geropsych pearls

antidepressants


Bruxism:

  • All SSRIs

Cognition:

  • Best: sertraline
  • Worst: paroxetine (fairly anticholinergic)

Anxiety:

  • Best: sertraline, citalopram,  escitalopram
  • Worst: Bupropion

Panic attacks:

  • Half doses of escitalopram good. Paroxetine also good if they don’t have cog probs

COPD:

  • Sertraline good for respiratory-related anxiety, use less nebs and PRN inhalers.
  • Avoid benzos, reduces resp. drive. 

Cardiotoxicity:

  • Sertraline best

Seizure disorder:

  • Avoid bupropion entirely
  • keep all SSRIs low

Sexual activity:

  •  Wellbutrin + Zoloft = “Well-off”

Nightmares:

  • all SSRIs can cause bad dreams. Lower the dose. 

OCD:

  • Fluvoxetine best, sertraline also good

Withdrawal symptoms:

  • Worst: paroxetine> venlafaxine
  • Intermediate: Sertraline > fluvoxetine > bupropion > mirtazapine
  • Minimal: citalopram > escitalopram > fluoxetine

Activating:

  • Most activating: bupropion > fluoxetine > sertraline       
  • Not too bad: paroxetine > venlafaxine > duloxetine                 
  • Most sedating: mirtazapine >fluvoxetine > citalopram


TIDBITS:

Sertraline is well-tolerated in older adults: Start with 25mg daily, go as low as 12.5mg if they are in the 90/90 club (older than 90 or weigh less than 90).  Higher doses can be overly activating. Think of sertraline as an upside-down U (kind of like your golf score when drinking). Your pt might start to look better when you push the dose, but it's easy to over-shoot your goal, and then it's all downhill. How do you know when you've gone too far? Watch for bad dreams, worsening of anxiety, they can look a bit tremulous.  


TIDBIT #2:

Watch out for excess activation when you combine 2 agents that are both boosting NE. For example, duloxetine + mirtazapine.  Or bupropion + venlafaxine. The psychopharmacology guru Stahl calls this "California Rocket Fuel", which is an appropriate nickname. CRF can cause your frail elder to become very, very, very agitated.  


PEARLS:

treating anxiety 

treating depression

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antipsychotics


ALL:  Risk of neuroleptic malignant syndrome.

ALL: Risk of tardive dyskinesia.

ALL have weight gain, risk of diabetes, hyperlipidemia (monitor glucose on all of them)
ALL: Enhance effect of antihypertensives.


Beware the “dines” and the “tines” (ranitiDINE, paroxeTINE, etc.) --> block primary pathways of many antipsychotics --> increased blood levels


Hyperprolactemia:

  • Risperidone is worst. Aripiprazole only antipsychotic that doesn’t increase prolactin (best).

EPS Potential:

  • Worst: risperidone > ziprasidone = olanzapine > quetiapine (best)

QT prolongation:

  • Worst: haloperidol > quetiapine > ziprasidone > risperidone > olanzapine (not bad) > lurasidone (best)   

Sedation:

  • Worst: olanzapine> quetiapine> risperidone > ziprasidone > aripiprazole (best)

Orthostatic hypotension:

  • Worst: Clozapine > quetiapine = olanzapine > risperidone (best)

Cardiovascular toxicity:

  • Worst: quetiapine > olanzapine = risperidone > lurasidone (best)

Constipation, dry mouth, urinary hesitancy:

  • Worst: quetiapine > risperidone = olanzapine > ziprasidone (best)

Hyperlipidemia:

  • Worst: clozapine > olanzapine > risperidone > ziprasidone > aripiprazole (best) 

Smoking caveat:

  • Olanzapine binds to tar in cigarettes. Nicotine patch won’t prevent this. If pt stops smoking, beware of EPS. Cut dose by half.

Gender:

  • Olanzapine better metabolized in women than in men, women can go with lower doses and still get a decent effect.


Typical starting doses for frail elders: 

Olanzapine: 2.5mg BID if they are good sturdy Norwegians. Lower them to 2.5mg qHS if they are in the 90/90 club (older than 90 or weigh less than 90).

Risperidone: 0.25mg BID for GSN, 0.125mg BID for 90/90

Aripiprazole: 2.5mg daily for GSN, 1-2mg for 90/90

Ziprasidone: 20mg BIDWM for GSN, titrate to 40mg.

