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13 - Psychiatric Issues |
387
Table 13-2. Diagnostic Criteria and Prevalence of Anxiety Disorders
Diagnostic Criteria Description
21
U.S. Prevalence in
Older Adults
21,70,71
Generalized anxiety
disorder
Anxiety and worry that is difficult to control, occurs most
days for at least 6 months, and leads to impairment of
daily function
The anxiety and worry are also associated with at least
three of the following:
• restlessness
•
easily fatigued
•
trouble concentrating
•
irritability
•
muscle tension
•
sleep disturbances
The symptoms are not substance-induced or due to another
medical/mental disorder
1.2%
Panic disorder Recurrent panic attacks; symptoms present abruptly and
peak within minutes, including (must have four or more):
• heart palpitations
• sweating
• trembling
•
shortness of breath
• feelings of choking
• chest pain
•
nausea
• dizziness
• chills or heat sensations
• paresthesias
•
depersonalization
• fear of losing control
• fear of dying
After an attack occurs, individual (1) continues to worry
about having another attack and/or (2) avoids situations/
places because of the fear of having another attack
The symptoms are not substance-induced or due to another
medical/mental disorder
0.7%
Social anxiety
disorder
Fear or anxiety about social situations in which the
individual could be scrutinized by others
The individual fears that he or she will act in a way that will
be negatively observed by others
Social situations almost always lead to fear or anxiety, and
the fear is greater than the actual threat of the social
situation
Social situations are often avoided
Fear, anxiety, or avoidance persists for 6 months or more
and causes impairment in daily function
The symptoms are not substance-induced or due to another
medical/mental disorder
2% to 5%
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Table 13-2. Diagnostic Criteria and Prevalence of Anxiety Disorders (cont’d)
Diagnostic Criteria Description
21
U.S. Prevalence in
Older Adults
21,70,71
Specific phobias Fear or anxiety about a specific object or situation
The phobia almost always leads to fear or anxiety, and the
fear is greater than the actual threat of the specific object
or situation
The phobic object or situation is often avoided
Fear, anxiety, or avoidance persists for 6 months or more
and causes impairment in daily function
The symptoms are not substance-induced or due to another
medical/mental disorder
3% to 5%
Posttraumatic stress
disorder
a
Exposure to a traumatic event (threat of or actual death or
serious injury)
Experiences symptoms from all four cluster of symptoms:
•
Re-experiencing (e.g., flashbacks, nightmares,
dissociative behavior)
•
Avoidance
• Numbing (e.g., detachment from others, restricted
affect, cannot remember the details of the traumatic
event)
• Increased arousal (e.g., insomnia, hypervigilance,
increased startle response)
Duration of symptoms is 1 month or longer
The symptoms cause impairment in daily function
0.4%
Obsessive-
compulsive
disorder
b
Obsessions, compulsions, or both are present
•
Obsessions:
» Thoughts that are intrusive, inappropriate, and
cause significant distress
» Attempts are made to suppress or eliminate the
thoughts
•
Compulsions:
» Repetitive behaviors performed by the person in
response to the obsession
» Behaviors are not pleasurable but are performed
to prevent discomfort or a negative event
The symptoms cause distress, are time consuming, or
impair daily function
The symptoms are not substance-induced or due to another
medical/mental disorder
0.7%
a
DSM-5 now classifies the disorder under Trauma and Stressor-Related Disorders.
b
DSM-5 now classifies the disorder under Obsessive-Compulsive and Related Disorders.
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consistent worrying, and graded exposure so
the patient can learn how to cope in stressful/
phobic situations.
75
Study results regarding
the efficacy of CBT for anxious elderly patients
conflict. Some studies have suggested that CBT
therapy may be less efficacious for older than for
younger adults with anxiety.
85-87
However, at least
three meta-analyses
have concluded that CBT
significantly reduced anxiety symptoms for older
adults compared to the active control groups.
