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Psychotropic Medications in the Elderly: A Comprehensive Study Guide, Study Guides, Projects, Research of Psychiatry

Virginia State University (VSU)Psychiatry

This guide offers a concise overview of prescribing psychotropic medications to elderly patients, highlighting physiological and pharmacological considerations. It covers geriatric prescribing principles, including screening, lab studies, drug interactions, and strategies for medication compliance and minimizing adverse effects. It details medications to avoid, age-related changes affecting drug metabolism, and guidelines for treating common psychiatric conditions like depression and anxiety. Emphasizing low starting doses and slow titration, it stresses careful monitoring and risk-benefit assessment. Useful for medical students, residents, and healthcare professionals, it aims to enhance knowledge in geriatric psychopharmacology, ensuring safer, more effective treatment. It also includes suicide assessment, antidepressant treatment, and the impact of comorbid anxiety, while addressing alternative causes of anxiety and depression.

Typology: Study Guides, Projects, Research

2024/2025

Available from 08/02/2025

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Psych Meds in Elderly Study Guide
Review
Week 12 Outline- Psych meds in the elderly
Principles of geriatric prescribing
•Screening for psych med use in elderly
oRule out medical conditions
oHas this happened before?
▪Treatment and side effects
oEvidence of dementia or delirium
•Lab Studies
oEvidence of decreased hepatic or renal fxn
▪Decreased albumin
▪Decreased creatinine clearance
oEstablish baseline labs
▪CBCD, BMP, TSH, cholesterol, triglycerides, EKG
•Check for drug interactions and consider development of interactions with med changes
•Stay the course or switch?
oNo change at 6 weeks; switch meds
oPartial response at 6 weeks; continue for the full 12 weeks
•Improving medication compliance
oCompliance reduces as treatment becomes more complex
▪Use once daily doses whenever possible
▪Avoid complex schedules
▪Write reason for med within prescription
oDrug cost plays role in compliance
oLarge print labels/ med reminders
•Minimize adverse effects
oLowest dose possible
oGeri: 1/3 or half dose can be sufficient
oDivide the dosage to reduce peak levels (cause of many s/e’s)
•Meds to avoid in elderly
oAnticholinergics: (Benadryl, hydroxyzine, promethazine)
▪Confusion, dry mouth/constipation
oAntiparkinson: (Cogentin, Trihexyphenidyl)
▪Don’t give for EPS
oAntispasmodics: (Dicyclomine)
▪Highly anticholinergic
oAnti-Infective: (Nitrofurantoin)
▪Avoid with impaired renal fxn
▪Avoid with long term use
•Potential for pulmonary toxicity, liver toxicity,
peripheral neuropathy
oThe following antidepressants that are all highly anticholinergic, sedating
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Psych Meds in Elderly Study Guide

Review

Week 12 Outline- Psych meds in the elderly Principles of geriatric prescribing

  • Screening for psych med use in elderly o Rule out medical conditions o Has this happened before? ▪ Treatment and side effects o Evidence of dementia or delirium
  • Lab Studies o Evidence of decreased hepatic or renal fxn ▪ Decreased albumin ▪ Decreased creatinine clearance o Establish baseline labs ▪ CBCD, BMP, TSH, cholesterol, triglycerides, EKG
  • Check for drug interactions and consider development of interactions with med changes
  • Stay the course or switch? o No change at 6 weeks; switch meds o Partial response at 6 weeks; continue for the full 12 weeks
  • Improving medication compliance o Compliance reduces as treatment becomes more complex ▪ Use once daily doses whenever possible ▪ Avoid complex schedules ▪ Write reason for med within prescription o Drug cost plays role in compliance o Large print labels/ med reminders
  • Minimize adverse effects o Lowest dose possible o Geri: 1/3 or half dose can be sufficient o Divide the dosage to reduce peak levels (cause of many s/e’s)
  • Meds to avoid in elderly o Anticholinergics: (Benadryl, hydroxyzine, promethazine) ▪ Confusion, dry mouth/constipation o Antiparkinson: (Cogentin, Trihexyphenidyl) ▪ Don’t give for EPS o Antispasmodics: (Dicyclomine) ▪ Highly anticholinergic o Anti-Infective: (Nitrofurantoin) ▪ Avoid with impaired renal fxn ▪ Avoid with long term use - Potential for pulmonary toxicity, liver toxicity, peripheral neuropathy o The following antidepressants that are all highly anticholinergic, sedating