Lurasidone: 40mg qHS, titrate to 60mg

Quetiapine 25mg qHS for GSN; 12.5mg QID for 90/90, 6.25mg QID if they have parkinsons

Haloperidol: 0.5mg BID for GSN, 0.25mg for 90/90, avoid in parkinsons 


OR, you can do this:Take the smallest pill that it comes in, and cut it in half if they are GSN, or into quarters if they are in the 90/90 club. That works too. 


PEARLS: 

treating delusions

treating cognitive disorders and dementia-related agitation 

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anticonvulsants


Frequently used for mood stabilization. Also used to manage aggression and impulsiveness in pts with dementia. Off-label warning applies. 

 

These  can be helpful:

  • Gapapentin: good mood stabilizer. But they will gain weight, can be sedating, peripheral edema. 
  • Pregabalin: son of gabapentin. Cleaner, less metabolites. Watch for weight gain, edema, rare angioedema. May cause PR prolongation. Also pricey.
  • Carbamezepine – useful. Increased risk of Stevens-Johnson syndrome in Asians. Screen for the variant HLA-B1502 allele, as they are at higher risk. 

These are not helpful:

  • Levetiracetam: associated with aggressive behavior, irritability, and increased anxiety and depression. Has the highest risk of psychiatric adverse effects of all of the AEDs. Works great for seizures, but not generally a good choice for mood stabilization.
  • Topiramate:  associated with affective and psychotic symptoms. Also worsens cognition. Increased risk of kidney stones, have to keep them hydrated.
  • Oxcarbazepine: higher risk of hyponatremia than carbamezepine, and hyponatremia can trigger delirium.
  • Valproate: has fallen out of favor due to risks of encephalopathy. Watch for tremor, thrombocytopenia, alopecia, elevated LFTs with higher doses. Watch for toxicity with hypoalbuminemia.


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sleepers


First, go read the section on sleep. Don't just start here. There is no one-size-fits-all agent for sleep in elders.


TIDBITS:

Nonbenzodiazepines:
 - Zaleplon (Sonata): Half-life is 1 hr. Good for sleep onset, not so good for sleep maintenance. Avoid long term use
 - Zolpidem (Ambien): Half-life is 1.5 - 2.5 hrs. Good for sleep onset. Some morning hangover. Avoid long-term use.
 - Zolpidem CR: Half-life is 1.5 - 2.5 hrs, but released over longer duration to help with maintenance.
 - Eszopiclone (Lunesta): Half-life is 5-7 hrs, longer in elders. Higher risk of next-day impairment. 
Benzodiazepines:
 - This should be your last, last, last resort. Try low dose temazepam if you have to. Avoid estazolam, flurazepam, quazepam, or triazolam. 
Melatonin agonists
 - Melatonin: trick is to give it at least an hour prior to sleep, even as much as 5 hrs in some cases. Dim light melatonin onset (DLMO) is the evening increase in endogenous melatonin, and is delayed in pts with delayed sleep phase syndrome. Exogenous melatonin tx given FIVE hours before DLMO is effective for promoting sleep onset.
 - Ramelteon (Rozerem): Improves sleep latency, but not sleep maintenance. Not limited to short-term use.
Antidepressants:
 - Doxepin has an FDA indication for insomnia; keep dose at 3mg or less, and watch for cognitive impairment.
 - Amitriptyline: cognitive risk tends to outweigh potential benefit, try to avoid it.
 - Trazodone: orthostatic hypotension risk tends to outweigh potential benefit. Also disrupts REM. Has fallen out of favor in geriatrics.
 - Mirtazapine: protects sleep architecture. Good for short term, but benefit may be short-lived. Sedating effects often normalize. Keep the dose at 7.5mg or less.
Antipsychotics:
 - Not recommended for tx of insomnia in pts without psychosis. Quetiapine should not be your first-line tx.
Herbals:

  - Not regulated. My momma always said unregulated OTC herbals were like a box of chocolates. You never know what you are gonna get. Run, Forest, run! 
 - Chamomile, Kava, wuling - no benefit over placebo, and risk of contaminants
 - Valerian - hepatoxicity risk, acts like a benzo, including a butt-ugly withdrawal that can cause psychosis. Avoid.
 - Melatonin - best for pts with circadian sleep/wake rhythm disorder or if low melatonin levels. See above.
Mood stabilizers:
 - Gabapentin. Useful, is also one of the only agents that enhances slow-wave delta sleep, which may be helpful for chronic pain syndromes.
What about the orexin receptor antagonists?
 - Suvorexant (Belsomra): keep dose low d/t next-day impairment. High potential for abuse. Plus, it’s expensive. 


back to sleep

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Useful tidbits about meds in older adults


These tips are offered with no implied warranty, they may or may not be helpful for your particular patient, and you still must use your own brain.