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8/6/2019 Psycho Pharmacology Elderly
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My inner child just turned 65My inner child just turned 65
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Yearly Prevalence RatesYearly Prevalence Rates
Age Ranges Major SubAge Ranges Major Sub--syndromalsyndromal
6565--79 3% 13%79 3% 13%
80+% 4% 18%80+% 4% 18%
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Unrecognized andUnrecognized and
Significantly UnderSignificantly Under--treatedtreated
AgeismAgeism
Inadequate screening:Inadequate screening:
Primary carePrimary care
Diagnostic problemsDiagnostic problems
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Diagnostic IssuesDiagnostic Issues
Symptomatic overlap withSymptomatic overlap with
medical illnessesmedical illnesses::
> fatigue, weight loss, impaired> fatigue, weight loss, impairedconcentration, poor selfconcentration, poor self-- care,care,
psychomotor retardationpsychomotor retardation
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Diagnostic IssuesDiagnostic Issues
DSM criteria not very usefulDSM criteria not very useful
DSM IV field trialsDSM IV field trialsnot done w/ eldersnot done w/ elders
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Diagnostic IssuesDiagnostic Issues
Cardinal Features of LateCardinal Features of Late--LifeLifeMajor Depression:Major Depression:
> Disengagement> Disengagement> Anxiety or irritability> Anxiety or irritability (much more than sadness)(much more than sadness)> Pessimism and feelings> Pessimism and feelings
of worthlessnessof worthlessness
> Suicidal Ideations> Suicidal Ideations> PMS> PMS
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Dementia and DepressionDementia and Depression
Very common coVery common co--morbiditymorbidityqq ADLs !!!ADLs !!! Treating depression can be very beneficialTreating depression can be very beneficial
Diagnostic problems: later stage dementiasDiagnostic problems: later stage dementias
>
sudden increase in aggression or>
sudden increase in aggression oragitationagitation
> 5> 5--10 pound weight loss in one month10 pound weight loss in one month
> Persistent tearfulness> Persistent tearfulness
> Screaming> Screaming
> Somatic delusions> Somatic delusions
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General IssuesGeneral Issues
PharmacoPharmaco--kineticskinetics::changes in liver and kidneychanges in liver and kidney
Do no harmDo no harmStart lowgo slowStart lowgo slow
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General IssuesGeneral Issues
Side effect sensitivitySide effect sensitivity: *: *
AnticholinergicAnticholinergic: (benadryl, Paxil,: (benadryl, Paxil,
tricyclicstricyclics [e.g. Elavil][e.g. Elavil], Cogentin) :, Cogentin) :constipation, urinary retention,constipation, urinary retention,
aggravates glaucoma,aggravates glaucoma, memorymemory
problemsproblems, delirium, delirium
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General IssuesGeneral Issues
Side effect sensitivitySide effect sensitivity::SedationSedation: (: (RemeronRemeron,, TrazodoneTrazodone,,
antipsychotics, TCAs, moodantipsychotics, TCAs, mood
stabilizers, tranquilizers!!!!! )stabilizers, tranquilizers!!!!! )decreased: activity, cognitivedecreased: activity, cognitive
impairment, increased fallsimpairment, increased falls
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General IssuesGeneral Issues
Side effect sensitivitySide effect sensitivity::ExtrapyramidalExtrapyramidal Side Effects:Side Effects:
tremors, gait problems, muscletremors, gait problems, muscle
spasms, inner restlessness.spasms, inner restlessness.(older antipsychotics,(older antipsychotics, RisperdalRisperdal,,sometimes SSRIs):sometimes SSRIs):aggravates Parkinsonaggravates Parkinson SxSx, falls, falls
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General IssuesGeneral Issues
Side effect sensitivitySide effect sensitivity: Cardiac: Cardiac
Orthostatic Hypotension:Orthostatic Hypotension: **
antipsychotics,antipsychotics, trazodonetrazodone
Increased Blood Pressure:Increased Blood Pressure:
EffexorEffexor (12%);(12%); PristiqPristiq
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General IssuesGeneral Issues
Side effect sensitivitySide effect sensitivity::
Serotonin Reuptake InhibitorsSerotonin Reuptake Inhibitors::
> activation> activation
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General IssuesGeneral Issues
DrugDrug--Drug Interactions:Drug Interactions:
> Especially with Prozac and Paxil> Especially with Prozac and Paxil
sometimes:sometimes: WellbutrinWellbutrin
2D6 enzyme inhibition2D6 enzyme inhibition
> Pain medications> Pain medications
> St. Johns> St. Johns WortWort
>> CelexaCelexa andand LexaproLexapro: least: least
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General IssuesGeneral Issues
Forgetfulness about taking medsForgetfulness about taking meds
Sharing medicationsSharing medications
Prescribing Cascade..Prescribing Cascade..exampleexample
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Polypharmacy Cascade: Case IPolypharmacy Cascade: Case I
78 year old female78 year old female
Hip fracturerecoveringHip fracturerecovering
Cognitive impairmentCognitive impairment
Mild high blood pressureMild high blood pressure
Urinary incontinenceUrinary incontinence
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Polypharmacy Cascade: Case IPolypharmacy Cascade: Case I
Ativan 0.5 mgAtivan 0.5 mg twice a daytwice a day Lorazepam 0.5 mgLorazepam 0.5 mg twice a daytwice a day Tylenol with codeineTylenol with codeine ProzacProzac DiureticDiuretic TrazodoneTrazodone BenadrylBenadryl
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A Few Specifics: AntidepressantsA Few Specifics: Antidepressants
Anergic DepressionsAnergic Depressions::
>>WellbutrinWellbutrin (very few cardiac SE)(very few cardiac SE)
very robust: N: 350 MDD86% 50%+very robust: N: 350 MDD86% 50%+ qq
HAMHAM--D and marked improvement inD and marked improvement in
social functioningsocial functioning
> R & R:> R & R: Ritalin and RemeronRitalin and Remeron
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A Few Specifics: AntidepressantsA Few Specifics: Antidepressants
Agitated DepressionsAgitated Depressions::> Watch for delirium and mania> Watch for delirium and mania
>> RemeronRemeron (some evidence: quicker response)(some evidence: quicker response)start with 7.5 mg qdstart with 7.5 mg qd
>> SSRIs with benzo augmentationSSRIs with benzo augmentation
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A Few Specifics: AntidepressantsA Few Specifics: Antidepressants
Psychotic DepressionsPsychotic Depressions::
> Common> Common
> Cautions: with Wellbutrin> Cautions: with Wellbutrin
> Must use AD and anti> Must use AD and anti--psychoticspsychotics
> ECT> ECT
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