This morning we discussed some common geripsych issues...
Form 1
- any physician can fill out within 7 days of seeing a patient
- mandates mental health assessment, can hold patient up to 72 hrs to do this
- mental health assessment does not have to be done by a psychiatrist; can be done by any physician comfortable with this assessment
- if patient deemed unsafe, next steps either: 1) put on Form 3 if involuntary, or 2) patient can stay voluntarily
- rarely use Box B (except psychiatrists who know the patient well because addresses patient's history)
- must give pt the Form 42: notifies the patient of why they're being held and by what authority (otherwise illegal to detain them)
Agitation
- clarify what agitation means and whether it warrants treatment
- treatment responsive versus non-treatment responsive
- treatment non-responsive: example -> wandering doesn't warrant treatment - there's no specific treatment except zonking them out
- treatment responsive: yelling, behavior driven by psychosis, striking/violence
- non-pharmacologic therapy: some "agitated" patients just need something to do like fold towels or stuff envelopes
- pharmacotherapy:
1. Atypical antipsychotics: mainly oral
- Risperidone: highest EPS, least sedating, ex: 0.25 OD or BID
- Olanzapine: most anticholinergic therefore avoid in elderly, mid EPS, mid sedating
- Quetiapine: Lowest EPS, most sedating, causes orthostatic hypotension (huge variation in dose, 6.25-200mg! Start low go slow, first couple days will have sedation)
Here is the Results portion of the article: L.B. Ozbolt; M.A. Paniagua ; R.M. Kaiser Atypical Antipsychotics for the Treatment of Delirious Elders. Journal of the American Medical Directors Association (January 2008), 9 (1), pg. 18-28
"Results: Risperidone, the most thoroughly studied atypical antipsychotic, was found to be approximately 80% to 85% effective in treating the behavioral disturbances of delirium at a dosage of 0.5 to 4 mg daily. Studies of olanzapine indicated that it was approximately 70% to 76% effective in treating delirium at doses of 2.5 to 11.6 mg daily. Very few studies have been conducted using quetiapine; it also appears to be a safe and effective alternative to high-potency antipsychotics. In comparison to haloperidol, the frequency of adverse reactions and side effects was found to be much lower with the use of atypical antipsychotic medications. In the limited number of trials comparing atypical antipsychotics to haloperidol, haloperidol consistently produced a higher rate (an additional 10% to 13%) of extrapyramidal side effects."
2. Typical
- Haldol: can be given po/im so gives you options, most EPS, least anticholinergic (ex 0.5-1mg po q4h prn); NB Haldol iv better for EPS but less safe from cardiac perspective ie long Qt
- Loxapine: slightly sedating, available in liquid form
3. Other
- Trazadone: good for nighttime restlessness
Stimulants in Depression:
- use for depression in the medically ill elderly who are anergic (apathetic) as opposed to sad, ex: flat affect, fatigued, low energy, no interest in eating in patient with no history of depression
- one week to titrate up and if it's going to work you expect it to work quickly within first week
- options: Buproprion or SSRIs
- NB: can use mirtazapine to stimulate appetite but caution because can increase cholesterol
