing, and dam aging/ & not responding  Distinguish behaviours that are/ are not likely to respond to medications

Antifeau & Drance

Part 2 : Reassessm ent w ith GP or NP for BPSD

 Behaviours that may respond to medications  Second-line intervention support  Evidence-informed behavioural categories: sleep disturbance, anxiety, psychosis, aggression, depression and sexually inappropriate behaviour.

Antifeau & Drance

What are the challenges when prescribing antipsychotics to seniors?

 Which medication works for which behaviour?  Right dose?  Side effects?  Tapering off medication  Changing medication  How long before we see desired effect?  Drug interactions  MDs not familiar with psychotropics  Colleagues wanting a quick fix  “Haldol Wobble”  Colleagues with differing opinions about meds  Not giving enough time for desired effect  Difficult to monitor

P . Diaz (Pharm)

Remember!

Team and Comprehensive Approach  Informed and involved: Person and family at the centre.  Informed interdisciplinary and intersectoral providers working together and sharing information. “Prevent the preventable; support the supportable, treat the treatable.” (Duncan Robertson)

P . Diaz (Pharm)

Antipsychotics

P . Diaz (Pharm)

Psychotropic Framework

(P.I.E.C.E.S. 6th Ed)

• 1. Detect: When should a psychotropic be

used or considered?

• 2. Select: How do I contribute to the

selection of the right medication?

• 3. Effect: How do I monitor the response

and side effects?

P . Diaz (Pharm)

Antipsychotics

Detect: When should it be considered? Clinical purpose: (1) Psychotic disorders (2) Dementia with specific BPSD target symptoms (aggression, psychosis) (3) Mood Disorders (4) Delirium

P . Diaz (Pharm)

P . Diaz (Pharm)

Safety and Antipsychotics

 Over-sedation  Postural Hypotension  Impaired cognition  Falls  Weight gain  Hyperglycaemia  QTc prolongation  Extra-pyramidal symptoms (EPS)  Tardive Dyskinesia  Cerebrovascular events  Mortality

(VCHA, Antipsychotic Guidelines BPSD, 2011)

P . Diaz (Pharm)

Newer / Novel/ Atypical Antipsychotics Select

Less effects on:

• EPS
• Tardive dyskinesia
• Cognition

A different set of concerns:

• Diabetes control/weight gain, cholesterol

levels

• In dementia increase mortality?
• In dementia, risk of cardiovascular events?

P . Diaz (Pharm)

Recently published article concludes deaths are due to symptoms rather than antipsychotic medications.

P . Diaz (Pharm)

• Tremor
• Akinesia
• Akathisia
• Rigidity (cogwheel)
• Drooling
• Pisa Sign
• Rabbit Sign
• Gait disturbance

Parkinson’s-Like Symptoms

P . Diaz (Pharm)

Should the Parkinson’s- like sym ptom s be treated w ith m edication ?  Anticholinergics such as benztropine NOT recommended in the elderly – may worsen cognition, in addition can cause adverse effects such as dry mouth, constipation and urinary retention.  Levodopa (e.g. sinemet) is for Parkinson's disease NOT for drug- induced symptoms

P . Diaz (Pharm)

Side Effect Profiles

3 6

EPS Hyperlipidemia Weight Gain QTc Prolongation Sexual Dysfunction Sedation Aripiprazole Olanzapine Quetiapine Risperidone Ziprasidone

Harrigan EP et al. J Clin Psychopharmacol. 2004; 24(1): 62-69. Keck PE et al. J Clin Psychiatry. 2006; 67(4): 626-637. Kim B et al. J Affect Disord. 2008; 105(1-3): 45-52. Miller D et al. J Clin Psychiatry. 2001; 62(12): 975-980. Olfson M, et al. Am J Psychiatry. 2006; 163(10): 1821-1825. Yatham LN et al. Bipolar Disord. 2009; 11(3): 225-255.

Neutral - Low risk Moderate risk High risk

EPS: extrapyramidal side effects

Newer Antipsychotics: Effect

DASH Dizziness – Agitation - Somnolence - Hypotension

Olanzapine may cause weight gain, (anticholinergic) diabetic dyscontrol Risperidone may cause EPS at higher doses Quetiapine watch for sedation

P . Diaz (Pharm)

Guidelines for Dosages in Dementia

 Risperdone 0.25 to 1.5 Target 1.0 mg  Olanzapine 2.5 to 10 mg  Aripiprazole 2 to 10 mg  Quetiapine 25 –125 mg

 Note: may need to use higher dosages (200-300 mg) for Quetiapine; always titrate to response and tolerability: GO SLOW

P . Diaz (Pharm)

When should “p.r.n.” doses be used?

 Uses:

 Urgent situation ie. Physical aggression, acting on hallucination/ delusion  Pre-task ie. Bathing, x-ray, dental work  Titration with goal of finding the therapeutic dose

P . Diaz (Pharm)

Drug interactions – a concern for elderly residents taking multiple medications

 Pharmacokinetic- a drug effects the absorption, distribution or metabolism/ excretion of another to alter the quantity of medication at the active site  Pharmacodynamic- two or more drugs have additive or opposite beneficial or adverse effects at their receptors

P . Diaz (Pharm)

Examples of Pharmacokinetic interactions with antipsychotics

 Quetiapine is primarily metabolised by an enzyme CYP3A4:  Inducers (e.g. phenytoin and carbamazepine) will cause faster metabolism and less effect of quetiapine and higher doses may be required  Inhibitors (e.g. erythromycin, grapefruit juice) can slow down the metabolism of quetiapine and lead to enhanced effects both beneficial and adverse

P . Diaz (Pharm)

Examples of Pharmacodynamic drug interactions

Additive sedation: opioids, benzodiazepines, zopiclone, sedating anti-depressants, anti-histamines Additive hypotension and dizziness: diuretics, ACE inhibitors, beta-blockers, calcium channel blockers, tamsulosin, terazosin Additive anti-cholinergic effects: oxybutynin, opioids, inhaled tiotropium/ ipratropium Additive parkinsonian effects: SSRIs, metoclopramide, prochlorperazine

P . Diaz (Pharm)

QTc Prolongation-detected by ECG

 Anti-psychotics have potential to prolong QTc, can lead to Torsade de Points, syncope and sudden death  Risk factors: female, older age, bradycardia, low potassium and magnesium levels, liver or cardiac disease  Effects of drugs may be additive extensive list includes: domperidone, SSRI e.g. citalopram, antibiotics e.g. clarithromycin, moxifloxacin, cardiac medications e.g. amiodarone, sotalol

P . Diaz (Pharm)

Antipsychotic medication templates as part

• f the www.bcbpsd.ca algorithm

P . Diaz (Pharm)

Antipsychotic medication templates as part

• f the www.bcbpsd.ca algorithm

THE END

Carol Ward Tertiary Menatl Health IHA