Clinical Case Studies Week 5 (Depression, Psychosis + Schiz, Dementia)

Question 1

What does the psychological treatment of depression consist of?

Answer 1

Structured problem-solving strategies

Stress management strategies

CBT

Interpersonal psychotherapy (IPT)

Short-term dynamic therapy

Question 2

Which SSRI/SNRI will have withdrawal effects? Why? What are these withdrawal effects?

Answer 2

Fluvoxamine, paroxetine, and venlafaxine as these have short half lives.

Withdrawal effects for SSRIs and SNRIs: Dizziness, nausea, paraesthesia, anxiety, agitation, tremor, sweating, confusion, electric shock-like sensations

Question 3

When do SSRI doses need adjustment?

Answer 3

Doses usually need adjustment in hepatic impairment

Question 4

What differentiates escitalopram from other SSRIs?

Answer 4

Escitalopram - causes less sedation, sexual dysfunction and no agitation or weight gain due to high receptor selectivity

Question 5

Explain the following drug interactions and precuations for SSRI

A) Platelet aggregation

B) Hyponatraemia risk

C) QT interval prolongation/arrhythmia risk

Answer 5

A)

• Caution with other drugs that effect clotting → bleeding risk (esp GI)
• E.g. Warfarin + SSRIs may increase anticoagulant effect and risk of bleeding; monitor INR and ↓ warfarin dose as needed.

B)

• Increase risk with other drugs causing this effect.

C)

• ↑ risk with other drugs causing this effect.

Question 6

What type of impairment affects SNRI (metabolism)?

Answer 6

Dosage adjustments required in renal impairment (CrCl < 30ml/min)

Hepatic impairment - variable recommendations depending on the agent (duloxetine contraindicated)

Question 7

What are the adverse effects of SNRIs? how do they differ from SSRIs?

Answer 7

Similar adverse effects and precautions to SSRIs due to serotonergic actions

Suicide risk, serotonin syndrome, hyponatraemia, risk of bleeding, narrow angle glaucoma

> narrow angle glaucoma is a NA side effect

Cardiac effects

Use cautiously in patients with cardiac disease

Increases in BP reported with desvenlafaxine, duloxetine (infrequent) & venlafaxine

Control hypertension before starting desvenlafaxine or venlafaxine

Lipid effects

Elevations have occured with desvenlafaxine, use with caution

Question 8

When is agomelatine contraindicated?

Answer 8

Contraindicated in hepatic impairment or if aminotransferase concentration is > 3 X ULN.

> Caution if aminotransferases are already elevated or other risk factors for hepatic damage

> Additive hepatotoxic effects with other drugs

Question 9

When are TCAs used? What do they have a role in? When are they potentially lethal?

Answer 9

Used generally after unsuccessful trials of at least 2 first-line treatments

• Have a role in severe melancholic depression
• Potentially lethal in overdose!!! (cardiotoxicity)

Question 10

Precatuons of TCA?

Answer 10

suicide risk, CV disease, elderly, epilepsy (lowers seizure threshold like all antidepressants), hyperthyroidism

Question 11

What makes vortioxetine desirable?

Answer 11

Can be stopped without tapering

Question 12

For serotonin toxicity:

A) What are mild symptoms

B) What are the moderate symptoms

C) What are the severe symptoms

Answer 12

A)

• Mydriasis, shivering, sweating, mild tachycardia

B)

• disorientation, excitement, rigidity, tachycardia, hyperthermia (> 40) tremor, clonus, hyperreflexia

C)

• Delirium, hypertension, hyperthermia, muscle rigidity, tachycardia

Question 13

What are te TWO treatment options for serotonin toxicity?

Answer 13

Cyproheptadine: 12mg single dose or 4 to 8mg tds

Chlorpromazine: 12.5 to 50mg slow IV infusion over 30 to 50min

Question 14

How to commence antidepressants?

