Psychopharmacological Treatment of Geriatric Disorders
Organization of inpatient care for
Geriatric Mental Health Care
MD(psych), DPM, FAMS
Sr.Professor, HOD & Supdt.
Psychiatric Centre Jaipur
Addl.Principal SMS Medical College Jaipur
• Individuals become more dissimilar as they
• Abrupt decline in any system is always due to
disease and not to normal aging.
• Normal aging can be attenuated by
modification of risk factors.
• In the absence of disease decline in
homeostatic reserve causes no symptoms and
imposes few restrictions in activities of daily
living regardless of age.
• Multiple Pathology
–Cataracts, deafness, degenerative joint
diseases, like osteoarthritis or osteoporosis,
varicose veins are all conditions which are
likely to develop slowly and to progress.
–Cancer, pernicious anaemia, thyrotoxicosis,
myxoedema common due to deterioration
of immune mechanisms.
–Obesity, diabetes, depression and
dementia frequently seen
Under reporting of illness
• Callous Attitude Towards
• Attitude of the Relatives
Barriers to Obtaining
• Cerebrovascular Diseases
• Depressive and other Psychiatric
• Cognitive Impairment and Dementia
• Neurodegenerative Disorders
• Infections of the Central Nervous
System, Sleep Disorders and Coma.
Facilities for an inpatients Geriatric
Mental Health Care
• Entrance with ramp and
• Adequate OPD space
with waiting facilities
• Consultation chambers
for mental health team
• Nursing Station and
• Inpatient wards with
• Semi ICU
• Lab investigations
• Recreation room
• Rehabilitation activities
• Storage and
• Medical internist Gynaecologist
• Ophthalmologist Orthopaedician
• Physiotherapist Dietician
• Yoga trainer
Age related changes in the Central
Gross brain atrophy
Selective regional neuronal loss
Remodeling of dendrite, axons &
Appearance of intraneuronal
Selective regional decrease in
neurotransmitter & neuropeptides.
Selective modification of
Possible dysregulation of gaseous
Changes in receptors
Changes in neurotrophins
Changes in signal transduction
Impairment of calcium homeostasis
Possible changes in cell cycle regulations
Possible changes in extra cellular matrix
proteins (eg. Laminin, proteoglycans)
Possible regional decline in cerebral blood
Possible regional decline in metabolic rate
Appearance of senile plaque &
PHARMACODYNAMICS AND AGING
Neurotransmitter Pharmacodynamic changes
↓ Dopamine D2 receptor in the striatum
↓ Choline acetyl transferase
↓ Cholinergic cell numbers
↓ cAMP production in response to beta-agonists
↓ Beta – adrenoceptor number
↓ Beta – receptor affinity
↓ Alpha 2 – adrenoceptor responsiveness
↓ Psychomotor performance in response to
? ↑ Post – synaptic receptor response to GABA.
Points to remember before
prescribing medication in elderly
Magnitude of effect (clinical response) = Pharmacodynamics x
Pharmacokinetics x biological variance
In elderly medical complication of pharmacotherapy alone
constitute a highly significant treatable health problem.
Adverse reaction to drugs of all types is seven times higher
in those aged 70 to 79 years, than in those 20 to 29 years old.
Non compliance with therapy is a major problem for
psychiatric patients, and this dilemma is exacerbated with
Age related health problems combines with physiological
changes to increase the probability of adverse effect from
medication which in turn increase the likelihood of non
Complexities of medication regimens are further
complicated by communication difficulties arising from
impaired hearing, cognitive impairment, language & cultural
Psychopharmacological Treatment of
The psychiatrist of an 87 year old patient suffering from
heart disease, arthritis and depression must ask a number
of questions to himself.
Q. What is the best treatment - Pharmacotherapy?
Q. If pharmacotherapy, what is the most appropriate drug?
Q. Balancing the adverse effect and efficacy. What is the
Q. How soon will the patient’s symptom decrease?
Q. If the drug is effective. How long will the treatment last?
Q. If the drug is ineffective how long should the wait before
changing the treatment?
Risk of Mania decline in late life, nonetheless mania
and hypomania affect 5-10% of psychiatric patients.
Established mood stabilizers
Calcium channel blockers
Putative Mood stabilizes"
Omega 3 fatty acid
old age depression
• Cumulative incidence of depression in
people aged upto 70 years is 26.95% for
men & 42.5% for women, still most of the
drug trials exclude elderly subjects.
• In addition, most of the drug trials also
exclude subjects with medical comorbidity,
which is a rule rather than exception. Hence
the results of drug trials done in young
adults can't be generalized to elderly.
…Antidepressants in old age depression contd.
• Prior to 1995, there were occasional
studies which evaluated the use of
antidepressants in elderly. But fortunately
in the last 10 years many studies have
evaluated the use of antidepressants in
• These studies can be broadly classified
• Noncomparative studies
• comparative studies using either placebo or
another antidepressant or both and
• meta-analyses of the above studies.