88-90
A recent study also found CBT to be effective in
reducing relapse of anxiety symptoms, similar to
SSRI therapy but better than placebo.
91
Most CBT studies in the elderly focus on
treating GAD, so there are less data addressing
the treatment of other anxiety disorders.
92
Much
of the CBT research often excludes sicker elderly,
the cognitively impaired, and patients older than
75. However, a limited number of studies have
been done to assess efficacy in these popula-
tions.
93-95
It has been suggested that CBT should
be modified for older adults. Recommended
modifications include using group therapy versus
individual therapy, providing more emphasis
on increasing the motivation of patients, using
learning and memory aids during discussions,
and providing the patients weekly calls to check
for questions or problems relating to the therapy
session homework assignments.
91,96
Antidepressants
Many of the SSRIs and SNRIs are FDA labeled
for anxiety disorders and considered first-line
treatment for chronic management of anxiety in
adults. There are limited data addressing these
antidepressants and their efficacy in late-life
anxiety, but they are still commonly prescribed
by geriatric clinicians because of their low risk
of serious adverse effects.
69
Agents that have
clinical data supporting their use in the elderly
with anxiety disorders include citalopram,
97,98
sertraline,
99
escitalopram,
91
duloxetine,
100
and
venlafaxine,
101
although the other SSRIs and
mirtazapine have proven effective in younger
adults.
Lenze and colleagues lead a randomized,
placebo-controlled study of citalopram for the
treatment of anxiety disorders in the elderly.
97
Diagnoses of the patients included GAD, panic
disorder, and PTSD, although a great majority of
the patients were diagnosed with GAD. Sixty-
five percent of patients assigned to citalopram
treatment (dose = 20–30 mg/day) achieved a
response by 8 weeks, whereas only 24% in the
placebo responded.
After 8 weeks of treatment, the study
patients were eligible to continue an open-label
study of citalopram for 24 more weeks. Patients
who responded to citalopram during the first 8
weeks continued to take citalopram, and indi-
viduals who failed to respond with placebo were
switched to citalopram for the rest of the long-
term study. Those who were taking citalopram
and did not respond during the first 8 weeks
were omitted from the long-term study. Blank and
colleagues
98
published the results of the long-
term study and found anxiety rating scale scores
continued to improve throughout the study; 60%
were responders at the end of the study.
Sertraline was compared to CBT and
placebo for treatment of late-life anxiety in
a 3-month study lead by Schuurmans and
colleagues.
99
The average age of the partici-
pants was 70, and their diagnoses included
GAD, panic disorder, agoraphobia, and social
phobia. Patients taking sertraline at a maximum
dose of 150 mg/day showed statistically signifi-
cant improvement in anxiety and depressive
symptoms compared to the waitlist controls.
Sertraline also showed to be better than CBT for
worry during the length of the study.
In a 2009 study performed by Lenze and
colleagues,
102
escitalopram 10–20 mg was not
more effective than placebo for treatment of
GAD after an intent-to-treat analysis. However,
a more recent study
91
did show escitalopram
to improve symptoms on the Hamilton Rating
Scale for Anxiety (HRSA) when used as mono-
therapy and when combined with CBT. Continu-
ation of escitalopram also decreased the risk of
relapse compared to placebo.
The clinical effects and tolerability of dulox-
etine in the elderly were investigated by Davidson
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| Fundamentals of Geriatric Pharmacotherapy
and colleagues.
100
The authors reviewed four
previous duloxetine studies and performed
a subgroup analysis for the older adults who
were enrolled (73 patients). Overall, patients
assigned to duloxetine had greater improvement
on anxiety and depression scales compared to
the placebo group after 9–10 weeks of therapy.
However, it was noted that 22% stopped therapy
due to adverse effects, with nausea and weight
loss being the most common.
Katz and colleagues
101
investigated the effi-
cacy and tolerability of venlafaxine extended-
release for treatment of GAD in elderly patients.
