ACUTE AGITATION = oral BZD when possible 1) VERBAL DE ESCALATE

2) SHOW OF FORCE
Antipsychotic first line if: 3) RESTRAINT
Already on antipsychotic 4) SEDATE = manage airway
Psychotic symptoms
Intense agitation/physical danger
BZDs havent worked

1st = Oral Diazepam (5-20mg 2-6 hourly) /Lorazepam

2nd = Olanzapine/Respiridone/Haloperidol PO

3rd = IM Midazolam (2.5-10mg IM repeat 20/60) /Olanzapine/Droperidol

ANTI PSYCHOTICS = Mainly block dopamine in mesolimbic pathway

Acute Rx psychosis: diazepam 5-20mg PO / midazolam 2.5-10mg IM olanzapine 5-10mg PO/IM

BASAL GANGLIA = Nucleus acumbens (Mesolimbic pathway) = controls delusions/hallucinations

Increased dopamine = delusions/hallucinations

TREAT = Decrease dopamine

Nigrostriatal pathway = Movement control PARKINSONISM
Hypothalamus = Dopamine inhibits Prolactin = INCREASED PROLACTIN
Nigrocortical pathway = Frontal lobe = NEGATIVE SYMPTOMS

Indications
Schizophrenia = Olanzapine IM in acute agitation
Psychotic disorders
Mood disorders with mania/psychosis = Olanzapine acutely / Quetiapine for biopolar/MDD
Generalised Anxiety Disorder
Behavioural disturbance in elderly = Respiridone
Delirium = Olanzapine

Onset = immediate calming and decrease in agitation - thought disorder respond in 2-4/52

Use = DONT COMBINE THEORETICALLY BUT DO IN REAL LIF E

All are equally effective but atypical has better side effect profile
o All moderately treat the positive symptoms Can add Lithium if resistant
o Only clozapine treats negative symptoms
o Choose a drug the patient has responded to in past
Route = PO, SA or LA depot for IM injections, sublingal
Duration = minimum 6/12, usually for life

Long Acting = deep IM injection received on outpatient basis - takes time to reach levels
Schizophrenia or chronic psychosis who relapse because of non adherence
Start at low dose then titrate every 2-4 weeks
AE = EPS, Parkinonism, increased NMS
TYPICALS = Dopamine receptor antagonists D2
Chlorpromazine, Pericyazine, Thioridazine / Haloperidol, Fluphenazine, Flupenthixol
Used as 2nd line Rx
IM works faster Can give depo
Effective for Rx of the positive sxs & for sedation (eg. if agitated)

SE = EPSE, NMS, Increased prolactin

Marked sedation
Thioridzine = QTc + Sedation + Anticholinergic
Chlorpromazine = sediation + postural hypo + anti SLUDGE + long QT + photosensitivity

ATYPICAL = Serotonin-Dopamine Antagonists (SDAs)

Used as 1st line Rx for schizophrenia & psychosis
Antagonises different dopamine receptors as well as 5-HT receptors
Very effective for negative Sx and and effective for +ve Sx
Minimal or no extrapyramidal Sx (except risperidone) due to looser bonding at D2-receptor sites

Disadvantages:
Expensive
Metabolic SE weight gain, hyperglycaemia, lipid abnormalities
Clonzapine: SE of agranulocytosis Blood monitoring system

Risperidone Olanzapine Quetiapine Clozapine

(Respiridal) (Seroquel)
Mech Blocks 5-HT, D2 & Blocks 5-HT, D1-D4, Blocks 5-HT, D1 & Blocks 5-HT, D1-D4,
adrenergic muscarinic, D2, adrenergic & muscarinic, and
receptors adrenergic and histaminergic histaminergic receptors
histaminergic
receptors
Adv Low incidence of Well tolerated Associated with less Most effective for Rx-
EPS at LD (<8mg) weight gain cf resistant schizophrenia
Low incidence EPS, clozapine & DOESNT worsen TD
TD olanzapine ~50% pts benefit
Disadv Insomnia, agitation, Mild sedation, Headache, Drowsiness/sedation,
, anxiety, prolactin, insomnia, dizziness, dizziness, hypersalivation,
postural hypoTN, minimal constipation tachycardia, dizziness,
constipation, anticholinergic EPS, NMS
dizziness, weight Most sedating 1% agranulocytosis
gain Early AST/ALT rise,
Metabolic Dry mouth Weight gain
EPSE! syndrome Postural hypo
Somnolence
Weight gain in 7%
Comments Quick dissolve & ACUTE ACUTE Weekly blood counts for
long acting 1 month then 2-wkly
formulations/ depo Acute use in ED No EPSE DO NOT use with dugs
Use if they have that BM suppression
Lasts 8 hours Parkinsons
Dose SD 1-2mg OD/BD SD 5mg/d PO SD 25mg PO BD SD 25mg PO BD
TD 4 8mg/d PO TD 10-30mg/d PO TD 400-800mg/d TD 300 900mg/d PO
PO
Aripirazole (Albilify) = block DA receptors but also DA agonistic
Helps negative symptoms
Less weight gain, No PRL
Rarely causes EPSE but akathisia + agitation in first 6 weeks, N/V, constipation, headache, insomnia

