Side Effects of Side Effects of Psychiatric Psychiatric Medications in Medications in Long Term Care Long Term Care Thomas Magnuson, M.D. Thomas Magnuson, M.D. Assistant Professor Assistant Professor Division of Geriatric Psychiatry Division of Geriatric Psychiatry UNMC UNMC
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Side Effects of Psychiatric Medications in Long Term Care Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry UNMC.
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Side Effects of Side Effects of Psychiatric Psychiatric
Medications in Medications in Long Term CareLong Term Care
Thomas Magnuson, M.D.Thomas Magnuson, M.D.Assistant ProfessorAssistant Professor
Division of Geriatric PsychiatryDivision of Geriatric PsychiatryUNMCUNMC
Objectives Objectives
Delineate common psychiatric Delineate common psychiatric medications used in long-term caremedications used in long-term care
Identify common side effects Identify common side effects associated with those medicationsassociated with those medications
The Falling ManThe Falling Man
78 year old white male78 year old white male Parkinson’s diseaseParkinson’s disease HypothyroidismHypothyroidism HypertensionHypertension High cholesterolHigh cholesterol Constipation Constipation Insomnia Insomnia Cognitive declineCognitive decline Depression Depression
The Falling ManThe Falling Man Getting along fairly well up to a week agoGetting along fairly well up to a week ago
Onset of delusions about wife and children Onset of delusions about wife and children stealing his money, staff is poisoning his foodstealing his money, staff is poisoning his food
Fearful, weight loss, verbal and physical Fearful, weight loss, verbal and physical aggressionaggression
CBC, CMP, TSH, UA, vital signs all normalCBC, CMP, TSH, UA, vital signs all normal Medical cause seems ruled outMedical cause seems ruled out
Seroquel 12.5mg at bedtime started Seroquel 12.5mg at bedtime started Within a day his delusions declineWithin a day his delusions decline Falls twice in three daysFalls twice in three days Medication stopped, delusions returnMedication stopped, delusions return
The Falling ManThe Falling Man
Other medicationsOther medications Sinemet and MirapexSinemet and Mirapex ZoloftZoloft AriceptAricept SynthroidSynthroid Lasix and LopressorLasix and Lopressor Colace, MOMColace, MOM Trazodone Trazodone
Why do you get side Why do you get side effects?effects?
Medications try to alter brain chemicalsMedications try to alter brain chemicals Just the wrong drugJust the wrong drug
Reasonable choice, dosage, etc.Reasonable choice, dosage, etc. Dose may be too highDose may be too high
Dose-dependentDose-dependent May not see at lower dosesMay not see at lower doses
Many of these chemicals present throughout the Many of these chemicals present throughout the bodybody
Medications cannot be specific only to the brainMedications cannot be specific only to the brain Targeting the brain, problems in the stomachTargeting the brain, problems in the stomach
Allergic reactionsAllergic reactions Rash to anaphylaxisRash to anaphylaxis
Drug to drug interactionsDrug to drug interactions
Don’t all medications have Don’t all medications have side effects?side effects?