and cause orthostasis ▪ Amitriptyline (Elavil) a TCA ▪ Doxepin: TCA/ SNRI ▪ Imipramine (Tofranil) a TCA/SNRI ▪ Nortriptyline (Pamelor) TCA/SNRI ▪ Paroxetine o Antipsychotics: ▪ Only use for bipolar or schizophrenia ▪ Greater risk for stroke ▪ Greater risk for cognitive decline ▪ Greater risk for mortality in persons with dementia o Barbiturates ▪ Avoid due to risk of dependence ▪ Greater risk of overdose o Insulin sliding scale ▪ Increases risk for hypoglycemia o Megestrol ▪ A breast cancer treatment drug for symptoms of anorexia ▪ Increased risk for stroke ▪ Increased risk for death o Cyclobenzaprine ▪ Muscle relaxant ▪ Poorly tolerated ▪ Sedating ▪ Anticholinergic ▪ Risk for fracture o BEERS Criteria ▪ Guideline for prescribing in elderly and addressing polypharmacy ▪ BEERS criteria is not:

  • An evil drug list
  • A punitive tool, or a list providing contraindication for certain meds
  • A substitute for individual clinical judgement
  • A rule or list of not to do o Polypharmacy ▪ If required, give interacting drugs as far apart as possible o Absorption: ▪ Not a passive process ▪ CYP 450 and 3A4 line gut to aide in metabolism ▪ P-glycoprotein lines the gut to aide in permeability
  • Antacids/fiber supplements can therefore interfere w/ permeability of drugs o P-Glycoprotein pump: ▪ A gate keeper in the intestinal wall that helps determine a drug’s destiny for metabolism or elimination ▪ There are pgp inhibitors and pgp inducers ▪ Pgp inhibitors:
  • Inhibit metabolism, increasing serum concentration
  • Example: erythromycin & ketoconazole

o High serum levels o LFT’s aren’t really indicative of much in regards to this o Half-lives of psychotropics ▪ Drugs w/ long half-lives are of concern bc they can accumulate leading to toxicity

  • Example: Amitriptyline & Flurazepam o Pharmacodynamics ▪ Target tissue of the drug can be pre-synaptic or post-synaptic or involve enzyme inhibition ▪ SSRI’s act on pre synapse ▪ MAOI’s & Acetylcholinesterase inhibitors, inhibit enzymes o Benzodiazepines ▪ Most common anxiolytic for elderly ▪ More side effects in elderly
  • Sedation, psychomotor impairment, memory
  • Reduced elimination rates
  • Contraindicated for long term use ▪ Can worsen sleep patterns ▪ If required:
  • Fall risk assessment
  • Screen for cognitive / functional decline ▪ To dc: consider inpatient, and work with family o Antihistamines ▪ Avoid due to delirium and anti-cholinergic effects o Alternative causes of anxiety ▪ Cardiac disorder ▪ Substance withdrawal ▪ Endocrine disorders ▪ Undiagnosed depression o SSRI’s: Celexa, Lexapro, Zoloft ▪ First line for depression, anxiety, insomnia ▪ Risk outweighs benefit
  • Only 15 of elderly receive tx for their depression o TCA’s ▪ Risks: falls, drug to drug interactions, hyponatremia, bleeding o Antipsychotics ▪ Often given to manage disruptive behavioral symptoms associated with cognitive impairments
  • Risks with typicals: elderly at higher risk for all of them o Tardive dyskinesia, EPS, NMS, anticholinergic effects - > including QT prolongation o Anticholinergic Toxidrome ▪ Altered mental status ▪ Mydriasis (blurry vision) ▪ Flushed skin ▪ Dry skin

▪ Dry mucous membranes

  • Atypicals: o Start slow o Fewer risks o Black box warning: cardiac and cerebrovascular risks in dementia patients ▪ ½ - 1/3 of usual dose - Physiological Age-Related Changes o Absorption o Distribution to tissues: ▪ Decreased cardiac output & serum albumin
  • Increased drug concentration o Longer half life ▪ Slower elimination ▪ Hence the need for lower doses ▪ Reduced total body weight, increased fat, decreased lean mass ▪ Dehydration o Liver ▪ By 65 years; hepatic fxn is reduced by 35% o Kidney ▪ Significantly reduced GFR (64% less)
  • CNS Age-Related Changes o Increased likelihood of depression ▪ More monoamine oxidase enzymes – so they metabolize monoamines more quicky ▪ Decreased dopamine & acetylcholine
  • Increased sensitivity to psych drugs
  • Increased sensitivity to anticholinergics ▪ Decreased choline acetyltransferase & acetylcholine
  • Impairs memory ▪ Prescribing Guidelines
  • Low and go slow ▪ Gold Standard: augment meds with therapy
  • When should depression be treated? o Any age o White males older than 75 = high risk for suicide
  • Sedative Hypnotics o Benzo’s ▪ Cognitive impact/ dementing ▪ Can cause psychotic symptoms ▪ Long half-life can cause cognitive impairment ▪ Reduced memory ▪ Reduced psychomotor coordination
  • Falls/driving etc
  • Lab changes in aging population