Paliperidone (Invega) = metabolite of respiridone very similar

QTc prolongation

Amisulperide = mainly D2/D3 no effect on serotnonin

No EPSE
Helps negative symptoms at low dose

Ziprasidone = only 2nd gen not associated with weight gain

AE = QT prolongation ECG
Least weight gain

Clozapine = atypical atypical blocks serotonin 2 receptors in prefrontal cortex which increases dopamine
Taken twice daily
Good for negative symtpoms can mask psychotic smyptoms

Indications:
1) Lack of improvement despite use of 2 antipsychotics for 4-6 weeks
2) Inability to achieve benefit from other antipsychotics because of severe SE

Contraindications:
Previous hypersensitivity to clozapine
Hx of granulocytopenia / agranulocytosis (from clozapine or otherwise)
BM disorders or BM suppressive drugs
Circulatory collapse and / or CNS depression due to any cause.
Alcoholic and other toxic states
Severe renal or cardiac disease (e.g. myocarditis)
Severe hepatic disease including active liver disease
Uncontrolled epilepsy
Paralytic ileus

Pharmacology = taken twice a day absorbed by GIT tract

T = 10-16 hours
Comes in 25 and 100mg tablets
Dose = start at 12.5 or 25 mg - usually 300 but max 900
CI = other BM suppression drugs, Lithium

Less AE = no EPSE or PRL BUT SOME SERIOUS ONES

Sedation, dizzy, syncope, hypos, tachy, N/V, fever, hypersalivation
Anticholinergic, fatigue, constipation, weakness
Metabolic syndrome = Dyslipidaemia
SEVERE = Seizures, Myocarditis (FIRST FEW DAYS) , Cardiomyopathy (LATE)
Causes agranulocytosis (1-2%) = blood test weekly occurs in first 3/12
o Stop Clozapine when WBC < 3/ NC < 1.5

MOINITOR = weekly FBE for first 3/12 then monthy

CRP/Trops weekly for 4/52, then 3/12 then annually
Baseline ECG/ECHO repeat 6/12 then yearly
BMI, Waist circumference, BSL/Lipids
Clozapine levels

Interruption = if > 48 hrs start against on 12.5 mg and titrate up + more monitoring
SIDE EFFECTS
Anticholinergic Blind as a bat (dilated pupils)
Red as a beet (vasodilation)
Hot as a hare (hyperthermia)
Dry as a bone (dry skin)
Mad as a hatter (hallucinations/agitation)
The bowel and bladder lose their tone (constipation, urinary retention)
And the heart runs alone (tachycardia)
-adrenergic Orthostatic hypotension, impotence, failure to ejaculate
blockage
Dopaminergic EPS (dystonia, akathisia, pseudoparkinsonism, dyskinesia), weight gain
blockade
Gynaecomastia, galactorrhoea, amenorrhea, anovulation, decreased libido/arousal,
Hyper prolactin impotence, anorgasm
Anti-histamine Sedation (Most at initiation/titrating up = DRIVING RISK)
Hypersensitivity Liver dysfunction, blood dyscrasia, skin rashes, Neuroleptic malignant syndrome,
altered temp
Endocrine Metabolic syndrome
Cardiac QTC prolongation = Torsades Male = 430 ms Female = 450 ms