Yes, so does breakfast cerealYes, so does breakfast cereal Look at common side effectsLook at common side effects
Help you with recognitionHelp you with recognition Much more informed patients and guardiansMuch more informed patients and guardians
Rare side effects not focusRare side effects not focus Make your head swimMake your head swim
Zillions listedZillions listed Even if it happened onceEven if it happened once
Someone may have gotten this from the medicationSomeone may have gotten this from the medication Some times concurrent things happenSome times concurrent things happen
Had gastroenteritis during the drug studyHad gastroenteritis during the drug study
Nausea, diarrheaNausea, diarrhea Sexual dysfunctionSexual dysfunction
Need to ask!Need to ask! HeadacheHeadache Rash Rash Agitation, anxiety, restlessness, insomniaAgitation, anxiety, restlessness, insomnia
Tend to be activatingTend to be activating Weight gainWeight gain Increased sweatingIncreased sweating DrowsinessDrowsiness Suicidal thoughtsSuicidal thoughts
Antidepressants Antidepressants
SNRIsSNRIs Serotonin and Norepinephrine Reuptake Serotonin and Norepinephrine Reuptake
retention, racing heart beat, confusionretention, racing heart beat, confusion Dizziness upon standingDizziness upon standing Sexual problemsSexual problems Dry mouthDry mouth
BuSpar (buspirone)BuSpar (buspirone) No dependency, sedation issuesNo dependency, sedation issues Efficacy, long time to workEfficacy, long time to work
Anti-anxiety AgentsAnti-anxiety Agents
BenzodiazepinesBenzodiazepines EpilepsyEpilepsy Restless leg syndromeRestless leg syndrome
Depress the brainDepress the brain SedationSedation Slurred speech, aspirationSlurred speech, aspiration Confusion, deliriumConfusion, delirium Falls Falls
Mild-moderate overdoseMild-moderate overdose N/V, diarrheaN/V, diarrhea DrowsinessDrowsiness Weak musclesWeak muscles Slurred speechSlurred speech Lack of coordinationLack of coordination
Severe overdoseSevere overdose GiddinessGiddiness AtaxiaAtaxia Blurred visionBlurred vision TinnitusTinnitus Large output of dilute urineLarge output of dilute urine
Usually takes yearsUsually takes years Common in persons with schizophreniaCommon in persons with schizophrenia Less time, less drug with the elderlyLess time, less drug with the elderly
No treatmentNo treatment RecognitionRecognition Stop medicationStop medication Change agentsChange agents
Antipsychotics Antipsychotics
Blood sugar and cholesterolBlood sugar and cholesterol May be partially due to weight gainMay be partially due to weight gain
Induce or worsen diabetesInduce or worsen diabetes Induce or worsen elevated cholesterolInduce or worsen elevated cholesterol Fasting blood glucose and lipids Fasting blood glucose and lipids
recommendedrecommended All can cause these symptomsAll can cause these symptoms
Zyprexa and Clozaril most likelyZyprexa and Clozaril most likely
Antipsychotics Antipsychotics
Risks with dementiaRisks with dementia FDA warningFDA warning
Increased mortality risk Increased mortality risk Almost double the rate of a sugar pillAlmost double the rate of a sugar pill
TrazodoneTrazodone Drowsiness, insomnia, fatigueDrowsiness, insomnia, fatigue AgitationAgitation Dry mouthDry mouth Constipation Constipation Headache Headache Drop in blood pressure upon standingDrop in blood pressure upon standing Priapism Priapism
Dementia MedicationsDementia Medications
All are capable of modestly slowing All are capable of modestly slowing functional declinefunctional decline Use both classes together Use both classes together
Less commonLess common Nightmares Nightmares Agitation Agitation Frequent urinationFrequent urination BruisingBruising
Dementia MedicationsDementia Medications
NamendaNamenda Well-toleratedWell-tolerated
No side effect occurred in 5% and double No side effect occurred in 5% and double the placebo rate in controlled trialsthe placebo rate in controlled trials
Plus could be contributing to the psychosisPlus could be contributing to the psychosis Trazodone orthostasisTrazodone orthostasis Dehydration, poor nutritionDehydration, poor nutrition HypothyroidismHypothyroidism Zoloft hyponatremiaZoloft hyponatremia Apraxia from cognitive decline/dementiaApraxia from cognitive decline/dementia
The Falling ManThe Falling Man OrthostasisOrthostasis
Per standing, sitting blood pressure readingsPer standing, sitting blood pressure readings Low blood pressure upon standingLow blood pressure upon standing Dizzy, fallDizzy, fall
Dementia changes Dementia changes Should be more insidiousShould be more insidious
Parkinson’s medicationsParkinson’s medications Not changed in doseNot changed in dose
Hypothyroidism, dehydration, nutrition, Zoloft, UTIHypothyroidism, dehydration, nutrition, Zoloft, UTI All ruled out by lab testsAll ruled out by lab tests
Multiple influencesMultiple influences Orthostasis from Parkinson’s disease, trazodone, SeroquelOrthostasis from Parkinson’s disease, trazodone, Seroquel
Seroquel pushed the risk of orthostasis over the topSeroquel pushed the risk of orthostasis over the top Must stop Seroquel?Must stop Seroquel?
Could stop trazodoneCould stop trazodone Still psychoticStill psychotic