The researchers performed a retrospective
review of data from five randomized placebo-
controlled trials. Data pertaining to the older
adults (≥60 years of age) enrolled in the studies
were collected. All five studies were at least 8
weeks in duration and two of them continued
through 24 weeks. Overall, the researchers found
that assessment score changes from baseline to
follow-up for the intention-to-treat group were
not significantly different compared to placebo.
One assessment score, the Clinical Global
Impression of Improvement (CGI-I), was the
only score that significantly improved among
the venlafaxine group compared to placebo.
Remission and response rates were noted as
secondary objectives. For the intention-to-treat
group, response rates were significantly higher
according to the CGI-I scale for patients taking
venlafaxine at both weeks 8 and 24. Venlafaxine
was found to cause more GI adverse effects
compared to the placebo group, but the overall
discontinuation rates were not significantly
different.
The authors also noted the outcomes for the
younger population (<60 years of age). Inter-
estingly, patients taking venlafaxine had more
improvement compared to the placebo group
according to all assessment reports. Also, the
younger patients taking venlafaxine continued
to have significantly higher response and remis-
sion rates through weeks 8 and 24. These results
suggest that a better response to venlafaxine is
observed in younger adults compared to older
adults. However, one should keep in mind the
number of geriatric patients may not have been
high enough to meet the power requirement of
the study.
101
Antidepressants need to be taken at a thera-
peutic dose for 6 weeks before a response will
be seen. Initially, these agents may appear to
worsen anxiety symptoms by causing jitteriness
and activation. Counseling the patient on these
transient adverse effects ahead of time is recom
-
mended, along with frequent follow-up during the
first 2 months of therapy. Also, initiating therapy
at a low dose and titrating carefully can decrease
the severity of adverse effects.
69,75
Additional
information regarding which SSRIs are better
in the elderly and common adverse effects
were discussed previously (see Depression).
Benzodiazepines
Benzodiazepines have a rapid onset of action
and are currently the only option for acute treat-
ment of anxiety symptoms. These agents are
efficacious but can cause significant adverse
effects such as excessive sedation, depressed
mood, cognitive impairment, tolerance and
dependence, amnesia, unstable gait, increase
risk for falls, and respiratory depression. Severe
withdrawal symptoms such as seizures and
exacerbation of anxiety can occur if these
agents are stopped suddenly or tapered too
quickly. Because the risk of benzodiazepines
often outweighs their benefit in the elderly popu-
lation, they are generally not recommended
for long-term use.
69,103
However, a recent study
found that more than 50% of older adults with
anxiety disorders were using a benzodiazepine
at baseline and use did not decline over a 9-year
period, suggesting this drug class is still over-
used.
104
If a benzodiazepine is needed, loraz-
epam and oxazepam are the preferred agents
because of their short half-life, no active metabo-
lite, and lack of CYP450 involvement.
69,75
Patients
who have been on benzodiazepine therapy
for many years may find it difficult to taper off
because of worsening anxiety symptoms. In this
case, if the medication is not causing significant
adverse effects, it may be better for the patient
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391
to continue it while trying to use the lowest dose
possible to control symptoms.
75
KEY POINT:
Generally, the risks of
chronic benzodiazepine use outweigh the
benets. However, older patients who have
been taking the drug for years nd it dicult
to discontinue therapy (even with gradual
tapering) without anxiety symptoms recurring.
Buspirone
Buspirone works as a partial agonist at the 5-HT
1A
receptors. Although the medication is efficacious
for GAD, it is not a recommended therapy for
other anxiety disorders.
83
Buspirone is not asso-
ciated with dependence, sedation, depressed
respiratory rate, or psychomotor impairment, as
seen with benzodiazepine therapy. Studies have
shown buspirone to be effective and well toler-
ated in the geriatric population.
105-107
However,
the therapeutic response is less predictable
compared to the antidepressants and benzo-
diazepines. Clinicians must remember buspi-
rone is not quick acting and can take up to 2–3
weeks before an effect is observed. The twice to
three times a day dosing schedule can often be
a burden for elderly who have multiple medica-
tions to organize.
