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Antipsychotic Medications in dementia Speaker: Rebekah Taylor Glenn’s pharmacy

Antipsychotic Medications in dementia Speaker: Rebekah Taylor Glenn’s pharmacy August 17 th 2017 10.30-11 Education Health Centre. Objectives. What is BPSD? Differentiate between the 3 Ds Medications that can worsen/precipitate symptoms

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Antipsychotic Medications in dementia Speaker: Rebekah Taylor Glenn’s pharmacy

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  1. Antipsychotic Medications in dementia Speaker: Rebekah Taylor Glenn’s pharmacy August 17th 2017 10.30-11 Education Health Centre

  2. Objectives • What is BPSD? • Differentiate between the 3 Ds • Medications that can worsen/precipitate symptoms • Side effect profiles of some commonly used antipsychotics • Monitoring to consider

  3. BPSD= behavioural & psychological symptoms of dementia • What is BPSD • 3Ds

  4. Ensure treatment of other conditions • Undetected medical conditions • The following medical conditions can potentially cause, contribute to or mimic BPSD and should be considered: • Pain • Infection (especially urinary tract infection) • Dehydration or hyponatraemia • Constipation • Urinary retention • Anxiety • Fatigue • Hearing/visual impairment • Poor dental health

  5. Medicines that could precipitate or worsen BPSD

  6. Pharmacological treatment • MEDICATIONS should be second line treatment • Behavioural and environmental factors should come first.

  7. Classes of antipsychotics • Typical • Haloperidol • Chlorpromazine • Atypical • Risperidone • Olanzapine • Quetiapine

  8. Principals on prescribing • Start low and go slow • Common medications used for treatment of BPSD Recommended starting and maintenance doses for antipsychotics

  9. Common side effects of antipsychotics • Sedation • Postural hypotension • Extrapyramidal symptoms such as • restlessness • Muscle twitching • Parkinsonian symptoms • Tardive dyskinesia (permanent involuntary movements) • Anticholinergic side effects • Constipation • Dryness • Dizziness • Blurred vision • Cardiovascular side effects (tachycardia)

  10. Common cardiovascular side effects of antipsychotics Cardiovascular: Orthostatic hypotension, increased heart rate, dizziness, reduced ST interval, longer Qtc Interval Antidepressants: Amitriptyline Clomipramine Imipramine Dothiepin Doxepin Citalopram Escitalopram Venlafaxine Antipsychotics: Risperidone Haloperidol Clozapine Ziprasidone Droperidol Quetiapine

  11. Metabolicsideeffects • Weight gain • Olanzapine, in particular is associated with weight gain. Long-term studies over 48 weeks have demonstrated a mean weight gain of 5.6kg. • If there is a weight gain of over 2kg within the first 2 weeks, consider discussing with the prescriber. • Diabetes • Olanzapine is associated with high risk of developing diabetes. Obesity or a family history of diabetes or those at risk should be closely monitored. Monitor for symptoms of diabetes during treatment. Monitor BSLs when initiating olanzapine in diabetics. • Lipids • If the patient has a pre-existing abnormal lipid profile, the atypical antipsychotic medications should be used with caution. Monitoring of lipids may not be necessary depending on your patient age/risk factors.

  12. Relative frequency of common adverse effects of antipsychotics 

  13. Risks to consider • There is an increased risk of mortality and an increased risk of stroke in elderly patients with dementia who are prescribed antipsychotic medication. • Older patients are also more susceptible to postural hypotension, hyperthermia in hot weather and hypothermia in cold weather. • It is advisable when initiating treatment to use half the adult dose, or less depending on comorbidity and other medications, and to review efficacy and the emergence of adverse effects regularly

  14. Recommended monitoring • Older people are especially vulnerable to adverse effects- monitor closely and ensure benefit outweighs this. • Adverse effects are generally dose-related and can be minimised by keeping the dose as low as possible. • Monitor for: • CNS depression • Anticholinergic side effects • Dizziness • EPS • Metabolic changes • Infection

  15. Interactions:Serotonin Syndrome • Serotonin syndrome can result from a pharmacodynamic interaction between medicines with serotonergic effects • Antidepressants • Tramadol, pethidine, fentanyl, methadone • Dextromethorphan • Selegilene • Lithium • Medsafe patient information sheet

  16. Serious side effects: Neuroleptic Malignant Syndrome (NMS) • NMS is a rare but potentially fatal adverse effect of all antipsychotic medications. • It is also more likely to occur with risperidone. • Symptoms include muscular rigidity, pyrexia, confusion, disorientation, tachycardia and increased sweating. • Patients with these symptoms require urgent assessment, cessation of antipsychotics, and supportive treatment. • Please remember that like the older antipsychotics, atypicals are also associated with raised hepatic enzymes and blood dyscrasias. Arrange blood counts if unexplained infection or fever develops.

  17. Resources • BPAC • http://www.bpac.org.nz/a4d/resources/docs/RANZCP_Clinical_recommendations.pdf • Antipsychotics for Dementia : www.bpac.org.nz/a4d • http://www.bpac.org.nz/a4d/resources/docs/bpac_A4D_best_practice_guide.pdf • Medsafe • http://www.medsafe.govt.nz/consumers/educational-material/Serotonin%20Syndrome%20December%202015.pdf • Saferx • http://www.saferx.co.nz/full/atypical_antipsychotics.pdf

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