Answer 14

Generally commence antidepressants with a low dose and gradually increase over 2 to 4 weeks

Question 15

When is the full effect of antidepressants seen?

Answer 15

Full effects may take 4 to 8 weeks but improvement seen within 1 to 3 weeks

Question 16

How long to continue drug treatment for after a single episode of major depression?

Answer 16

Continue drug treatment for 4 to 12 months after a single episode of major depression

> high risk of relapse

Question 17

How to adjust treatment for depression medication?

Answer 17

Increase dose if full response not achieved (check adherence before adjusting therapy)

• Up to maximum possible dose
• Depending on side effects

Assess respone after 2 to 4 weeks

If a change is necessary can switch to an antidepressant from the same or a different class

Question 18

What to do for patients who fail to respond to antidepresasnt therapy? What are the key questions in assessing failure to respond to psychotropic drugs?

Answer 18

Is diagnosis correct

Has the patient been taking their medication regularly

Have possible underlying medical causes been identified and treated

Is the patient reacting adversely to a current medication

Have the drug dose and duration of administration been adequate

Have relevant psychosocial or personality factors been addressed

Have alcohol or other substance use problems been addressed n

Could an interacting drug be compromising the response

Question 19

What are the FOUR options in treatment of resistant patients (refractory depression)?

Answer 19

Switching antidepressants

Augmentation strategies

Antidepressant polypharmacy

Electroconvulsive therapy (ECT)

Question 20

For switching antidepressants;

A) What requires long washout periods?

B) TCAs and most SSRI (except fluoxetine) clear the drugs from the body within how long?

C) For other switches, what needs to be considered?

Answer 20

A)

• Specified long washout periods are mandatory for irreversible MAOIs
• Non selective irreversible MAOI and serotonin toxicity drug stays in body 2-3 weeks after it has been ceased –> severe HTN and serotonin toxicity

B)

around 5 days, the half life is around 20-30 hours

C)

Potential for withdrawal effects and need for tapering dose of agent being ceased

Half life of drug & continued effects → potential for interaction/toxicity during switch if the drug has a long half life

Clinical urgency for change/potential for relapse and exacerbation

Question 21

What two antidepressants are most common for withdrawal effects? What is the general rule for discontinuing a drug?

Answer 21

Paroxetine and venlafaxine

Halve the dose every week until the daily dose is half of the lowest unit available, then stop after 1 week

Question 22

What can rapid withdrawal of the more potently anticholinergic tricyclic antidepressants (TCAs) (eg amitriptyline) result in?

Answer 22

Cholinergic rebound (agitation, headache, sweating, gastrointestinal symptoms), parkinsonism and problems with balance.

> sailvation, lacrimation, urination, diarrhoea, GI distress, emesis SLUDGE = cholinergic effects

Question 23

What is Electro-convulsive therapy (ECT)?

Answer 23

Delivery of an electric current to induce a seizure for a therapeutic response (uni or bilateral)

• Indicated for severe and unresponsive forms of depression
• Response rate of 50 to 80%

Question 24

How often is ECT given? What is done to prevent high relapse rate? What are the side effects?

Answer 24

• Treatments given 3 times weekly or ↓ if cognitive impairment emerges
• 6 to 14 treatments (up to 24 treatments)

Relapse rate high

• Maintain recovery with pharmacotherapy (that has not been previously ineffective), lithium or mood stabiliser or combination

Side effects

• Memory loss, muscle aches and pains, headaches, transient confusion

Question 25

How does exercise alleviate symptoms of depression?

