Psychotropic Medications in
Older Adults: Pearls and
Pitfalls
Dr. Janet P. McMillan, APRN-BC
Psychiatric Nurse Practitioner
Hattiesburg, MS
Objectives
› 1. Provide information on how the most commonly
prescribed psychotropic medications affect the elderly.
› 2. Examine recent concerns about the use of psychotropic
medications with older adults.
› 3. Describe implications for the advance practice nurse
prescribing psychotropic medications the older adults.
Understanding the Scope of the Problem
› Psychotropic medications are more prevalent among
community dwelling older adults than any other age group.
Community dwelling elder adults are 7 to 18 times more likely
to use psychotropic drugs than are middle-aged adults.
› More than half of community dwelling older adults who are
admitted to nursing homes receive psychotropic medications
within two weeks of their admission.
› In fact, in a study of older adults with dementia in nursing
homes and psychiatric care geriatric units, researchers found
the 87% of patients were taking 1 psychotropic medication,
66% were taking 2, 36% were taking 3, and 11% were taking 4
or more psychotropic medications.
Adverse Affects in the Elderly
› It is well documented that older adults are highly vulnerable
to the adverse effects of psychotropic medications. Those
older than age 70 are 3 1/2 times more likely than younger
individuals to be admitted to the hospital for adverse
reactions associated with psychotropic medications.
› In short, psychotropic medications can induce or worsen
hypotension and get put elderly patients at risk for falls and
skeletal fractures, particularly when given in combination with
other medications.
What Are Psychotropic Medications?
› Psychotropic medication is a broad term referring to
medications that affect mental function, behavior, and
experience.
› These medications are typically administered to older adults
to manage symptoms of anxiety, depression, psychological
distress, and/or insomnia.
› The 3 most commonly prescribed categories of medications
include anxiolytic, antidepressant, and antipsychotic
medications.
Age-Related Changes
› Age-related changes such as altered absorption, altered
distribution, changed hepatic metabolism, reduced renal
excretion, and altered neurophysiology all affect the
pharmacokinetics and pharmacodynamics of medications.
› Comorbid medical diagnoses and polypharmacy also affect
pharmacokinetics and pharmacodynamics properties of soccer
tropic medications putting older adults at risk for adverse drug
reaction and interactions.
› These facts are well-known to prudent prescribed and should
be taken into consideration.
Anxiolytic/Hypnotic Medications
› Anxiolytic medications are most commonly prescribed for
anxiety disorders or symptoms. The most common anxiolytic
medications prescribed for older adults are the
benzodiazepines.
› Older adults experience an increased magnitude of the
common side effects of these drugs, particularly sedation and
memory and psychomotor impairment.
› This is most likely due to the reduced rates of drug clearance
and elimination in older adults. Some older adults experience
paradoxical excitement from benzodiazepines.
Hazards of BZD Use in Older Adults
› Long-term use (more than 30 days) of benzodiazepines are
contraindicated in older adults due to the risk of cognitive
decline, reduced physical coordination, and addiction;
however, many older adults are prescribed benzodiazepines
for months or even years.
› Many older adults are prescribed benzodiazepines as a sleep
aid; however, this might actually worsen sleep patterns in
older adults.
› About 10% of geriatric hospitalizations are related to the use
of benzodiazepines.
Are Antihistamines OK?
› Sedating antihistamine drugs should also be avoided, as they
may be associated with delirium and other anti-cholinergic
side effects.
› If prescribed, hypnotic drugs should be tapered to
discontinue, if taken longer than two weeks.
What is the Alternative?
› First of all be sure that the symptom you are treating is indeed
anxiety.
› Recognizing and being able to differentiate anxiety from other
underlying medical illnesses such as cardiac disorders,
endocrine disorders withdrawal from alcohol, caffeine or
nicotine can be difficult because patients may exhibit similar
symptoms.
› Many elderly patients have undiagnosed depression, which
can present with atypical symptoms similar to an anxiety
disorder, or patients may have comorbid anxiety and
depression.
If A Benzodiazepine Medication is Needed…
› If the patient has been taking benzodiazepines long-term,
closely monitor them for cognitive and/or functional decline
using screening tools such as the mini mental status exam.
› Fall risk should be assessed, as well as symptoms of increasing
tolerance and/or dependence.