69,75
Also, buspirone has been
shown to be less efficacious for those who have
chronically used benzodiazepines in the past.
108
For treatment of GAD, buspirone is considered a
second- or third-line agent for chronic manage-
ment, falling behind antidepressants.
84
If used,
the recommended starting dose in older adults
is 5 mg twice daily. It can be increased by 5 mg
every 4–5 days to a target dose of 20–30 mg/day
given in divided doses.
75
Common Problems Encountered
When Treating Elderly Patients
Due to the lack of data in older adults, much of
the treatment guidelines are extrapolated from
data obtained from younger adults.
69,75
When
anxiety is suspected, a thorough history of the
illness should be obtained, including current
and past symptoms, history of medications
used, family history of mental illness, and history
of substance abuse. Along with a mental status
examination, a physical examination with labora-
tory values should be performed. A full medical
history will help decide whether physical factors
or medications are contributing to a patient’s
anxiety (Table 13-1).
Because of the high prevalence of psychi-
atric comorbidity, elderly patients who screen
positive for an anxiety disorder should also be
assessed for depression.
75
For patients who
meet diagnostic criteria for both major depres-
sive disorder and GAD, a separate diagnosis of
GAD is not needed unless it is clear the patient
has experienced GAD symptoms outside the
depressive episodes.
75
CBT can be used as monotherapy or in
combination with medications for treatment
of anxiety disorders, but, as mentioned previ-
ously, CBT may need to be modified to meet
the needs of older adults.
92
SSRIs and SNRIs
are both considered first-line medication thera-
pies for long-term treatment of anxiety disorders.
However, according to the published data, SNRIs
may be more likely to cause adverse effects.
100,101
Doses of the agents should be started low but
continue to be titrated to therapeutic doses. If a
patient does not respond to the first-line agent
after 6 weeks of therapy, switching to a different
class of antidepressant (i.e., switch from an SSRI
to a SNRI, or vice versa) is recommended.
75
Because antidepressants take several weeks
to induce a response, short-term benzodiaz-
epine use is indicated if the patient needs acute
treatment. An antidepressant should be started
with the benzodiazepine, and the purpose of
each, along with the expected outcome, should
be explained to the patient. After 6 weeks of
combination therapy, a tapering schedule for the
benzodiazepine should be initiated and even-
tually discontinued if possible.
69,75
For patients
who do not receive adequate anxiety relief
with an antidepressant alone, long-term treat-
ment with benzodiazepines may be neces-
sary. In this case, the lowest dose possible
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| Fundamentals of Geriatric Pharmacotherapy
to treat symptoms should be used. Agents
of choice for older adults include lorazepam
(0.5–2 mg/day) and oxazepam (10–30 mg/day).
75
After an adequate response is achieved,
therapy should be continued for at least 1 year.
Elderly with chronic recurrence of anxiety should
continue treatment long term. If anxiety presents
with major depressive disorder, then treatment
duration should be decided by the patient’s
depression history.
75
I
Etiology, Epidemiology, and
Clinical Presentation Specic to
Geriatrics
Insomnia is a condition that can affect patients at
any age. It is often assumed that older patients
require less sleep, especially because sleep
complaints are common in the elderly popula-
tion. However, insomnia is not a normal charac-
teristic of aging and should be evaluated and
treated appropriately.
Approximately 60% of community-dwelling
elderly patients report some form of disruption
of sleep, with difficulty falling asleep, nocturnal
waking, and waking up too early being the
most common complaints.
109
When compared
to the younger population (<60 years of age),
older patients (>80 years of age) have more
complaints regarding decreases in sleep
quality, waking repeatedly during sleep, and
having a difficult time getting back to sleep
after waking up in the middle of the night.
