Geriatric Pharmacotherapy - Health Psychopharmacology for Therapists

PsychopharmacologyLecture 14 - Psychopharmacology of Aging

Colorized image of axon button with vesical of neurotransmitters

Gladys Wilson is in the later stages of her experience of dementia - we often step back & let the person go seeing only a shell. This teaches us that everybody can be reached. I felt some discomfort watching initially but had to put that down to my arrogance when I saw the end,

Validation Therapy

Here is the work…

Modern culture has created the illusion that the

self is in the brain

Where Is The Self?

Some Factors in Aging

Ages of Brain Maturity

Aging Mind – Aging Brain – Aging Self

Aging Mind and Neurodegeneration

Aging Mind

Environmental Changes

Dopamine Reduction w Aging• Dopamine – Aging brains have

changes in dopamine synth., receptors and binding sites. • Dopamine loss may relate to loss of

brain tissue, change in cognitive flexibility, and postural rigidity. • Specific Systems• D2 & D3 - Reductions in anterior

cingulate cortex, frontal cortex, lateral temporal cortex, hippocampus, medial temporal cortex, amygdala, medial thalamus, and lateral thalamus• D1 & D2 – Caudate nucleus and

putamen.

Serotonin Reduction w Aging• Decreased levels of serotonin

receptors. • Specific Systems: • S2 Receptor declines in

caudate nucleus, putamen, and frontal cerebral cortex, decline with age. • Decreased binding capacity

in frontal cortex (5-HT2)• Decreased 5-HHT

transporter in the thalamus and the midbrain.

• Glutamate reduction is found in normal aging.

• Specific Areas:

• Motor Cortex (Normal Aging)• Parietal lobe (Dementia)• Basal ganglia (Dementia)• Frontal lobe (Normal Aging)

Glutamate Reduction w Aging

• Decreased dendritic arboring (responsible for the majority of loss in brain density with aging). • Brain Area Loss: Insular, Superior

parietal gyri, Frontal and temporal cortex, Putamen, Thalamus, and Accumbens.• Neurocognitive Changes:

processing speed, executive functions, and episodic memory--are seen in healthy aging

Structural and Functional Changes in Normal Aging

• Benzodiazepines most common antianxiety medications prescribed for elders: alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonopin), diazepam (Valium), and temazepam (Restoril) • Elimination and Clearance rates are reduced in elders. • Increased magnitude of sedation, memory, and psychomotor impairment. • Long-term use is contraindicated due to exacerbation of cognitive decline, and increased fall rates.

Psychotropic Medication Use among Older Adults: What All Nurses Need to Know. J Gerontol Nurs. 2009 September; 35(9): 28–38. doi: 10.3928/00989134-20090731-01

Benzodiazepines and Elders

Aging

well

Outlook on Life

• Mental Health• Self-Efficacy• Valued by

community spirituality

Connections• Piratical

support• Social support• Engagement in

life • Hoppy

Physical Health

• Physical activity• Nutrition and food

security• ADLs• IADLs

Triangle of Well Being

MIND

RELATIONSHIPS

BRAIN

Antidepressants• SSRIs – More effective and less severe

side-effects.

• SSRI - Side-effects include headache, gastrointestinal disturbances, increased sweating, and sexual dysfunction.

• TCA’s increase risk of falls, psychomotor retardation, sedation, orthostatic hypotension, anticholinergic effects (e.g. blurred vision and cognitive impairment)

Psychotropic Medication Use among Older Adults: What All Nurses Need to Know. J Gerontol Nurs. 2009 September; 35(9): 28–38. doi: 10.3928/00989134-20090731-01

• Anxiety, nervousness, increase worry

• Apathy• Cognitive complaints(Difficulty

with concentration and memory)• Confusion• Irritability• Lack of energy/fatigue• Lack of feeling of emotion• Low motivation• Slowed movements• Unexplained somatic complaints

Atypical Symptoms of Depression in Elders

• Frequently administered for behavioral disturbances.

• Older adults are more at risk for tardive dyskinesia, acute extrapyramidal side effects (EPSEs), and neuroleptic malignant syndrome (NMS).

• “U.S. Food and Drug Administration (FDA) have emerged regarding the use of these medications with older adults due to cardiac, cerebrovascular, and mortality risks associated with their use in patients with dementia”• Antipsychotic drugs can cause parkinsonism and lower the seizure

threshold, elderly patients with a history of Parkinson's disease or seizure disorders should be monitored closely. Psychotropic Medication Use among Older Adults: What All Nurses Need to Know. J Gerontol Nurs. 2009 September; 35(9): 28–38. doi: 10.3928/00989134-20090731-01

Antipsychotic Medications for Elders

• Cohen-Mansfield (2005) recommended the following non-pharmacological interventions to prevent or manage disruptive behaviors: • Social support and contact (e.g., talking with the person,

video or audiotapes of family members, music therapy, pet therapy, dolls, massage)

• Engaging activities (e.g., stimulation, active engagement, and allowing self-stimulation)

• Relief from discomfort (e.g., pain, hearing or vision problems, positioning, and addressing activity of daily living needs).

Psychotropic Medication Use among Older Adults: What All Nurses Need to Know. J Gerontol Nurs. 2009 September; 35(9): 28–38. doi: 10.3928/00989134-20090731-01

Behavioral Interventions for Behavioral Challenges

• Lithium:• has been commonly prescribed. Due to

changes in metabolism and low threshold for lethalitythis medication needs close monitoring.

• Anticonvulsants:• Are commonly prescribed and reportedly well

tolerated. sedation, tremor, and gait disturbance, were common in bipolar PT prescribed medications. Depakote half-life is prolonged.

Young, R. (2005) Evidence-Based Pharmacological Treatment of Geriatric Bipolar Disorder.

Anticonvulsants and Lithium