Answer 25

↑ energy Improve sleep Positive distraction Social support ↑ sense of control and self-esteem May change levels of neurotransmitter **Trials have demonstrated regular exercise to be equally effective as antidepressants in mild to moderate depression** \> decrease risk of developing depression

Question 26

Key Messages about depression

Answer 26

* Depression may result in significant disability * Depression may be associated with a number of medications and medical conditions, in particular co-morbid psychiatric illnesses * Pharmacotherapy is indicated in moderate to severe MDD only * SSRIs are first line (in general) – need to consider what is best for the individual * Drug choice should be based on patient preference, past history of response, adverse effect profile, potential for toxicity in overdose, potential for drug interactions * Consider interactions due to CYP450 enzymes * Monitor for serotonin syndrome * Avoid withdrawal syndrome * Observe washout periods when switching antidepressants to reduce adverse effects * There is little evidence to support combinations of antidepressants, although the risk of adverse events is well documented

Question 27

Pyschosis from this card onwards ...

Question 28

What to do if EPSE occurs?

Answer 28

ideally reduce antipsychotic dose or switch to alternative antipsychotic

Question 29

What treatment for the following EPSE? A) Dystonias - stiffness, uncontrolled muscular spasms B) Akathisia - inner restlessness, strong desire or compulsion to move C) Parkinsonism - tremor and/or rigidity, mask- like face, shuffling gait, slow movements D) Tardive Dyskinesia - involuntary abnormal movements of face, tongue, lips, hands or feet

Answer 29

A) benzatropine (oral, inj), trihexyphenidyl (benzhexol) B) propranolol, clonazepam C) benzatropine, trihexyphenidyl D) Can be irreversible. Stop antipsychotic (preferred) Treatment poor efficacy – tetrabenazine, Ginkgo biloba

Question 30

What is first line treatment in schizophrenia?

Answer 30

**2nd Generation Antipsychotics (SGAs)** More metabolic adverse effects More expensive

Question 31

Pharmacalogy of aripiprazole? What is it used to agument?

Answer 31

Is a dopamine system stabiliser (increased dopamine output when conc are low and decreased dopamine output when conc. are high) * Less sedation, weight gain and prolactin elevation * Good 1st choice antipsychotic * Doesn’t provide sedation if patient acutely unwell * May cause insomnia, akathisia and/or activation \> often used to augment other antipsychotics \> to reduce weight gain e.g. clozapine, olanzapine \> to reduce prolactin e.g. risperidone

Question 32

Pharmacology of brexpiprazole

Answer 32

Indicated only in schizophrenia May have positive effects on mood Well tolerated – little weight gain, prolactin elevation, akathisia

Question 33

Pharmaclogy of lurasidone

Answer 33

Take with food to increase absorption Low incidence weight gain, small rise in prolactin Theorised to improve mood & be useful in bipolar Reports of increased irritability/rage

Question 34

Pharmacology of olanzapine

Answer 34

Sedating – may be beneficial in acute psychosis **WEIGHT GAIN +++** Metabolic syndrome major concern. For this reason falling out of favour as long term treatment

Question 35

Pharmacology of paliperidone

Answer 35

Active metabolite of risperidone, similar adverse effects to risperidone * Swallow tablets whole --\> Cannot be halved, crushed --\> Empty tablet may appear in stools - always with food or always on an empty stomach - oral not commonly used but depot common

Question 36

Pharmacology of Quietiapine

Answer 36

Prone to abuse – watch for doctor shopping and picking up supply earlyn More sedating at lower doses To get antipsychotic effect, some patients require higher dose

Question 37

Pharmacology of Amisulpride? How does its MOA change from low to higher doses?

Answer 37

Indicated for treatment of schizophrenia * At low doses (50-300mg) it is more effective for negative symptoms * At higher doses (400-800mg) it is more effective for positive symptoms * Not metabolised in the liver; reduce dose in renal impairment * Dose-related EPSE & hyperprolactinemia

Question 38

Clozapine pharmacology? Why is it not 1st line?

Answer 38

The most effective antipsychotic 50% of non-responders will improve with clozapine Particularly effective for negative symptoms **Not 1st line due to serious adverse effects** * Agranulocytosis * Neutropenia * Cardiomyopathy * Myocarditis * Gastrointestinal Hypomotility – i.e. constipation = highest risk of mortality

Question 39

What is the condition of clozapine being used?

