Geriatric Pharmacotherapy - Health Psychopharmacology for Therapists

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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 brainWhere 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 SystemsD2 & D3 - Reductions in anterior cingulate cortex, frontal cortex, lateral temporal cortex, hippocampus, medial temporal cortex, amygdala, medial thalamus, and lateral thalamusD1 & D2 Caudate nucleus and putamen.

Serotonin Reduction w AgingDecreased 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 agingStructural 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): 2838. doi: 10.3928/00989134-20090731-01

Benzodiazepines and Elders

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Triangle of Well Being

MINDRELATIONSHIPSBRAIN

AntidepressantsSSRIs More effective and less severe side-effects.

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

TCAs 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): 2838. doi: 10.3928/00989134-20090731-01

Anxiety, nervousness, increase worryApathyCognitive complaints(Difficulty with concentration and memory)ConfusionIrritabilityLack of energy/fatigueLack of feeling of emotionLow motivationSlowed movementsUnexplained somatic complaintsAtypical 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 dementiaAntipsychotic 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): 2838. 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): 2838. doi: 10.3928/00989134-20090731-01Behavioral 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