110,111
Sleep complaints, and the resulting daytime
sleepiness, are associated with a significant
impact on both community-dwelling and facility-
dwelling elderly patients, including decreased
quality of life, impaired cognition, more depres-
sive symptoms, higher risk of frailty, lower func-
tional status, decreased social interactions, and
increased mortality.
109,112-122
Sleep Changes in the Elderly
Brief (<30 seconds) nocturnal awakenings occur
in patients of any age; aging is associated with
an increased frequency and duration of these
nocturnal awakenings.
123
Sleep latency and the
number of early morning awakenings increase
with age. Total sleep time, sleep efficiency, and
rapid eye movement (REM) sleep latency are
also affected.
111,123-125
From midlife until the ninth
decade, total sleep time may decrease by an
average of 27 minutes per decade.
126
Changes
in sleep architecture in the elderly are evident on
polysomnography. Time spent in stages 1 and
2 increases, and time spent in stages 3 and 4
(“deep sleep”) and REM sleep decreases.
111,123-125
Age-related changes in sleep maintenance
and sleep architecture alter the homeostatic
drive for sleep. Decreased sleep during night-
time hours increases the homeostatic drive for
sleep during the day, resulting in daytime drowsi-
ness and daytime napping. The increase in the
frequency and duration of daytime naps causes
the homeostatic drive for sleep to decrease on
the subsequent night.
123,125,126
The amplitude and the shifting (to an earlier
time) of the circadian rhythm may result in sleepi-
ness at earlier-than-usual times. Several studies
have demonstrated that these changes are
associated with poor sleep quality, altered sleep
architecture, increased awakenings during
sleep, early morning awakenings, and increased
daytime sleepiness.
124,125,127
Growth hormone and cortisol levels have
been associated with sleep quality in healthy
older men. In one study, growth hormone levels
decreased by nearly 75% from young adulthood
to midlife (fifth decade) and continued to decrease
into late adulthood. Reduced amounts of short-
wave/deep sleep were associated with reduced
amounts of growth hormone secretion. Cortisol
levels, specifically the evening nadir levels, were
significantly increased from midlife to late life as
compared to younger counterparts. This was
associated with decreased amounts of REM sleep
and increased amount of wake time.
125,128
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KEY POINT:
Age-related changes in
sleep architecture and physiology may
result in decreased sleep maintenance
and quality in the elderly patient.
Due to the decreased time spent in stages 3
and 4, elderly patients are more likely to awaken
from noise in the environment.
125
Residing in
a long-term care facility is not conducive to
promoting quality sleep because of night-time
noise or light and room sharing. Long-term care
residents are often in poor physical health as
compared to their counterparts residing in the
community, and this may impact their sleep
quality.
114,129,130
Assessment of Insomnia in the Elderly
Many elderly patients do not discuss their sleep
complaints with their healthcare provider. These
patients tend to try interventions that may actu-
ally worsen sleep, such as watching TV, listening
to the radio, reading, taking a nap, drinking
alcohol, or smoking a cigarette.
131
Healthcare
providers should routinely ask older patients
about their sleep habits and the treatments that
have been tried.
The assessment of daytime functioning may
be an appropriate clinical measure to evaluate
the significance of insomnia on an individual
patient. Negative impact on daytime functioning
is stressed in the DSM-5 diagnostic criteria for
insomnia disorder.
21
Sleep disturbances in an
elderly patient may adversely affect daytime
functioning, including complaints of napping
and not feeling well rested on awakening.
109
KEY POINT:
Older patients should
be routinely asked about their sleep habits
and which treatments have been tried.
Sleep diaries or questionnaires are often
used to assess sleep complaints. Some ques-
tions that may be helpful include asking patients
what time they fall asleep at night and wake up
in the morning, if they feel sleepy during the
day, if they have difficulties falling asleep, how
many times they wake up during the night, and if
other symptoms are present while sleeping (e.g.,
snoring, leg discomfort, breathing difficulty,
movements).