Answer 39

Must have trialled ≥2 antipsychotics prior to clozapine initiation * Not effective or not tolerated * At least 1 must be atypical antipsychotic

Question 40

What is done before treatment of clozapine can be done (monitoring)?

Answer 40

**Monitoring systems record WCC and neutrophil count** * Clopine Connect * Clozaril Patient Monitoring Service **Pre-treatment** * FBP, CRP, troponin, ECG, echocardiogram ( pregnancy test) * Desired: LFTs, U&Es, lipids, weight, BSL/HbA1c, weight, waist circumferance,

Question 41

What ongoing monitoring for clozapine?

Answer 41

Ongoing monitoring. Medication only supplied until next blood test * FBP weekly for first 18 weeks * CRP, troponin weekly for 4 weeks **red range (stop immediately)** \> WBC less than 3.0 x 10⁹ \> Neutrophils less than 1.5 x 10⁹ **amber range (continue therapy with twice weekly blood tests)** \> WBC 3.0-3.5 x 10⁹ \> Neutrophils 1.5-2.0 x 10⁹ **green range** \> WBC greater than 3.5 x 10⁹ \> Neutrophils greater than 2.0 x10⁹

Question 42

Clozapine dosing/drug concentration

Answer 42

Slow dose titration to avoid/reduce dose dependent adverse effects \> Target drug concentration: 350-1000mcg/L

Question 43

For clozapine; A) What to use to treat hypersalivation B) What to use to treat GI hypomotility (constiaption)

Answer 43

A) * Atropine 1% eye drops sublingually * Hyoscine wafers * Ipratropium MDI sublingually * Moclobemide, metoclopramide B) * Macrogol first line and BE AGGRESSIVE! * Docusate/senna first line for prophylaxis

Question 44

Why is medication used in acute agitation and arousal in patients with schizophrenia? What drugs to use?

Answer 44

**Medication is used to calm/lightly sedate the patient and reduce the risk to self and/or others** * Oral benzodiazepine (lorazepam, clonazepam, diazepam) * Oral antipsychotic (olanzapine, risperidone, quetiapine, haloperidol) * IM medication (lorazepam, olanazapine, ziprasidone, haloperidol, droperidol, midazolam, clonazepam) * IV med --\> used in EDs, not used in psychiatric inpatient wards

Question 45

Which IM medication is preferred for acute agitiation?

Answer 45

IM lorazepam available under SAS – more predictable absorption & effect --\> refrigerate, 3 months shelf life once out of fridge

Question 46

What is needed when benzodiazepines used IM/IV? When to use?

Answer 46

Have flumazenil available when benzodiazepines used IM/IV Use if respiratory rate falls below 10/minute

Question 47

Pharmacology of Zuclopenthixol acetate. When are they used?

Answer 47

Used if other short-acting treatment options for acute agitation and arousal have been ineffective \> Not for long-term use. Duration of Tx cannot exceed 2 weeks, 400mg or 4 injections

Question 48

When is long acting (depot) antipsychotics used? How is it used?

Answer 48

Antipsychotic long-acting injections (LAIs) used where non-adherence to oral treatment is problematic, or patient prefers this formulation type * Deep intramuscular injection (gluteal or deltoid) * Medication slowly released into bloodstream, providing steady supply of medication. * LAIs do not ensure adherence: they assure awareness of adherence * Allow regular assessment of patient (due to regular injections)

Question 49

Advantages and disadvantages of LAI antipsychotics?

Answer 49

**Advantages** Proven reduction in relapse Improved adherence Fewer hospitalisations Less fluctuation in drug concentration Regular contact with clinicians Less risk of overdose Avoids first pass metabolism **Disadvantages** Pain at injection site Cannot be withdrawn quickly (E.g. side effects) Patient loses control of treatment Less dosing flexibility Monitoring required (olanzapine)

Question 50

Pharmacology of aripiprazole LAI?