NEUROLEPTIC MALIGNANT SYNDROME = due to massive dopamine blockade,

incidence with high potency & depot neuroleptics
Risk Factors: sudden increase in medication/new drug, medical illness, dehydration, exhaustion, poor
nutrition, external heat load, male, young adult
Presentation
o fever, autonomic reactivity (sweating, BP), rigidity, dystonia, akinesia, mental state changes
o Develops over 24-72hours
o Labs: CK, WCC, myoglobinuria
Features
Treatment Requires hospital admission and urgent treatment
Fever
o Discontinue drug, hydration, cooling blankets
Encephalopathy
o Dantrolene (used as muscle relaxant) and bromocriptine (DA agonist)
Vitals unstable
5% mortality
Elevated WBC/CPK
Rigid
EXTRAPYRAMIDAL SYMPTOMS = from dopamine blockage
Incidence related to increased dose and potency
Acute (early-onset; reversible) vs tardive (late-onset; often irreversible)

Dystonia Akathisia Pseudoparkinsonism Dyskinesia

Acute/Tardive Both Both Acute Tardive
Risk Group Acute: young asian & Elderly females Elderly females
black males
Presentation Sustained abnormal Motor restlessness; Tremor Purposeless,
posture; torsions, crawling sensation Rigidity (cogwheel) constant
twisting, contraction
in legs relieved by Akinesia movements
of muscle groups, walking; very Postural instability involving facial
muscle spasms (i.e. distressing, (/absent arm-swing, and mouth
laryngospasm, increased risk of stooped posture, musculature or
torticollis) suicide and poor shuffling gait, difficulty less commonly,
Beware Larynx adherence pivoting) limbs
Onset Acute: within 5 daysAcute: within 10 Acute: within 30 days >90 days
Tardive: > 90days days
Tardive: > 90days
Treatment Acute: benztropine Lorazepam, Acute: benztropine No good
DECREASE or diphenhydramine propanolol or treatment,
DOSE diphenhydramine Prevention only
**benztropine, amantadine, diphenhydramine = anticholinergic agents (antiparkinsonian)
ANTIDEPRESSANTS = Block reuptake = Serotonin/Noradrenaline Block enzymes = MAO/COMT
Onset = neurovegetative 1-3/52, emotional/cognitive 2-6/52
May use mild stimulant (methylphenidate) for severe neurovegetative sx briefly
Patients at risk of suicide over first 2/52 = neuroveg resolve while emotional/cognitive dont
Once improved = 6-12 month course to prevent relapse
o 2nd episode = 5 years
o 3rd episode = Lifelong AVOID ALCOHOL
Must take drug daily

AE Common = N/V, Diarrhea Weight gain Sexual dysfunction

Postural hypo, tachycardia Sedation/Agitation Insomnia

Withdrawal = Depends on t and patient sensitivity Tape TCAs slowly

Bipolar Depression = DONT USE MONOTHERPAY as can trigger mania

Mood stabiliser + SSRI/bupropion
Already on a mood stabiliser = add/switch to lithium/lamotrigine

How to choose antidepressant = 50% respond to initial assess at 2-4/52 START LOW THEN INCREASE
Well = continue dose
No response = increase dose -> assess at 2-4/52
o Partial response = increase dose
o No response = change

Which drug? = All SSRIs have similar effectiveness, but consider side effects and half lives
Bupropion causes less sexual dysfunction, weight gain and sedation but is CI for patients with PHx of seizure,
stroke, brain tumour, brain surgery, closed head injury
Mirtazapine useful if insomnia or agitation are prominent, or to Rx depression with cachexia
Sertraline, citalopram, escitalopram least interactions with other drugs & sleep-wake neutral
Fluoxetine and paroxetine most activating drugs, taken in the morning
Fluvoxamine always sedating, taken in the evening
Moclobemide = no sexual dysfunction

COMBO = Californian Rocket Fuel = Mirtazapine + Venlafaxine (fewer AE + better tolerated for resistant)

SELECTIVE SEROTONIN RE UPTAKE INHIBITOR - trial 2 SSRI for 4-6/52 then move to another class
Citalopram (Cipramil) = not for oldies with heart stuff (20mg max 40mg) Prolonged QT
Fluoxetine (Prozac) = best for teenagers (20mg mane long t so less likely to get discontinuation syndrome)
Fluvoxamine (Movox) = (100mg nocte)
Paroxetine (Aropax) = (20mg, mane) HTN, Weight gain , Sexual dysfunction
Sertraline (Zoloft) = OCD SD 50mg, TD 50-200mg Diarrhea
Escitalopram (Lexapro) = depression w/anxiety lowest issue with libido (SD 10mg, TD 10-20mg) Less AE

