New drugs in the long-term care setting, part 1: a quick look at the benefits, uses and abuses of some recent candidates for LTC formularies - Feature Article

Nursing Homes, May, 2002 by James W. Cooper

Anti-infectives

While amoxicillin, trimethoprim/sulfamethoxazole (TMP/SMX) (Septra/Bactrim), erythromycin and doxycycline are still flrstline drugs for upper and lower respiratory tract infections, it is important to save Ceftin, Vantin, Spectracef, Avelox, Levaquin and Tequin for cases involving resistant pneumococcus, Moraxella catarrhalis and Haemophilus influenzae. It is especially critical for clinicians to follow residents' renal function when they are receiving Tequin and Levaquin; otherwise, more confusion, delirium, disorientation and seizures will be seen, especially in those residents with a seizure or stroke history. It is critical for clinicians to restrict the use of Zyvox and save it for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) as it is the only oral drug that is effective against them.

Newer Psychotropics

Most of the newer atypical anti-psychotics (Risperdal, Zyprexa and Seroquel) are clearly safer and more cost-effective than the older antipsychotics (Mellaril, Thorazine, Stelazine and Haldol). Mellaril has been removed from the market in the United Kingdom as a result of retrospective evidence of a much higher rate of sudden cardiac deaths possibly related to its use.

Risperdal is the most used atypical. In as-yet-unpublished research I have conducted on the atypicals, Risperdal was the least sedating at 0.5 to 1.5 mg/day, and least likely to increase fall risk. Zyprexa was much more sedating, even at a lower dose of 2.5 to 10 mg/day, and the most likely of the three atypicals to increase falls. Seroquel was also sedating at the 25 to 100 mg/day recommended in older adults, and intermediate in fall risk.

Even the newer atypicals can affect the heart, and the newest atypical, Geodon, is not recommended in the elderly because of its association with arrhythmias.

A newly recognized problem--and potential benefit in the older adult--of the atypicals is weight gain. This might be beneficial in residents with significant psychoses and poor appetite. On the other hand, the weight gain might be so significant in well-nourished adults that new-onset type 2 diabetes or worsening diabetic control in previously well-controlled patients could be seen. Interestingly, this effect appears to occur in direct relation to the drugs' sedation effects (i.e., with Zyprexa, Seroquel and Risperdal).

Antidepressants are increasingly being used in long-term care residents for three reasons: (1) to treat depression or depressive symptoms, which might be seen in 30% or more of residents and can be an early indication of dementia; (2) to treat anxiety, depressive symptoms and agitation in early to midstage dementia; and (3) to replace or allow tapering of anti-anxiety agents called benzodiazepines (BZs). The BZs can be especially harmful to the elderly because they cause cognition and motor impairment, as well as fall risks, related to their length of action. For example, Valium, Librium, Tranxene, Centrax, Paxipam, Dalmane and Klonopin might be active for as long as 200 hours; Ativan, Xanax, Restoril and Doral are active for up to 24 hours; and Halcion and Serax, 6 to 9 hours.