Answer 50

Gluteal or deltoid muscle Oral test doses of aripiprazole Oral antipsychotic required for 14 days after LAI is commenced **Indicated for treatment of:** Schizophrenia BPAD – maintenance treatment (not PBS) * Favourable metabolic and prolactin-sparing effects

Question 51

All antipsychotics can reduce the seizure threshold/ What antipsychotics to avoid?

Answer 51

Clozapine, chlorpromazine – most epileptogenic

Question 52

What are the effects of smoking and smoking cessation with antipsychotics?

Answer 52

Cigarette smoking induces CYP1A2 * Reduces plasma levels of drugs eg BZD, clozapine, olanzapine Smoking cessation --\> increased drug plasma levels --\> consider dose reduction

Question 53

What to use for smoking cessation?

Answer 53

NRT has been used effectively for smoking cessation * Varenicline – Champix® - pschiatric adverse effects reported, but can be used with careful monitoring * Bupropion – Zyban® - not routinely used in psychiatric setting. Lowers seizure threshold

Question 54

What are effects of caffeine on antipsychotic drugs?

Answer 54

Caffeine can increase drug levels (clozapine and olanazapine)--\> possibly due to competitive CYP1A2 inhibition * Patients with mental illness have been reported to drink large amounts of caffeinated drinks

Question 55

Why does NMS occur (Neuroleptic Malignant Syndrome)?

Answer 55

Thought to be due to a sudden over-blockade of dopaminergic function \> a very rare life-threatening syndrome that can occur with any antipsychotic medication \> antipsychotics that act on stronger dopamine receptors

Question 56

Symptoms of NMS (Neuroleptic Malignant Syndrome)? How to treat?

Answer 56

**_Characterised by fever, muscle stiffness, altered consciousness and problems with the autonomic nervous system_** * can be fatal if left untreated * treatment is symptomatic and antipsychotic should be ceased

Question 57

Concerns with elderly patients?

Answer 57

* More susceptible to adverse effects including EPSE and TD * Lower starting doses of medications are used * There is some concern that olanzapine and risperidone may increase the chance of a stroke * Elderly patients more likely to have other illness or be on other medications

Question 58

How to deal with side effects A) Akathisia B) Sedation C) nausea D) constipation weight gain: combination of good diet and exercise, prevention better than treatment \> metformin and augmentation with aripiprazole can reduce weight gain

Answer 58

A) stretching & exercise B) take medication at night (if once daily dose) e.g. clozapine small dose in morning and large dose at night C) take with or after food D) balanced diet, increase fibre and fluid intake Coloxyl & Senna, Movicol

Question 59

Dementia after this card...

Question 60

What is dementia defined as?

Answer 60

Distinguished from lifelong intellectual disability and single learning disorders as dementia develops during life, and involves alteration in two or more cognitive functions

Question 61

What is used to treat primary symptoms such as memory loss in alzheimers?

Answer 61

Anticholinesterases NMDA antagonists

Question 62

What is used to treat seconday symptoms such as depression and hallucinations in alzheimers?

Answer 62

Antipsychotics and Sedatives

Question 63

How do anticholinesterases work? \> donepezil, galantamine, rivastigmine

Answer 63

Accumulation of AB (beta amyoloid) peptide results in destruction of cholinergic neurones and a fall in ACh concentration \> neurotransmitter essential for learning and memory * **Cholinesterase inhibitors (CIs) inhibit breakdown of ACh to increase concentrations in synaptic cleft** \> enhances cholinergic function and reduces loss of cholinergic neurotransmitter activity

Question 64

All three CIs seem to have similar efficacy, they dont alter pathology of AD, so how do they work? \> donepezil may be slightly more effective

Answer 64

temporarily delay progression and improve symptoms according to subjective measurements or cognitive assessment tools (e.g. MMSE) \> not everyone responds to treatment

Question 65

What are the adverse effects (CIR) associated with CI? Which one has most GI adverse effects?