123
Asking the spouse or caregiver
these questions may also provide some insight
for the clinician. The Pittsburgh Sleep Quality
Index is a valid and reliable self-rated question-
naire that gathers information on sleep habits,
daytime effects of sleep disorders, and etiology
of nocturnal sleep disruption.
132
A thorough evaluation of the patient’s
overall physical and psychological health
and medication use should be performed.
Multiple conditions affect the quality and quan-
tity of sleep by impacting a patient’s pain/
discomfort level, ability to breathe, ability to
urinate, or general mental condition. Almost
all diseases that are common in the elderly
population can adversely affect sleep (see
Table 13-1).
109,126,131,133
When identifying these
comorbid conditions, the clinician should
consider if these diseases are appropriately
treated or controlled before initiating pharma-
cologic therapy for insomnia.
Medications that cause stimulation, anxiety,
increased urination, excessive drowsiness, or
mental status changes should be evaluated.
Some examples of medications that may cause
these symptoms are found in Table 13-1. Many of
these medications have specific negative effects
on sleep staging and quality.
123,127,133
KEY POINT:
Several comorbid
conditions can adversely aect sleep.
Before initiating pharmacologic therapy
for insomnia, the clinician should
evaluate if any comorbid conditions are
appropriately treated or controlled.
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Summary of Standard Treatment in
the Adult Population
Education on proper sleep hygiene or cogni-
tive behavioral therapy is typically provided
when insomnia is diagnosed. When nonphar-
macologic therapy is ineffective, a short course
of a hypnotic agent is added. Hypnotic agents
include sedating antihistamines, benzodiaz-
epines, benzodiazepine-receptor agonists,
doxepin, or ramelteon. Use of hypnotic agents
should be at the lowest effective dose for the
shortest duration possible.
133
Review of Evidence Supporting
Treatment Recommendations for
Geriatric Patients
Proper sleep hygiene addresses healthy lifestyle
habits and environmental factors that influence
sleep. Sleep hygiene alone is often insufficient
to treat insomnia in an elderly patient. A variety
of other nonpharmacologic therapies, such as
relaxation, stimulus control, sleep restriction,
and cognitive behavioral therapy can be benefi-
cial for an elderly patient.
127,134
Cognitive behav-
ioral therapy and pharmacologic therapy in
combination is more effective in the treatment of
insomnia than either treatment approach alone.
The use of cognitive behavioral therapy when
drug therapy is discontinued maintains remis-
sion of insomnia, is preferred, and is perceived
by patients to be effective.
134-136
Several studies have demonstrated that Tai Chi
is effective in improving sleep quality and daytime
sleepiness in elderly patients.
137,138
Moderate exer-
cise, consisting of 30–40 minutes of low-impact
aerobics or brisk walking performed four times per
week, has been shown to improve sleep quality,
sleep latency, and sleep duration in patients
between 50 and 76 years of age.
139
Exercise
should not be performed within an hour of bedtime.
Decreasing or eliminating daytime napping may
not be as beneficial as initially thought, as one study
revealed that day or evening naps were not corre-
lated with poor sleep characteristics (sleep latency,
awakenings after sleep onset, impaired sleep effi-
ciency) in older patients.
140
Older patients report that prescrip-
tion hypnotic agents are effective in treating
sleep difficulties.
131,141
Several epidemiologic
studies have shown that benzodiazepines are
commonly prescribed in the elderly popula-
tion.
130
These agents reduce sleep latency,
reduce the number of awakenings, and
increase total sleep time. Although benzo-
diazepines have little or no effect on REM
sleep, the duration of sleep stages 1 and 4 is
decreased whereas the duration of sleep stage
2 is increased. The hypnotic benzodiazepines
(estazolam, temazepam, triazolam, quazepam)
are effective in treating insomnia and can be
used in short courses (<14 days). However,
due to the frequency of adverse effects that
typically occur in an elderly patient with the
use of these agents, they should be avoided
as first-line treatment for insomnia. Benzodiaz-
epines have been associated with worsening
sleep complaints, increased falls, excessive
daytime sleepiness, increased fractures, and
motor vehicle crashes in elderly patients.