Use depression (typical & atypical), anxiety, OCD, eating disorders

MoA Selectively inhibits CNS serotonin reuptake

SE Few (even at high doses (i.e. safe in overdose) better compliance

CNS: tremor, insomnia, headache, drowsy, initial anxiety may occur (suicide risk) Rx w BZDs
GI: N/V, diarrhoea, abdo cramps, weight loss GIT bleed
Sexual dysfunction, impotence, anorgasmia (most common)
CVS: HR, conduction delay
Serotonin syndrome, EPS SIADH ( hyponatriaemia in elderly) CHECK UEC

OD Safe
Interactions inhibits P450
SEROTONIN NORADRENALINE REUPTAKE INHIBITOR (SNRI)
Desvenlafaxine(Pristiq) Venlafaxine (Efexor) = 75-375mg
Use Depression & anxiety, PTSD, OCD Fibromyalgia, Hot flushes, Incontinence
MoA Blocks noradrenaline and serotonin (5HT) Like a suped-up SSRI; efficacy with matching toxicity

SE LD insomnia HD tremors, tachycardia, sweating, hypertension (diastolic) Sexual dysfunction

OD Seizures, Tachycardia and N&V Taper slow
Interactions: MAOI, SSRI

REVERSIBLE INHIBITOR OF MONOAMIDE OXIDASE (RIMA) Moclobemide (Arima)

Use Refractory depression to other therapies
MoA Reversible inhibitor of monamine oxidase A (MAO-A) to CNS monoamines (NA and 5HT)

SE Only antidepressant that does not cause sexual dysfunction; SEs similar to SSRIs otherwise
OD Fatal overdose if combined with citalopram or clomipramine NO CHEESE REACTION

NORADRENERGIC AND SPECIFIC SEROTONERGIC AD (NaSSA) Mirtazapine (Avanza)

Use patients with insomnia, agitation or depression with cachexia
MoA Blocks 2-receptors 5HT & NA, & also block 5HT2, 3 receptors, enhancing 5HT1 serotonergic
transmission. **Good for elderly w insomnia/low appetite
Have long elimination lives, allowing once daily dosing

SE: Weight gain, Sedation, postural hypotension, dry mouth

Interactions: MAOI, SSRI, SNRI, RIMA OD: Less lethal

2nd Line Pharm. Rx (MDD)

TRICYCLIC ANTIDEPRESSANTS (TCAs) Amitriptyline, Nortriptyline, Imipramine, Clomipramine
Use Melancholic depression, OCD (clomipramine)
MoA Non-selective reuptake inhibitors of 5HT & NA
Extensively metabolised in the liver, Long life once-daily admin, usually in the evening

SE Prolonged QRS and arrythmias

Anticholinergic SE = dry mouth, blurred vision, constipation, urinary retention
Noradrenergic SE tremors, tachycardia, sweating, insomnia, erectile dysfunction
-1 adrenergic: orthostatic hypotension, weight gain, sedation
Antihistamine sedation, weight gain
CNS seizures DELIRUM IN ELDERLY

OD Toxic 3x therapeutic dose is lethal = anticholinergic, CNS stimulation, then depression & seizures
ECG: prolonged QT
Rx activated charcoal, cathartics, supportive Rx, IV diazepam for seizure

C/I CVS disease, glaucoma, bladder neck obstruction.

MONOAMIDE OXIDASE INHIBITOR (MAOIs) Phenelzine (irreversible no selective)

Use depression that doesnt respond to SSRI or is atypical
MoA irreversibly inhibit MAO-A & MAO-B NA & 5HT in brain and other tissues.
Duration of action = 2-3 weeks while new enzymes form.

SEs Hypertensive crisis w tyramine foods (wine, cheese) headache, flushes, palpitations, N&V,
photophobia ONLY WITH NON SELECTIVE
Dizziness, tachycardia, postural hypotension, sedation, insomnia, weight gain
Social dysfunction, energy
Minimal anticholingeric & antihstamine**

Interacts: alcohol, noradrenergic medications (TCA, decongestants, amphetamines), SS with SSRIs

NORADRENALINE DOPAMINE REUPTAKE INHIBITOR (NDRI) Bupropion

Use Depression, seasonal depression; also eating disorders, smoking cessation NOT for anxiety
MoA Blocks noradrenaline & dopamine
SE Less than others
OD tremors and seizures
C/I drugs and states (conditions) that reduce seizure threshold