Answer 65

Adverse effects occur frequently with all three agents Better tolerated if slowly titrated to target dose --\> increase every four to six weeks * full dose oral rivastigmine may have more GI adverse effects than donepezil or galantamine **_Common​_** nausea, vomiting, diarrhoea, anorexia, abdominal pain, dyspepsia, headache, insomnia, vivid dreams, depression, fatigue, drowsiness, dizziness, tremor, weight loss, muscle cramps, urinary incontinence, increased sweating, hypertension, syncope **_Infrequent or rare_** bradycardia, heart block, seizure, agitation, hallucination, confusion, GI haemorrhage

Question 66

Which non-alzheimer dementia should CI be used in?

Answer 66

There is good evidence to support treatment with rivastigmine and donepezil in in dementia with Lewy bodies and Parkinson’s disease dementia

Question 67

Properties of memantine? MOA, is it effective? Who is it used for?

Answer 67

Thought to protect against elevated levels of glutamate * NMDA antagonist * but memantine does not stop AD progression **Generally reserved for severe dementia or those intolerant to CIs**

Question 68

Factors to consider in relation to continuing CI/ memantine use are the level of? How is this demonstrated?

Answer 68

Clinically meaningful response to treatment may be demonstrated by the person’s: * quality of life * cognitive function * behavioural symptoms \> The presence of adverse effects that impact on quality of life and clinical symptoms should prompt a review of the ongoing need for the agent \> People who demonstrate ongoing, meaningful clinical benefit (functionally and/ or cognitively stable) should continue on the medication with ongoing monitoring for continued benefit or the development of any adverse effects

Question 69

What are behavioural symptoms associated with dementia?

Answer 69

physical aggression, screaming, restlessness, agitation, wandering, culturally inappropriate behaviours, sexual disinhibition, hoarding, cursing and shadowing.

Question 70

What are psychological symptoms associated with dementia?

Answer 70

anxiety, depressive mood, hallucinations and delusions

Question 71

1st line treatment for psychological and behavioural symptoms?

Answer 71

Non-pharmacological approaches first line for responsive behaviours because of a favourable balance of benefits and harms \> Drug therapy should not be first-line for patients with responsive behaviours

Question 72

Who are antipsychotics reserved for? What symptoms are they ineffective for? Why risk of AE so high?

Answer 72

Reserve for residents with distressing agitation, aggression, delusions or psychoses * Ineffective in treating wandering or disinhibition AE: increased risk of mortality, stroke and extrapyramidal symptoms

Question 73

what antipsychotics to use for hallucinations, delusions or seriously disturbed behaviour?

Answer 73

Risperidone or olanazapine

Question 74

AE of antipsychotics?

Answer 74

AEs frequent as antipsychotics affect multiple neurotransmitter receptor types and subtype **Common:** sedation, anxiety, agitation, EPSE, orthostatic hypotension, tachycardia, sexual adverse effects, weight gain, hyperprolactinaemia (may result in galactorrhoea and/ or gynaecomastia) \> EPSE and orthostatic HTN with risperidone \> Olanzapine and some older agents: blurred vision, mydriasis, constipation, nausea, dry mouth, urinary retention \> Avoid typical antipsychotics in residents with Lewy bodies dementia or Parkinson’s disease --\> worsen movement disorders

Question 75

When is extrapyramidal side effects highest? What drugs to avoid?

Answer 75

Incidence dose-related \> highest with haloperidol, lowest with some of the newer agents * Reduce antipsychotic dose to avoid recurrent EPSE when possible * Avoid anticholinergic drugs (e.g. benztropine) \> **may add to anticholinergic effects and worsen tardive dyskinesia and cognition**

Question 76

What are some extrapyramidal side effects that may be mistaken for responsive behaviours when using antipsychotics?

