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

Antipsychotics Detect, Select, Effect (P.I.E.C.E.S. 6 th 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 (3 rd 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 (3 rd 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 one 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 older 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 outmoded Carol Ward Tertiary Mental Health IHA

Select (P.I.E.C.E.S.) What class of antipsychotic is it? Traditional Atypical Haloperidol Risperidone Loxapine Olanzapine Chlorpromazine Quetiapine Perphenazine Clozapine Paliperidone Aripiprazole Ziprasidone Asenapine Lurasidone 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

The Algorithm is m eant to be used from the top dow n: Part I: Interdisciplinary Decisional and Practice Support for BPSD: • Assessment (green) • Problem Solving (yellow ) • Care Planning (blue) 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  MDs not familiar with works for which psychotropics behaviour?  Colleagues wanting a  Right dose? quick fix  Side effects?  “Haldol Wobble”  Tapering off medication  Colleagues with differing opinions about  Changing medication meds  How long before we  Not giving enough time see desired effect? for desired effect  Drug interactions  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. 6 th 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  Extra-pyramidal symptoms (EPS)  Postural Hypotension  Tardive Dyskinesia  Impaired cognition  Cerebrovascular  Falls events  Weight gain  Mortality  Hyperglycaemia  QTc prolongation (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)

Parkinson’s-Like Symptoms • Tremor • Akinesia • Akathisia • Rigidity (cogwheel) • Drooling • Pisa Sign • Rabbit Sign • Gait disturbance 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)