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Book Forum: Geriatric Care   |    
Psychiatric Medications for Older Adults: The Concise Guide
MICHAEL R. BIEBER, Ph.D.
Am J Psychiatry 2002;159:890-a-891. doi:10.1176/appi.ajp.159.5.890-a
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By Carl Salzman, M.D. New York, Guilford Publications, 2000, 171 pp., $30.00.

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Perhaps the biggest growth in the practice of mental health over the last two decades is in work with older patients, particularly geriatric patients in nursing homes and assisted living centers. This group of adults over 65 years of age will continue to grow with the aging of the large population born during the 10 years after World War II. In its second decade of development as a specialty, geriatric psychopharmacology is coming to maturity with recent publications. Dr. Salzman’s Psychiatric Medications for Older Adults is one of these. The book is indeed concise (it can be read rapidly in about 2 hours), and it covers all the questions and problems I see on a daily basis in my geriatric work. The book is coherent and orderly: a first chapter on basic issues and chapters 2 through 7 on depression, mania, anxiety, sleep disorders, dementia, and agitation and psychosis. In the appendix are two very useful tables listing medical drugs that interact with psychiatric drugs and drug interactions among psychiatric drugs. Psychiatrists involved in geriatric practice could consult this information daily.

Two basic issues in using psychiatric medication that Dr. Salzman highlights in chapter 1 are that it usually is better to "start low and go slow" when prescribing and that many older adults under 80 may need doses similar to those for a middle-aged adult because they are often relatively healthy. In other words, start low, go slow, but keep on going to get the desired effect. Most people older than 80 do not need the higher dose.

The first of the six chapters on psychiatric conditions is on depression. Twenty-five percent of nursing home residents have clinical depression or depressive symptoms. Dr. Salzman discusses major depressive disorder, dysthymic disorder (persistent mild depression), suicidal ideation and intent, masked depression (depression masked as illness), and delusional depression (major depression with psychotic thinking). The frequently seen delusions are paranoid ("I’m being punished by someone"), somatic ("I have cancer that nobody is telling me about"), and nihilistic ("I’m hopeless"). I would add a fourth delusion I’ve seen often, a grandiose or hopeful delusion ("I’m getting married tomorrow" or "I’m moving to my house tomorrow").

Dr. Salzman provides a good description contrasting the cognitive impairment associated with depression and dementia. Patients with depression complain constantly about memory impairment when it is only mild, but patients with dementia deny or try to conceal their memory impairment.

The last half of the chapter on depression describes the uses, side effects, and cautions with tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), stimulants for apathy and withdrawal (methylphenidate can be very effective at low doses), and ECT (also very effective in serious late-life depression). SSRIs are probably most preferred for older adults as the initial drug of choice. For more severe depression that doesn’t respond to SSRIs, tricyclic antidepressants and MAOIs are often successful (remember to start low because of the anticholinergic side effects with tricyclic antidepressants and orthostatic hypotension with MAOIs). The use of mood stabilizers such as lithium, divalproex sodium, carbamazepine, gabapentin, and lamotrigine to treat severe depression and mania is discussed. Finally, Dr. Salzman discusses the treatment of bipolar disorder with low starting doses of antidepressants (monitoring for acceleration into mania) and mood stabilizing drugs. I have found low doses of divalproex sodium (100–200 mg) to be very useful combined with an antidepressant for depressed and irritable patients.

The chapter on mania discusses the mood stabilizing drugs (lithium, divalproex sodium, carbamazepine, lamotrigine, and gabapentin). Initial treatment is to start with low doses. Lithium is effective but harder to tolerate for the elderly, so caution is advised. Elderly patients with rapid cycling bipolar disorder do not respond well to lithium. Divalproex sodium with an additional neuroleptic is usually effective. Lamotrigine, an anticonvulsant, can be very effective for mania and bipolar disorders but, again, it needs to be started at low doses (12.5–25.0 mg). I’ve seen remarkable improvement in patients taking this medication who have previously not done well with lithium.

In the chapter on treating anxiety, Dr. Salzman suggests that benzodiazepines with short half-lives (alprazolam, lorazepam, and oxazepam) are almost always preferable to benzodiazepines with long lives (diazepam, chlordiazepoxide, and clonazepam). Although benzodiazepines are overprescribed and inappropriately prescribed, they can also be very useful in restoring the quality of life for the elderly person. These medications are effective and safe, especially when doses are kept low. Long-term use can be very helpful, but it should be noted that the aging process increases sensitivity to benzodiazepines. Monitoring the patient might reveal that the dose can be reduced over time.

Sleep disorders are probably the most common complaint of older people. Sedating antidepressants, like trazodone (or nefazodone hydrochloride for chronic insomnia) are often useful. Benzodiazepines are also discussed. Neuroleptic medications, such as olanzapine at low doses (2.5–5.0 mg.), can also be effective.

The final two chapters deal with dementia and with agitation and psychosis. Atypical neuroleptics (risperidone, olanzapine, and quetiapine) are first-choice medications for agitation and psychosis. When they are ineffective, divalproex sodium and carbamazepine can be used, especially for severe anger. I have found that risperidone and olanzapine increase the symptoms in Parkinson’s patients who are agitated and psychotic but that quetiapine has a better effect. Antidepressants added to neuroleptics can also be very useful. The old-line, typical neuroleptics such as haloperidol and thioridazine rather than atypical neuroleptics need to be considered in more severe and intractable cases of agitation. The potential side effects (extrapyramidal symptoms, oversedation, anticholinergic side effects, and, possibly, delirium) need to be monitored.

Overall, I found this concise guide to be very readable and useful. I now carry it with me to work. I would like to add a few comments about two issues that I think are important in using psychiatric medications. First, I often see patients started on two psychiatric drugs, like olanzapine and fluoxetine, at the same time, and I think this is poor practice unless it is an acute situation. How do you know what drug is working? Psychiatric medications should be changed one at a time so you can better judge their effect. Second, it has been my experience that most severely ill psychiatric patients can usually be managed with one, two, or, at most, three medications. For example, an antidepressant with an atypical neuroleptic for depression and agitation, a mood stabilizer with an atypical neuroleptic for agitated psychosis, and a short-acting benzodiazepine with an atypical neuroleptic for agitated Huntington’s chorea can often be effective. It is my experience that if you use more than three psychiatric medications you have problems with increased agitation and oversedation.

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