Answer 76

**Dystonias** * Torticollis, carpopedal spasm, trismus, perioral spasm, oculogyric crisis, laryngeal spasm and opisthotonos **Akathisia** * Feeling of motor restlessness; usually occurs 2–3 days (up to several weeks) after starting treatment and may subside spontaneously * May present as agitation secondary to psychosis **Parkinsonism** * Tremor, rigidity or bradykinesia; usually develops after weeks or months **Tardive dyskinesia** * Involuntary movements of the face, mouth or tongue, and sometimes head and neck, trunk or limbs

Question 77

Clozapine, olanzapine and quetiapine, associated with?

Answer 77

increased blood glucose, weight gain and dyslipidaemia * clozapine and olanzapine associated with increased risk of type 2 diabetes

Question 78

Increased death rate in which antipsychotics? Increased risk of fatal and non-fatal strokes and TIAs in which antispychotics?

Answer 78

Increased death rate noted in placebo-controlled trials of **aripiprazole, olanzapine, quetiapine and risperidone** in dementia patients (due to CVD events or infections) **Olanzapine and risperidone** associated with increased risk of fatal and non-fatal strokes and TIAs \> use for lowest possible dose and shortest amount of time

Question 79

Risk of CVA increased for patients being treated with _________ for vascular or mixed dementia, compared with those taking it for Alzheimer’s dementia

Answer 79

**risperidone** * TGA approval for use in responsive behaviour is limited to treatment (up to 12 weeks) of moderate to severe dementia only of the Alzheimer type

Question 80

Points for withdrawal of antipsychotics?

Answer 80

* Most responsive behaviours tend to be transient exacerbations * Many will resolve naturally as dementia progresses * Regular monitoring and dose reduction/ withdrawal attempts should be undertaken to minimise exposure to antipsychotic use * **E.g. halve the dose every two weeks until the lowest possible dose is achieved, treat for a further two weeks then cease** * Antipsychotic treatment can always be reintroduced if required

Question 81

How do BZDs work? what ar they used for? Which one to use?

Answer 81

Potentiate inhibitory effects of GABA throughout CNS --\> results in Potentiate inhibitory effects of GABA in the CNS --\> anxiolytic, sedative, hypnotic, muscle relaxant and antiepileptic effects * **Short term use may assist some behavioural and psychological symptoms of dementia (BPSD), especially insomnia, anxiety, irritability and tension** \> also use as premedication for anxiety-inducing events \> **To relieve symptoms of severe anxiety and agitation, use: oxazepam 7.5 mg orally, 1 to 3 times daily**

Question 82

AE of BZD? What happens if used for more than 2 weeks?

Answer 82

Worsen cognitive impairment, impair gait and increase the risk of falls \> Particularly long-acting agents, such as nitrazepam and diazepam \> Associated with increased risk of hip fracture among older people by \>50% * **Use \>2 weeks associated with tolerance to sedative effect** - Longer term use results in dependence - Cognition and gait effects maintained

Question 83

\_\_\_\_\_ ______ are often amongst the most difficult symptoms of dementia to adequately support. What medications have been used to try to alleviate these symptoms?

Answer 83

Responsive behaviours * anticonvusaltant mood stabilisers, antidepressants, clonidine, cannabis, dextropropoxyphene \> citalopram for agitation has been shown to be effective

Question 84

What is the most effective strategy for this: responsive behaviours are often amongst the most difficult symptoms of dementia to adequately support

Answer 84

Identifying and addressing the unmet need/ sources of responsive behaviour is typically the most effective strategy \> Specialist services are available for these situations --\> DBMAS, SBRT, OAMHS

Question 85

Summary

Answer 85

* Development of disease- modifying treatments has been unsuccessful * Current pharmacological treatments for dementia are generally of limited effectiveness \> This includes medications for both the cognitive and behavioural/ psychological aspects of the condition * Any medication used in managing dementia symptoms requires regular review for ongoing effectiveness and adverse effects \> Particularly antipsychotics and other sedatives