142-145
The benzodiazepine-receptor agonists
(zolpidem, zaleplon, and eszopiclone) have
been shown to be effective for the treatment for
insomnia in the elderly population. These agents
increase total sleep time, decrease the number of
nocturnal awakenings, decrease sleep latency,
and improve sleep quality.
141,146-153
A meta-analysis
has found that zolpidem, zaleplon, and
eszopi-
clone have similar efficacy compared to benzo-
diazepines.
141
Their effects on improving sleep
onset and sleep maintenance enable these
agents to target common sleep disturbances in
an elderly patient. The benzodiazepine-receptor
agonists cause minimal effects on tolerance,
rebound insomnia, and residual daytime drowsi-
ness.
141,154
Recent data have shown that the
benzodiazepine-receptor agonists may increase
the risk of hip fracture, motor vehicle accidents,
and may cause similar adverse effects (confu-
sion, memory loss, falls) as the benzodiaze-
pines.
141,145,154,155
Benzodiazepine-receptor agonists can
cause complex sleep-related behaviors, such
as sleep-driving, making phone calls, and
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395
preparing and eating food (while asleep),
with subsequent amnesia of these behaviors.
Patients should be counseled to take the medi-
cation immediately before going to bed, to avoid
taking the medication with or immediately after
a meal, and to alert the bed partner to watch for
these behaviors so alternative treatment can be
tried. These agents may also cause anaphylaxis
and angioedema. As a result of postmarketing
surveillance, labeling of these products is now
required to state these potential effects.
156
In melatonin-deficient elderly patients,
melatonin replacement is beneficial in improving
sleep latency and
sleep efficiency.
157
Its use in
patients who are not specifically deficient in
this hormone is ineffective in treating primary
insomnia.
158,159
The melatonin-receptor agonist,
ramelteon, has been proven to be effective
in elderly patients with insomnia. Ramelteon
improves self-reported sleep latency and
total sleep time.
160
Recent data indicate that
ramelteon can impair driving performance.
161
It
carries the revised warning labeling regarding
possible anaphylaxis and angioedema but,
in general, is safer in elderly patients than the
benzodiazepine-receptor agonists.
156
Doxepin causes sedation because of its
high selectively for the histamine-1 receptor.
Low-dose doxepin is effective in increasing total
sleep time, decreasing the number of nocturnal
awakenings, and improving sleep quality and
efficiency in elderly patients with insomnia.
Low-dose doxepin (3- or 6-mg tablets) causes
minimal effects on residual daytime drowsiness,
rebound insomnia, and cognition and is not asso-
ciated with complex sleep behaviors. Doxepin
may cause anticholinergic adverse effects, such
as constipation, xerostomia, or urinary reten-
tion; however, clinical trials for low-dose doxepin
reported incidence rates comparable to placebo
or no anticholinergic adverse effects.
162-165
Common Problems Encountered
When Treating Elderly Patients
Residual daytime drowsiness is a common
phenomenon for geriatric patients because of
the pharmacokinetic alterations in renal func-
tion, hepatic function, and volume of distribution
that occur with aging. For this reason, the lowest
doses are recommended, even for agents that
are short acting. Extended-release agents may
not be an optimal choice because of slowed
motility of the GI tract in addition to the other
altered pharmacokinetic parameters.
Common nonpharmacologic interventions
for sleep difficulty used by older adults are
watching TV, listening to the radio, reading, or
taking a nap. Approximately 50% of older adults
that use alcohol for sleep do not discuss their
sleep difficulties with their healthcare provider.
131
These self-treatments may worsen insomnia,
and healthcare providers should routinely ask
older patients about their sleep and the treat-
ments that have been tried. This information
will aid in the selection of the most appropriate
therapy.
Over-the-counter (OTC) products are
frequently chosen by older adults.