Antidepressant Drugs and Dosages Preferred for
Use in the Elderly
(mg per day)
Sedation Agitation Anticholinergic
Desipramine 25 50 to 150 Low Low Low Low
Nortriptyline 10 to 25 40 to 75 Moderate Low Low
Selective serotonin reuptake inhibtiors
Citalopram 20 20 to 40 Low Low - -
Fluvoxamine 50 50 to 200 Low Low - -
Paroxetine 10 20 to 30 Low Low - -
Sertraline 25 to 50 50 to 150 Low Low - -
Bupropion 100 100 to 400 - Moderate - Low
Nefazodone 100 100 to 600 Moderate -- Low Low
Trazodone 25 to 50 50 to 300 High - Low Moderate
Venlafaxine 75 75 to 350 Low Low Low Low
Psychotic agitation in the elderly with mania
Haloperidol 0.25 to 0.5 mg IM or PO
After one hour, administer lorazepam 0.5mg IM or PO
Repeat alternating doses every hour until calm
Monitor carefully to avoid over sedation
Alternative regimen if extra pyramidal symptoms develop
Atypical antipsychitic riseperidone (0.5mg), or olanzapine (2.5
- 5 mg)
Avoid chlorpromazine and thioridazine due to their
anticholinergic and hypotensive side effects.
Daily dose of medication is determined by adding the total
dose of each medication required to calm the patient and
dividing it equally throughout the day.
Adjunctive antipsychotic medication
Daily divided doses of .5 to 3mg
Monitor patient carefully for orthostatic hypotension and EPS as dose
Daily doses of 2.5 to 10 mg /day’
Transient elevation in liver enzyme have been reported
Risepeidone plus olanzapine
Observe for increased agitation or other manic symptom because of
breakthrough mania with risperidone.
Reserved for patients who are intolerant of risperidone and olanzapine,
Daily doses start at 12.5mg, increase to 50mg
If history of seizure disorder should be maintained on an
Monitor for orthostatic hypotension and weekly complete blood count
ATYPICAL ANTIPSYCHOTICS IN THE
Drug Metabolite t½ (h) CLR and T½
CYP enzyme involved in
Clozapine Norclozapine, clozapine
N- oxide (very limited
Risperidone 9 hydroxy risperidone
CYP2D6 (inhibitor drugs
such as quinidine) 2
Olanzapine 10-N-glucoranide, N-
CYP2D6 (inhibitor drugs
such as quinidine) 10
Quetiapine Multiple (main
metabolite is a
COMMON ANTIPSYCHOTIC DRUG
INTERACTION IN THE ELDERLY
TCAs and conventional
Raises blood antidepressant
SSRIs and clozapine Raises blood clozapine concentrations
Risperidone and clozapine Raises blood clozapine concentration
Smoking Lower blood antipsychotic concentration
Cimetidine Lower blood antipsychotic concentration
Anticholinergic drugs Additive memory and delirious effects
and sedative drugs
Additive sedative and delirious effects
Expert consensus guidelines
SPECIAL ISSUE IN USING ANTIPSYCHOTICS IN
Formulatory decision should be based on
cost when drug of comparable efficacy are
It is especially important to consider safety
and tolerability along with efficacy and cost.
Avoid low and mid-potency conventional
antipsychotics as well as clozapine &
ziprasidone in elderly patients who have
corrected QTc interval prolongation.
…Expert consensus guidelines
DISEASE DRUG INTERACTION
Avoid low & mid potency conventional antipsychotics,
clozapine and olanzapine in patients who have
diabetes mellitus, dyslipedimia and or obesity.
Avoid ziprasidone, low and mid potency conventional
antipsychotics and clozapine in patients who have a
prolonged QTc interval or congestive heart failure.
Quetiapine is the first line recommendation for a
patient with Parkinson’s disease , also consider low
dose olanazapine or clozapine for patients with
Avoid high dose of risperidone in patients with
Management of Cognitive
• Cholinesterase inhibitors-mild to moderate
dementia (Cummings et al., 2004).
– Prescription only for-
• probable Alzheimer’s disease
• duration of illness > 6months
• MMSE > 10
– 3 phase response evaluation-
• Early (2 wk)-assess tolerance & side effects
• Late (3 mth)-assess cognition
• Continued (6 mth)- assess disease state
…Management of Cognitive symptoms contd.
–Stop treatment if-
• Early evaluation-poor tolerance or
• Deterioration continues at pretreatment rate
after 3-6 month of medication
• On maintenance doses, accelerated
Drugs useful for reducing the
signs of dementia
Donepezil 5-10 mg daily
Rivastigmine 1.5-6 mg b.i.d.
Galantamine 4-12 mg b.i.d.
Memantine 5-20 mg daily