Gastrointestinal Disorders in the Older
Adult: The Psychiatrist’s Role
72
Alberto Cortes-Ladino
Questions
1. The most commonly associated type of cancer associated
with depression is:
a. Colon
b. Small bowel
c. Liver
d. Stomach
There is a clear association between gastrointestinal cancer and increased incidence of depression. The most
common malignancy associated is stomach (20.2%), followed by pancreas (17.3%) and colon (8.6%). The mechanism is not well known, but appears to be related to the
release of cytokines.
2. The first line of treatment for depression in an elderly
patient is:
a. Imipramine
b. Selegiline
c. Paroxetine
d. Escitalopram
e. Paroxetine and escitalopram
Antidepressant medications of the SSRI type (e.g., paroxetine, escitalopram, sertraline, fluoxetine, citalopram)
remain the best option for treatment of depression in the
elderly. These medications are well tolerated and have fewer
anticholinergic effects compared to other antidepressants
such as the tricyclics or MAO inhibitors. Other side effects
include dry mouth, appetite disturbances, constipation,
diarrhea, and abdominal discomforts. Delirium may be the
only presenting feature of the life threatening Serotonin
Syndrome, resulting from the interaction between citalopram and fluconazole, in frail, susceptible individuals such
as cancer and elderly patients. FDA has issued a warning for
every antidepressant, in which patients of all ages should
be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior.
3. The treatment of delirium that results as an adverse drug
effect from the use of ifosfamide in an elderly patient with
gastrointestinal cancer is:
a. Clozapine
b. Risperidone
c. Methylene blue
d. Ativan
Ifosfamide is a chemotherapeutic agent commonly
used in the treatment of several solid tumors and hematologic malignancies. Common ifosfamide toxicities
are bone marrow suppression, alopecia, nausea, and
vomiting. Less common, but striking, are the rare but
dramatic neuropsychiatric toxicities with discrete neurological symptoms and delirium that occurs in 5–30%
of patients with cancer. Methylene blue is widely used
for treatment and prevention of ifosfamide neurotoxicity in clinical practice. It is important to monitor not
only for neurological but also for psychiatric manifestations during ifosfamide treatment.
4. Which single answer amongst the following best
describes the anticholinergic adverse drug effects in the
geriatric patient?
a. Worsening cognition
b. Urinary retention
c. Constipation
d. All of the above
The medication of choice for the treatment of depression
in the geriatric patient relies on the safety and adverse
reaction profiles. Medications are started a low dose and
the dosage is increased more slowly than with a younger
patient. Worsening cognition, sedation, and anticholinergic effects are more often seen with the use of tricyclic
antidepressants, mainly nortriptyline. Likewise, constipation and urinary retention are an unwanted side effect of
this class of medication that also includes amitriptyline, a
tertiary amine with more side effects than nortriptyline.
C.S. Pitchumoni and T.S. Dharmarajan (eds.), Geriatric Gastroenterology,
DOI 10.1007/978-1-4419-1623-5_72, © Springer Science+Business Media, LLC 2012
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