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This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #10

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LEARNING OBJECTIVES

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Learning Objectives

  • Learn the appropriate indications, dosage, and adverse effect profile of commonly used psychoactive drugs in older adults.

  • Understand the principles of safe prescribing of antidepressants, especially the newer second-generation selective serotonin reuptake inhibitors (SSRI), serotonin norepinephrine reuptake inhibitors (SNRI), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs) in older adults with depression.

  • Gain state-of-the-art knowledge about the proper indications, efficacy, safety, and results of randomized clinical trials targeting use of atypical antipsychotics for management of behavioral symptoms in patients with dementia.

  • Learn about the appropriate use, side effects, and efficacy of anxiolytics and mood stabilizers in older patients with anxiety and dementia.

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Key Clinical Points

  1. The use of psychotropic medications is only second to cardiovascular drugs among older patients. Nearly one in five community-dwelling older adults and over 47% older residents of nursing homes are on psychoactive medications.

  2. In nursing homes, psychotropic drugs and anticoagulants are the most common medications associated with adverse drug reactions (ADRs).

  3. There is a significant interindividual variation in efficacy and clearance of psychoactive medications in older adults.

  4. The most common adverse effects of SSRIs include nausea, dry mouth, constipation, drowsiness, and sleep problems.

  5. Use of antidepressants is associated with increased risk for falls, hip fractures, and osteoporosis.

  6. Administration of atypical antipsychotics is associated with an increased risk for sudden death and cerebrovascular accidents in older patients with dementia.

  7. Quetiapine is the drug of choice for older patients with Parkinson disease and Lewy body dementia due to low incidence of extrapyramidal side effects.

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INTRODUCTION

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This chapter focuses on the use of psychotherapeutic medications in older adults, including antidepressants, psychostimulants, antipsychotics, mood stabilizers, and anxiolytics. These classes of drugs are used to treat psychiatric disorders across the lifespan into late life, including major depression, anxiety, psychosis, and the behavioral and psychological disturbances that frequently accompany Alzheimer disease (AD) and other neurocognitive disorders.

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Mood and behavioral disturbances are commonly encountered in older adults. Late-life depression, including major depressive disorder and dysthymia, affects 8% to 16% of older adults. These rates are found to be consistent with those in younger adults; however, older people face a disease profile that is more chronic and treatment resistant, as it is often accompanied by age-related and pathologic cognitive decline. Depression in community-living older patients frequently remains unidentified and untreated. Depression occurring in persons greater than 60 years is likely distinct from that which occurs among younger age groups. For example, late-life depression is often associated with significant vascular disease. Structural abnormalities in frontal white matter thought to be secondary to cerebrovascular disease are associated with unremitted depression.

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Late-life depression leads to further deterioration in quality of life and increases the risk for dementia and suicide. Depressed elders are known to suffer greater rates of disability, mortality, and nursing home placement. Furthermore, when ...

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