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13 - Psychiatric Issues |

407

C S

Depression and GAD are the most common

psychiatric disorders observed in geriatric

patients and if left untreated lead to decreased

daily function and increased morbidity and

mortality. SSRI and SNRI therapy are recom-

mended as ﬁrst-line when medications are

needed. Doses should be started at the lower

end of the range but eventually titrated to

a moderate dose to provide an adequate

response. Frequent follow-up, monitoring, and

support should be provided once therapy is initi-

ated to increase chances of remission, compli-

ance, and quality of life.

Benzodiazepines can be used if acute

treatment of an anxiety disorder is needed.

Short-acting agents such as lorazepam and

oxazepam are the preferred agents to use in the

elderly. Generally, chronic benzodiazepine use

is discouraged because of the risk of adverse

effects and should be gradually tapered after a

patient has had time to respond to antidepres-

sant therapy.

Insomnia is a common complaint among

elderly patients. If left undiagnosed and

untreated, insomnia may adversely affect a

patient’s overall health status and quality of life.

When an older patient complains of sleep difﬁ-

culties, it is important to evaluate the patient as

a whole, which includes assessing comorbid

conditions, medication use, and environment.

Assessing the elderly patient’s daytime func-

tioning can help the clinician in selecting the

appropriate therapy. Nonpharmacologic therapy

is beneﬁcial for the elderly. If nonpharmaco-

logic strategies are ineffective, the use of drug

therapy (e.g., a benzodiazepine-receptor agonist,

ramelteon, or doxepin) may be warranted.

The prevalence of substance-use disorders

in older adults is less than that observed in young

to middle-age adults. However, as the geriatric

population continues to grow and the “Baby

Boomers” begin to enter their sixties, the preva-

lence of late-life abuse is expected to increase.

Currently, alcohol abuse is noted to be more

concerning in the elderly population compared

to prescription drug or illicit substance abuse.

Clinical Pearls

• Older adults with sleep difﬁculties often try self-treatment interventions before report-

ing these symptoms to their healthcare provider. Interventions often tried are watch-

ing TV, listening to the radio, OTC sleep aids, or drinking alcohol, which may worsen

insomnia or cause adverse effects. When assessing older adults, ask about their

sleep and sleep habits, including any treatments that they have tried to help them

sleep.

•

Current federal regulations require periodic dose reductions for all psychoactive

medications for nursing home residents. Antidepressants, benzodiazepines, and

benzodiazepine-receptor agonists must be tapered to lower doses within 6 months to

meet this regulation. This is repeated until the medication is discontinued or until the

resident demonstrates symptoms of disease recurrence. This is problematic with the

use of antidepressants, which are recommended for use a minimum of 9 months with

late-life depression and sometimes needed for life-long therapy. Clear documentation

of need is necessary to ensure optimal pharmaceutical care and prevent placing the

nursing home at risk for regulatory noncompliance.

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408

| Fundamentals of Geriatric Pharmacotherapy

S-A Q

1. What other complaints are associated more

with late-life depression and late-life anxiety

compared to young adult depression and

anxiety?

Which therapies are considered ﬁrst line for

treatment of late-life depression and late-life

anxiety?

3. Which benzodiazepines are considered

safer for older adults? When and how should

benzodiazepines be discontinued?

4. What physiologic changes on sleep archi-

tecture, circadian rhythm, and homeostatic

drive occur as a patient gets older? How

do chronic diseases and medication use

contribute to sleep disturbances in elderly

patients?

Of the available pharmacologic therapies

indicated for insomnia, which are preferred

in the elderly population and why?

6. What are the limitations of using the DSM-5

criteria to diagnose a geriatric patient with

substance abuse and dependence?

7. Which pharmacologic agents can be

considered as adjunct therapy for older

adults trying to abstain from alcohol?

8. Which classes of prescription medications

are more likely to be abused because of

increased prescribing in the elderly popula-

tion?

R

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