o Teens are high risk o 80–84-year-olds are high risk if depressed

  • Treatment with Antidepressants o Presence of comorbid anxiety reduces likelihood of successful treatment o Takes 4-6 weeks for full response ▪ No response by 3 weeks= slim chance of doing anything o 1 st^ line: SSRI’s ▪ Prozac: 10-80 mg/day ▪ Zoloft: 100-200 mg/day ▪ Paxil: 20-50 mg/day ▪ Luvox: 100-200 mg/day ▪ Celexa: 20-60 mg/day - Do not go above 40 mg/day ▪ Lexapro: 10-30 mg/day o SSRI Side effects ▪ GI upset ▪ CNS: - Headache - Insomnia- give in morning - Anxiety - Akathisia - Agitation - Apathy - Long-term weight gain in some ▪ Sexual dysfunction in 30-35% ▪ Activation of underlying bipolar o DNRI: Wellbutrin (IR or SR/XR) ▪ IR: 225-450 mg/day ▪ XR: 150-400 mg/day ▪ Side effects: seizure, irritability, constipation ▪ Don’t give if hx of an eating disorder, b/c can cause weight loss o 2 nd^ line: Remeron, esp w/ sleep problems or low weight ▪ Most effective at lowest dose vs highest dose o TCA’s: not used anymore due to potential for fatal OD’s ▪ Amitriptyline (Elavil): 100-300 mg/day ▪ Nortriptyline (Pamelor): 50-150 mg ▪ Imipramine (Tofranil): 100- 30 ▪ Desipramine (norpramine): 100-300 mg/day ▪ Doxepin (Sinequan) 100-300 mg/day ▪ Clomipraine (Anafranil): 100-250 mg/day (for OCD) o TCA Side Effects: ▪ Anticholinergic s/e’s ▪ Weight gain ▪ Sedation, seizures ▪ Postural hypotension ▪ Tachycardia

▪ Rhythm disturbance ▪ Lethal OD o Trazadone: ▪ Sleep: 50-100 mg/day ▪ Depression: up to 600 mg/day ▪ Can cause priapism ▪ Half-life: 5-9 hours o Remeron: SNRA/ A2 antagonist ▪ 15-45 mg/ day ▪ Effective at lower dose ▪ Antihistamine sedation at lower dose ▪ Weight gain ▪ Dry mouth, ▪ Rare reduction in WBC ▪ Half-life 20-40 hours ▪ Safe o SNRI’s ▪ Effexor:

  • Start at 37.5-75 mg/day
  • 225-375 mg/day divided
  • XR up to 225 mg/day
  • No anticholinergic side effects
  • Can improve concentration
  • S/e: o Increased BP o Don’t stop suddenly o No sexual side effects o Mood Stabilizers ▪ Lithium
  • Goal serum level: .4-. ▪ Tegretol ▪ Depakote ▪ Lamictal o Antipsychotics ▪ Lowest dose for shortest amount of time ▪ Black Box Warning o Alzheimer’s Disease ▪ Cause: Deficit in cholinergic (Ach) neurotransmission function o Not enough acetylcholine o To combat this: inhibit acetylcholine’s metabolizing enzyme: acetylcholinesterase ▪ Cholinergic inhibitor’s can enhance memory or just slow the cognitive decline
  • Receptors are muscarinic & nicotinic

▪ Can boost attention and focs o Synergistic (cooperates w/) cholinergic synapses o 8, 16, 24 mg/ day for 24 weeks for full effect o Higher mortality rate than with other AChEs

  • Efficacy o Donepezil + Galantamine ▪ Helps with vascular impairments as well as A.D ▪ Behavioral benefits ▪ Improved ADL’s ▪ Stabilize rather than improve
  • Memantine (Namenda) o Moderate affinity noncompetitive NMDA receptor antagonist o Targets glutamatergic system o Reduces further deterioration of A.D o Good for moderate to severe symptoms o Helps with focus and memory o Not shown to reduce agitation o Can inhibit glutaminergic mechanisms of synaptic plasticity o Mild side effects ▪ Dizziness, confusion, h/a, constipation o Dosing: titrated up over 4 weeks ▪ 5mg/day for 1 week ▪ 5 mg BID for 1 week ▪ 15 mg qd for 1 week ▪ 10 mg BID for 1 week ▪ Most commonly prescribed antipsychotics in nursing homes
    1. Seroquel
    1. Risperidone
    1. Olanzapine
    1. Haldol
    1. Aripiprazole
    1. Clozaril