Basic variations when prescribing psychotropics to elderly and children

1. VARIATIONS IN
PSYCHOPHARMACOLOGY FOR
ELDERLY AND CHILDREN
AHMED ELAGHOURY
Egyptian & Arab Boards in Psychiatry
Abbassia Hospital for Mental Health, MOH
Cairo, Egypt

2. Pre assessment in elderly
• Current medical problems / medications
• Exam: physical & mental
• Labs: esp LFT & KFT
• Drug interactions: esp warfarin with Enz Inhib
• POTENTIALLY INAPPROPRIATE PRESCRIBING:
Beers Criteria 2012 ( free / in apps)
• Smartphone apps: your “peripheral brain”
ajhuri@gmail.com Cairo, DEC 2014 2

3. Anticholinergic Activity (AA)
• Familiarize yourself with one of the following:
– Beers criteria
– STOPP criteria
– FORTA criteria
ajhuri@gmail.com Cairo, DEC 2014 3
American Geriatrics Society 2012 Beers Criteria Update Expert Panel.
American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults.
J Am Geriatr Soc. 2012 Apr;60(4):616-31. doi: 10.1111/j.1532-5415.2012.03923.x. Epub 2012 Feb 29.
Review. PubMed PMID: 22376048; PubMed Central PMCID: PMC3571677.
Gallagher P, O'Mahony D. STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions):
application to acutely ill elderly patients and comparison with Beers' criteria. Age Ageing.
2008 Nov;37(6):673-9. doi: 10.1093/ageing/afn197. Epub 2008 Oct 1. PubMed PMID: 18829684.
Kuhn-Thiel AM, Weiß C, Wehling M; FORTA authors/expert panel members.
Consensus validation of the FORTA (Fit fOR The Aged) List:
a clinical tool for increasing the appropriateness of pharmacotherapy in the elderly.
Drugs Aging. 2014 Feb;31(2):131-40. doi: 10.1007/s40266-013-0146-0.
PubMed PMID: 24353033; PubMed Central PMCID: PMC3907693.

4. Beers criteria: by drug
ajhuri@gmail.com Cairo, DEC 2014 4

5. Beers criteria: by diagnosis
ajhuri@gmail.com Cairo, DEC 2014 5

6. Neuropsychiatric symptoms of
dementia
• One of these symptoms is
observed in up to 90% of
pts of dementia
ajhuri@gmail.com Cairo, DEC 2014 6

7. • Nonpharmacologic therapy: environmental
• AntiChEIs: Rivastigmine, Donepezil
• Antipsychotics: Olanzapine, Risperidone,
Quetiapine
• Antidepressants: Citalopram
• AEDs: CBZ, VPA, GBP, LMT
• Analgesics
• Physical restraint
• Avoid: BZD, AntiH
ajhuri@gmail.com Cairo, DEC 2014 7

8. • Depression: Citalopram & Sertraline
• Insomnia: Trazodone, Melatonin
ajhuri@gmail.com Cairo, DEC 2014 8

9. Suggested durations of antipsychotic
treatment
ajhuri@gmail.com Cairo, DEC 2014 9

10. Children variations
• Dose by body weight
• Consider rapid metabolism esp AEDs
ajhuri@gmail.com Cairo, DEC 2014 10

11. Minimum age to start: Rough lines
• Amphetamine, Chlorpromazine, Thioridazine,
Haloperidol, Risperidone, Benztropine,
Clonazepam, Diazepam, Carbamazepine, ( ?
Valproate), Oxcarbazepine, Lamotrigine,
Gabapentin, Topiramate: May start at Preschool
age
• MPH, Atomoxetine, Imipramine, Fluoxetine,
Sertraline, Fluvoxamine, Trazodone: NOT BEFORE
School age
• All others: At adolescent age
ajhuri@gmail.com Cairo, DEC 2014 11

12. Disorders associated with aggressive
or violent behaviors
ajhuri@gmail.com Cairo, DEC 2014 12
Greydanus DE, et al: Pediatric and Adolescent Psychopharmacology. 2008, Cambridge University Press

13. • Off label prescribing:
– Very common in children
– Identify target symptoms
– Manage adverse effects
– Second opinions
ajhuri@gmail.com Cairo, DEC 2014 13