Psycho Pharmacology Elderly

8/6/2019 Psycho Pharmacology Elderly

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My inner child just turned 65My inner child just turned 65


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Yearly Prevalence RatesYearly Prevalence Rates

Age Ranges Major SubAge Ranges Major Sub--syndromalsyndromal

6565--79 3% 13%79 3% 13%

80+% 4% 18%80+% 4% 18%


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Unrecognized andUnrecognized and

Significantly UnderSignificantly Under--treatedtreated

AgeismAgeism

Inadequate screening:Inadequate screening:

Primary carePrimary care

Diagnostic problemsDiagnostic problems


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Diagnostic IssuesDiagnostic Issues

Symptomatic overlap withSymptomatic overlap with

medical illnessesmedical illnesses::

> fatigue, weight loss, impaired> fatigue, weight loss, impairedconcentration, poor selfconcentration, poor self-- care,care,

psychomotor retardationpsychomotor retardation


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DSM criteria not very usefulDSM criteria not very useful

DSM IV field trialsDSM IV field trialsnot done w/ eldersnot done w/ elders


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Cardinal Features of LateCardinal Features of Late--LifeLifeMajor Depression:Major Depression:

> Disengagement> Disengagement> Anxiety or irritability> Anxiety or irritability (much more than sadness)(much more than sadness)> Pessimism and feelings> Pessimism and feelings

of worthlessnessof worthlessness

> Suicidal Ideations> Suicidal Ideations> PMS> PMS


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Dementia and DepressionDementia and Depression

Very common coVery common co--morbiditymorbidityqq ADLs !!!ADLs !!! Treating depression can be very beneficialTreating depression can be very beneficial

Diagnostic problems: later stage dementiasDiagnostic problems: later stage dementias

>

sudden increase in aggression or>

sudden increase in aggression oragitationagitation

> 5> 5--10 pound weight loss in one month10 pound weight loss in one month

> Persistent tearfulness> Persistent tearfulness

> Screaming> Screaming

> Somatic delusions> Somatic delusions


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General IssuesGeneral Issues

PharmacoPharmaco--kineticskinetics::changes in liver and kidneychanges in liver and kidney

Do no harmDo no harmStart lowgo slowStart lowgo slow


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Side effect sensitivitySide effect sensitivity: *: *

AnticholinergicAnticholinergic: (benadryl, Paxil,: (benadryl, Paxil,

tricyclicstricyclics [e.g. Elavil][e.g. Elavil], Cogentin) :, Cogentin) :constipation, urinary retention,constipation, urinary retention,

aggravates glaucoma,aggravates glaucoma, memorymemory

problemsproblems, delirium, delirium


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Side effect sensitivitySide effect sensitivity::SedationSedation: (: (RemeronRemeron,, TrazodoneTrazodone,,

antipsychotics, TCAs, moodantipsychotics, TCAs, mood

stabilizers, tranquilizers!!!!! )stabilizers, tranquilizers!!!!! )decreased: activity, cognitivedecreased: activity, cognitive

impairment, increased fallsimpairment, increased falls


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Side effect sensitivitySide effect sensitivity::ExtrapyramidalExtrapyramidal Side Effects:Side Effects:

tremors, gait problems, muscletremors, gait problems, muscle

spasms, inner restlessness.spasms, inner restlessness.(older antipsychotics,(older antipsychotics, RisperdalRisperdal,,sometimes SSRIs):sometimes SSRIs):aggravates Parkinsonaggravates Parkinson SxSx, falls, falls


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Side effect sensitivitySide effect sensitivity: Cardiac: Cardiac

Orthostatic Hypotension:Orthostatic Hypotension: **

antipsychotics,antipsychotics, trazodonetrazodone

Increased Blood Pressure:Increased Blood Pressure:

EffexorEffexor (12%);(12%); PristiqPristiq


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Side effect sensitivitySide effect sensitivity::

Serotonin Reuptake InhibitorsSerotonin Reuptake Inhibitors::

> activation> activation


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DrugDrug--Drug Interactions:Drug Interactions:

> Especially with Prozac and Paxil> Especially with Prozac and Paxil

sometimes:sometimes: WellbutrinWellbutrin

2D6 enzyme inhibition2D6 enzyme inhibition

> Pain medications> Pain medications

> St. Johns> St. Johns WortWort

>> CelexaCelexa andand LexaproLexapro: least: least


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Forgetfulness about taking medsForgetfulness about taking meds

Sharing medicationsSharing medications

Prescribing Cascade..Prescribing Cascade..exampleexample


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Polypharmacy Cascade: Case IPolypharmacy Cascade: Case I

78 year old female78 year old female

Hip fracturerecoveringHip fracturerecovering

Cognitive impairmentCognitive impairment

Mild high blood pressureMild high blood pressure

Urinary incontinenceUrinary incontinence


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Polypharmacy Cascade: Case IPolypharmacy Cascade: Case I

Ativan 0.5 mgAtivan 0.5 mg twice a daytwice a day Lorazepam 0.5 mgLorazepam 0.5 mg twice a daytwice a day Tylenol with codeineTylenol with codeine ProzacProzac DiureticDiuretic TrazodoneTrazodone BenadrylBenadryl


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A Few Specifics: AntidepressantsA Few Specifics: Antidepressants

Anergic DepressionsAnergic Depressions::

>>WellbutrinWellbutrin (very few cardiac SE)(very few cardiac SE)

very robust: N: 350 MDD86% 50%+very robust: N: 350 MDD86% 50%+ qq

HAMHAM--D and marked improvement inD and marked improvement in

social functioningsocial functioning

> R & R:> R & R: Ritalin and RemeronRitalin and Remeron


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Agitated DepressionsAgitated Depressions::> Watch for delirium and mania> Watch for delirium and mania

>> RemeronRemeron (some evidence: quicker response)(some evidence: quicker response)start with 7.5 mg qdstart with 7.5 mg qd

>> SSRIs with benzo augmentationSSRIs with benzo augmentation


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Psychotic DepressionsPsychotic Depressions::

> Common> Common

> Cautions: with Wellbutrin> Cautions: with Wellbutrin

> Must use AD and anti> Must use AD and anti--psychoticspsychotics

> ECT> ECT


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Psycho Pharmacology Elderly