SEROTONIN SYNDROME = rare, more common with SSRI/ MAO I together Within 24 hours
Rare but potentially life-threatening, Due to over-stimulation of the serotonergic system
SSRIs SHOULD NOT be co-administered with a MAOI, lithium or L-trytophan as 5HT levels
Can myoclonus, seizures, hyperthermia, rigor, H tonia delirium, coma & CVS collapse, death
SSRI + MAOI / Serotenergic TCA (Clomipramine, Amitriptyline) Tramadol/Pethidine

COGNITIVE = headache, agitation, hypomania, confusion, hallucination, coma

AUTONOMIC = shiver, sweat, hyerpthermia, HTN, tachycardia, nausea, diarrhoea, dilated pupils, flushed

NEUROMUSCULAR HYPERREACTIVITY = myocolonus, Hreflexia, tremor, ocular clonus, muscle rigidity,

Babinski signs

Mx = Discontinue medication, administer emergency care = O2 > 94, IV fluids, cardiac monitor
Severe = Cyproheptadine (5 HT antagonist) bolus 12 mg PO then 2mg every hour
If hyperthermia = Rapid Sequency intubation

Hyperthermia
Autonomic instability
Rigidity
Myoclonus
Encephalopathy
Diaphoresis

DISCONTINUATION SYNDROME
Caused by abrupt cessation of antidepressant, most frequently paroxetine, fluvoxamine, venlafaxine
Sx begin within 1 3 days: anxiety, insomnia, irritability, mood lability, N/V, dizziness, headache, Dystonia,
tremor, chills, fatigure, lethargy, myalgia
Rx: restart antidepressant at same dose patient was taking, & initiating a slow taper over several weeks

Flu like
Insomnia
Nausea
Imbalance (Dizzy)
Sensory disturbance
Hyperarousal (anxiety/agitation)

MOOD STABILISERS Before initiating = FBE, UEC, CMP, FBG, TFT, ECG, Urinalysis + ACR (BHCG)
Can use Olanzapine (good for pregnancy)
LITIHUM = harder to take but more effective
Use Acute mania, maintenance of bipolar disorder, augmentation antidepressants, schizoaffective,
chronic aggression & antisocial behaviour, recurrent depression

MoA Unknown; therapeutic response within 1-2weeks ( ?acute coverage w BZD pr antipsychotic)

Dose Start at 300mg, titrate up to 900-1800mg/day ACUTE = 750-1500mg

Adult: 600-1500mg/d Geriatric 150-600mg/d (once daily dosing)
Taper slowly if ceasing. If taken erratically, efficacy diminishes and may not work again

Monitoring BASELINE = FBE, ECG, Urinalysis, UEC, TSH, Blood urea nitrogen
Monitor serum levels until therapeutic - always wait 12h after dose
Lithium Levels = biweekly/monthly until steady state is reached, then every 2 months
Aim = 0.6-0.8 mmol/L ACUTE = 0.8-1.2mmol / L
Every 6 months: thyroid and renal (Cr) function; every year urinalysis, CMP, PTH

Side effects Withdrawal over 2/12 as can have withdrawal

GI, CNS (fine tremor, headache), haem (reversible leucocytosis)
Renal = polyuria, renal failure, microalbimunira
Thyroid = hypothyroidism and hyper PTH
Cardiac = Sinus blocke Serotonin syndrome
Acne and psoriasis Weight gain hypo TH
Teratogenic (Ebsteins anomaly) ECG Muscles weakness

Combinations with sodium valproate or carbamazepine in non-responders

Interactions NSAID, ACEi/ARB, Antidepressants (SSRI), Anti epileptics, Anti psychotics, Diuretics
AVOID CALICUM CHANNEL BLOCKERS = rare fatal neurotoxicity

Lithium toxicity = diagnose clinically = overdose, Na/Fluid loss/medical illness TOXIC > 1.5mmol/L
Sx: GI N&V and diarrhoea;
Cerebellar ataxia, slurred speech, loss of coordination,
Cerebra drowsy, myoclonus, chorea/parkinsonism, UMN signs, seizures, delirium, coma

Management = Discontinue lithium for several doses restart at lower dose when was non-toxic
Serum lithium levels, UEC, renal function tests
Saline infusion + Hemodialysis if lithium >2mmol/L, coma, shock, severe dehydration, failure to respond
in 24h, deterioration

