1. Management of Geriatric Psychiatric Disorders Arash Mirabzadeh Psychiatrist University of Social Welfare and Rehabilitation Sciences

2. Management of Disease Recognition of disease Opinion of patients & relatives Availability of treatment

3. The Main Geriatric Psychiatric Disorders Dementia Mood Disorders Psychotic Disorders

4. “Objectives” Key Questions Diagnose of Dementia – Alzheimer`s Disease or Other Dementias Determine of Indication of Pharmacological Approach – Cognitive/ BPSD Select a Medication – When? What? Psychopharmacology of Aging/ Type of Medications Determine of Indication of Non Pharmacological Approach – Patients/ Caregivers

6. Clinical Steps in Pharmacological Treatment of AD Establishment of a Diagnosis Development of Treatment Plan Treatment of Cognitive Dysfunction Diagnosis and Pharmacotherapy of BPSD

7. Therapeutic Approaches to AD Stopping the disease Prevention of disease onset Slowing symptomatic progression

8. Psychopharmacology of Aging pharmacokinetics Absorption Distribution Metabolism –First Pass Metabolism –Phase I Oxidation –Phase II Glucuronidation Acetylation Sulfation Excretion pharmacodynamics Receptor Function Neurotransmitter Function

10. AchEIs Tacrine (Cognex) Donepezil (Aricept) Rivastigmine (Exelon) Galantamine (Reminyl)

11. Other Medications Memantine Metrifonate

12. Preventive Treatment Anti-oxidative agents Anti-inflammatory agents Estrogen replacement therapy Ginkgo biloba Nootropics

14. When to start? MMSE score between 10 & 24 May be effective in other dementia

15. How & What? How to choose? How to monitor? What to tell relative?

16. When to stop? Primary Treatment failure Secondary Treatment failure

18. BPSD Common & more prominent in moderate stages Depression Anxiety Agitation & Aggressive behavior Delusion & Hallocination Sleep disturbances Response Behavior

19. PSYCHOSIS

20. FDA Risperidone is only Atypical Antipsychotic officially labeled for: ‘Severe Dementia, Short term management of inappropriate behavior due to aggression and/or Psychosis’ BBW/OLU

21. Dosage of Antipsychotics in Dementia Drug ClassChemical Name Start Dosage (mg) Usual Dosage (mg) Maximal Dosage (mg) Antipsychotics 1, 2 nd -generation Haloperidol Aripiprazole Risperidone Quetiapine Olanzapine Clozapine 0.25 2.5 0.25 12.5 1.25 6.25 0.5-1 5-10 0.5-1 75-100 5-10 6.25-12.5 2 15 2 125 15 100

22. Good Practice Starting – Low Dose – Slow Upward Titration Continuing – Until 6 Weeks – Monitor for Effectiveness Every 6 weeks – Monitor for Adverse Effects Discontinuing – Safe in Low doses & Symptom Free Conditions – Nursing Homes

24. Cerebrovascular Adverse Events CVAEs Haloperidol> Risperidone> Quetiapine With Olanzapine !!! Dose dependent

25. Mortality Mortality Rate: 54%, 60-70% Mortality usually caused by cardiac event or infection or CVA Mechanism of CVA adverse events is unknown 2012: Haloperidol> Risperidone> Olanzapine >Quetiapine Dose dependent

26. Diabetes Mellitus More with Clozapine & Olanzapine No with Aripiprazole & Ziprasidone

27. Weight Gain Clozapine>Olanzapine>Quetiapine>Risperidone Lower with Aripiprazole & Ziprasidone No dose dependent

28. Dyslipidemia Clozapine> Olanzapine> Quetiapine> Ziprasidone> Aripiprazole No with Risperidone

29. Sedation Long Half-life and Significant Antihistaminic Activity = Sedation Clozapine> Olanzapine> Quetiapine> Risperidone

30. EPS Risperidone: Dose dependent > 6mg/day Olanzapine: Rarely Quetiapine: No

31. Prolactin Levels Risperidone> Olanzapine>Clozapine> Quetiapine>

32. Other Side Effects Rash, Hypertension with Ziprasidone Cataract with Quetiapine !! Seizure with Clozapine & Olanzapine Agranulosytosis with Clozapine

33. Nonpharmacologic strategies Reality Oriented Therapy – Using clocks and calendars to maximize orientation Reminescence Therapy – Using old music & photos Attention to the environment – Over & Under Stimulation – Keeping daily activities routine Family intervention – Education – Treat the caregiver Preventive Strategies – Life Style

34. DEPRESSION

35. Choosing an Antidepressant Profile of Side effects Past Use of Antidepressant Patient`s Preference Expertise of Psychiatrist Co-morbidity Associated Symptoms Drug Interactions Safety in Overdose Availability Costs

36. Profile of Side Effects Postural Hypotension Cardiac Anticholinergic Delirium Hyponatremia GI Bleeding Sexual Akathisia

37. Principles of Acute Phase Appearing of significant therapeutic effects It takes up to 2-4 weeks Effective Trial Ideal time: 6-8 weeks Clinical Guide A minimal response up to 2 weeks is a significant predictor of subsequent response after 6-8 weeks No Response or Partial Response after 2- 4 weeks Continuation No Response after 4- 6 weeks / Partial Response after 8 weeks Ineffective Changing Cross Tapering No Remission after 4- 6 weeks / Partial Remission after 8 weeks Augmentation

38. Principles of Maintenance Phase Maintenance Treatment Three episodes of Depression Two episodes of Depression if Episodes that less than 2.5 yrs apart Seriousness of previous episode Severity Significant suicidal ideation Genetic predisposition Impairment of psychosocial functioning One episode of Late onset Depression Long term treatment for 2 – 5 years

39. SSRIs Citalopram 10-40mg/day Minimal to no P450 inhibition Well tolerated in elderly and those with comorbid medical conditions Serteraline 12.5-50mg/day Less P450 inhibition Well tolerated, most GI effects, most response with increased dosing

40. SSRIs Fluoxetine 5-20 mg/day Inhibits P450 High risk of seizure in >80 mg/day Long half life Paroxetine 10-30mg/day Inhibits P450 Decreases seizure threshold Anticholinergic effects

41. SNRIs Venlafaxine 75-300 mg/day Minimal to no P450 inhibition Well tolerated in elderly Hypertension, ADH secretion Duloxetine 20-60 mg/day Minimal to no P450 inhibition Milder Cardiac effects Increased LFT