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The non-SSRIs venlafaxine (Effexor), mirtazapine (Remeron), and bupropion (Wellbutrin) are also “pretty good” and lack significant interactions, Dr. Monoamine oxidase inhibitors (MAOIs) have significant drug-drug and dietary interactions, however. Mirtazapine is a favorite of his consult service, in part because it has a sedating effect and reduces nausea.
Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmalogical options (e.g., behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others.
Antipsychotics are associated with greater risk of cerebrovascular accident (stroke) and mortality in persons with dementia.
aroxetine—otherwise known by the trade name Paxil—is generally not your best friend on the hospital medicine service, according to Leo Pozuelo, MD, FACP, section head of psychiatric consultation at the Cleveland Clinic, who spoke about psychotropic drugs at Hospital Medicine 2013 in National Harbor, Md., in May.
Consider this scenario, which “happens once a month at our hospital,” said Dr. A patient with cardiac disease and diabetic neuropathy is given amitriptyline—a tricyclic antidepressant—to alleviate pain and promote sleep.
Stimulants can help stroke patients with initial psychomotor slowing, as well as with poor appetite, he said, but be aware this is an off-label use.
Methylphenidate (Ritalin) at 2.5 mg twice daily (one dose in the morning and one in the early afternoon), with a few days' titration to 5 mg and then 10 mg twice daily, “hits the mental energy and helps with rehab.The Centers for Medicare and Medicaid Services (CMS) has identified the drugs listed here as posing a higher risk to patients, especially to seniors.Download and print a copy of the CMS High-Risk Medication guide (313KB PDF) Highly anticholinergic (risk of confusion, dry mouth, constipation, blurred vision, drowsiness, hallucinations, difficulty urinating); clearance reduced with advanced age (risk of toxicity); tolerance develops when used as hypnotic.Alternatives: Consider discontinuing or dose reduction (e.g. Disopyramide is a potent negative inotrope and may induce heart failure in older adults.Strongly anticholinergic (risk of confusion, dry mouth, constipation, blurred vision, drowsiness, hallucinations, difficulty urinating) Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.Best to start at 20 to 30 mg and titrate up after a few days and to administer the drug with a meal, Dr. For pain patients, “norepinephrine is the key to treat the pain,” so serotonin- norepinephrine reuptake inhibitors (SNRIs) are a good bet, he said.