Sodium Valproate SD 200-400mg BD; TD 1500-3000mg Therapeutic level = 660+mol/L

Alternative; also 1st line Rx acute mania & bipolar maintenance; Antidepressant action in 1/3 of pts.
Better tolerated in ELERLY can combine with lithium for nonresponders/rapid cyclers
SE: alopecia, weight gain, hepatitis (initial) tremor and sedation. Iatrogenic (neural tube defects),
pancreatitis (ongoing), GIT, Angranulocytosis Baseline= FBE, UEC, LFT and repeat 3/12

SECOND LINE
Carbamazepine (Tegretol) 400-1600mg/d (BD, TDS), Therapeutic level = 350-700mol/L
2nd line Rx for acute mania & bipolar prophylaxis = non-responders, rapid cycling
Potent enzyme inducer so many drug interactions (eg. warfarin, OCP)
Weekly blood counts for first months risk of agrunylocytosis
AE = hepatitis, agranulocytosis, drug interactions, rash, sedition, CNS toxicity (ataxia, diplopia, dizzy)

Lamotrigine (Lamictal) =2nd line Rx bipolar, also mania & depression

inhibits 5-HT3 & potentiates Da activity
SE: CNS dizziness, headache, ataxia, nausea, fever, anxiety, skin: rash, Steven-Johnson syndrome (0.1%)
ANIXIOLYTICS/HYPONOTICS = mask or alleviate symptoms, DO NOT CURE
Indications
 Acute anxiety = BZA
Chronic anxiety
o Anti depressant = SSRI Venladaxine
o Mirtazapine = sedative, increase appetite and weight gain
o Buspirone MAO I/TCA
Panic disorder = Clonazepam + Paroxetine
OCD = SSRI
Insomnia
o BZD = Flurazepam, Temazepam
o Trazodone
o Non BZD = Zolpidem (Still nox) , Zaleplon
o Quetiapine = may cause daytime sedation
o Ramelteon = Melatonin receptor agonist
Agitation in dementia
EPSE
Seizure disorders, MSK disorders

Relative Contraindications = MDD, History of drug/alcohol abuse, Pregnancy/Breastfeeding

BENZODIAZEPINES = potent binding of GABA to receptors = neuronal activity

Should be used for limited periods (week months) to avoid dependence
All benzodiazepines are sedating; all have similar efficacy

High potency = Alprazolam (Xanax), Clonazepam Good for panic attacks

Rapid onset = Diazepam (2-40mg/d), Triazolam Worse withdrawal

Slow onset = Oxazepam Builds up Impairs concentration/memory

Very short = Midazolam t 1/2 < 6 hours

Short = Oxazepam/Temazepam t 6-12 hours Temazepam = sleep
Medium = Lorazepam 12=24 hours Better for elderly
Long = Diazepam >24 hours

Side effects
Cognitive Impairment= memory impairment, drowsy
Behaviour disinhibition = hostility, aggressive, rage reaction, irritability
Psychomotor impairment = synergistic effects with alcohol -
Physical dependence, tolerance

Withdrawal = Taper slowly over weeks to months (otherwise risk of withdrawal reactions)
LD withdrawal: Flu like, HR, HTN, panic, insomnia, anxiety, memory & concentration, perceptual
HD withdrawal: hyperpyrexia, seizures, psychosis, death

Onset: 1 2 days (short-acting), 2 4 days (long acting) Duration: weeks to months

Cx: >50mg diazepam: seizures, delirium, arrhythmias, psychosis = similar to bad etOH withdrawal; can be fatal
Rx: taper with long-acting benzodiazepine

Overdose = commonly used, rarely fatal, more dangerous & can lead to death if combined w depressants
Rx: Flumazenil (benzodiazepine antagonist)

Buspirone =Partial agonist of 5-HT receptors Generalised Anxiety Disorder

Preferred to BZD bc: non-sedating, no interaction with alcohol, no affect on seizures, not prone to abuse
Onset of action at 2 weeks
Side effects: dizziness, drowsiness, nausea, headache, nervousness

STIMULANTS = decrease hyperactivity, increase attention, reduce impulsivity

 Critical for success in school
Short duration of action = 2-3 daily dose school nurse

Methylphenidate (Ritalin) Dextroamphetidine

AE = poor appetite (dose after breakfast), growth impairment (catch up), poor sleep, tics

CHOLINESTERASE INHIBITORS = increase synaptic Ach

Mild moderate Alzheimers
Delays decrease in function and memory loss

Donepizil (Aricept)
Rivastigmine (Exelon) = more AE
Memantine (Namenda)