131
These
medications typically contain diphenhydr-
amine or doxylamine, potentially inappropriate
medications for use in the elderly patient. Due
to the high potential of anticholinergic effects,
possible mental status changes, and residual
daytime drowsiness/excessive somnolence,
OTC sleep products should be avoided in the
elderly.
123,134
The use of other sedating antidepressants
(e.g., trazodone and mirtazapine) for the treat-
ment of insomnia should be reserved for elderly
patients who have depression. Trazodone was
commonly recommended by many experts as
a safe medication for sleep before the avail-
ability of the benzodiazepine-receptor agonists;
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396
| Fundamentals of Geriatric Pharmacotherapy
however, there are no data to support this asser-
tion. Antipsychotics with sedating adverse
effects should be reserved for elderly patients
with psychotic symptoms because of the multi-
tude of adverse effects associated with their
use.
123,130,134,165
S U D
Etiology, Epidemiology, and
Clinical Presentation Specic to
Geriatrics
Substance-use disorder is one of the leading
causes of disability. With the elderly population
increasing, and with the “Baby Boomers” now in
their sixties, it appears the prevalence of late-
life substance-use disorders will continue to
increase.
166-169
Alcohol abuse is noted to be a
significant health issue for the elderly popula-
tion, and over the last two decades more data
have become available addressing the epide-
miology, assessment, and treatment of late-life
alcoholism.
Non-alcohol substance disorders include
illicit and prescription drug abuse. Clinicians are
more likely to encounter prescription abuse than
illicit drug use in older adults.
167,170
Currently, the
prevalence of illicit drug use is very low in the
elderly, even though it will likely increase as the
geriatric population continues to grow.
166-169
Due
to the higher prevalence and moderate amount
of data available, late-life alcohol and prescrip-
tion drug use disorders will be the primary focus
of this section.
170
Recent reports note the majority of older
adults (50% to 60%) are reported to abstain (no
alcohol within the previous year) from alcohol
compared to 30% to 40% of younger adults.
171,172
The prevalence of alcohol-use disorder within
community dwelling elderly is reported to be
low (1% to 3%),
172
but prevalence of unhealthy
or at-risk drinking is higher (13% to 19%).
170
In
nursing homes, 29% to 49% of patients met
criteria for alcohol-use disorder during their life-
time, with 10% to 18% having met criteria within
1 year of admission to the home.
173,174
Two-thirds of older alcoholics developed
alcoholism earlier in life and continued to drink
through their elder years. These individuals are
considered to have early-onset alcoholism.
Late-onset alcoholism/abuse, which encom-
pass the remaining one-third of older alcoholics,
includes individuals who did not drink heavily
until late in life. There are many differences
between these groups regarding epidemiology
and social history.
175
Early-onset alcoholics are more likely to have
a family history of alcoholism, socioeconomic
decline due to their alcohol use, and antiso-
cial behavior. Due to their many years of use,
these patients will often have significant medical
history such as cirrhosis, cognitive decline, and
other psychiatric disorders. Late-onset alco-
holics usually do not report any alcohol-related
problems until after age 50. These individuals
are often well educated and have maintained a
high socioeconomic status through their working
life. Alcohol-related illnesses are less frequent in
this population. A stressful life event is usually
what precipitates the excessive drinking. Late-
onset alcoholics are noted to be more agreeable
to treatment and recover more easily compared
to early-onset patients.
175,176
However, late-onset
abuse and dependence are often missed by
healthcare providers.
170
Alcohol and drug abuse are often associ-
ated with other psychiatric illnesses in younger
adults. Approximately 20% of older adults with
a diagnosis of depression meet diagnostic
criteria for alcohol-use disorder, and more than
90% of those who abuse alcohol have a history
of depression.
177
It has also been found that
the prevalence of dementia is five times higher
in elderly who are heavy drinkers compared to
those who do not abuse alcohol.
178
Risk Factors for Alcohol Abuse and
Comorbidities
Major risk factors include male gender, major life
changes or stressors, and recent loss. Overall,
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