› If a problem is noted and discontinuation is indicated, work
collaboratively with the family or an inpatient facility in a
carefully titrated withdrawal program.
Tolerance Vs. Dependence
› Tolerance: requiring higher doses to achieve the same effect
› Dependence:
– taking the drug in larger amounts over a longer time than intended;
– persistent desire or unsuccessful attempts to control use;
– spending a great deal of time trying to obtain the medication, such as
going to multiple doctors.; and
– impaired social functioning as a result of the substance.
› Discontinuation withdrawal symptoms will occur after use of
more than 30 days and must be carefully monitored. Half-life
will determine symptoms severity.
Common Benzodiazepines
Half-Life (hours)
Generic Name
Trade Names
5-10
Temazepam
Restoril
6-10
Oxazepam
Serax
10-14
Alprazolam
Xanax
22-54
Clonazepam
Klonopin
20-48
Diazepam
Valium
25-30
Flunitrazepam
Rohypnol
Benzodiazepine Withdrawal
› Onset:
2-3 days for short-acting
5-7 days for long-acting
› Symptoms typically last 2-4 weeks, up to a few months
› Symptoms can be more intense at the beginning and end of
reduction.
› Symptoms typically fluctuate
› Symptoms vary from mild to severe and may require
hospitalization
Non-Pharmacological Management of Anxiety
› Nonpharmacological interventions such as activity-based
therapies (music, art, dance, drama), reality orientation,
reminiscence, validation, and multi sensory stimulation should
be explored to ameliorate symptoms of anxiety and insomnia
prior to reliance on anxiolytic medications.
› Treatments for generalized anxiety disorder overlap greatly
with those for depression.
› First line treatments include SSRIs, SNRIs, buspirone (BuSpar),
pregabalin (Lyrica), and gabapentin (Neurontin).
› There is a place for the use of benzodiazepines in treating the
patient with an anxiety disorder when prescribed responsibly.
› When initiating an SSRI or an SNRI, the serotonergic agents
are often activating, difficult to tolerate early in dosing, and
have a delayed onset of action.
› Therefore short-term use (2-4 weeks) of a benzodiazepine
might be indicated for these patients to provide relief of
anxiety symptoms.
Antidepressant Medications
› Antidepressant medications are prescribed for depressive
disorders, anxiety disorders, and insomnia or depression with
comorbid anxiety.
› SSRIs have become the preferred first-line treatment for
depression in older adults due to the benign side effect
profile, reduced anti-cholinergic and cardiovascular effects.
› However, older adults have increased sensitivity to adverse
effects than the younger patients. Citalopram (Celexa),
escitalopram (Lexapro), and sertraline (Zoloft) are generally
well tolerated.
Tricyclic Antidepressants in the Elderly?
› Tricyclic antidepressants
have a number of side
effects that increase the
elderly patients risk for falls
including:
–
–
–
–
sedation,
psychomotor retardation,
postural hypotension, and
anti-cholinergic effects
› This risk is greatest during
the first 90 days of
treatment.
There is a Caveat…
› Although there is a risk with prescribing antidepressant
medications in the elderly, there is concern that depression in
older adults often goes unrecognized.
› One study reported that the rate of undiagnosed depression in
the elderly could be as high as 85%, with only 15% to 19% of
older people receiving ample antidepressant medication.
So What Can We Do?
› Work closely with mental health professionals to identify
elderly individuals with depressive symptoms.
› Understand that depression and older adults can be
manifested through atypical symptoms of depression
including:
–
–
–
–
–
anxiety,
difficulty with concentration and memory,
confusion,
slow movements, and
unexplained somatic complaints.
Resources
› Work with patients and families to provide resources for:
–
–
–
–
–
psychoeducation,
family counseling,
home care,
grief/loss support groups, and
outpatient senior care programs.
› Complementary or alternative therapies such as prayer,
massage, or aromatherapy can also be helpful.
When Medications Are Needed…
› When prescribing antidepressant medications to older adults,
be familiar with the side effect profile and the major drug to
drug interactions.
› Some SSRIs and TCAs cause hyponatremia and increased risk
of bleeding when combined with NSAIDs, aspirin, or warfarin.
› Bupropion (Wellbutrin) can increase the risk of seizures in a
patient with a previous seizure disorder.
› Serious side effects of antidepressant medications include the
risk for activation of mania in patients with bipolar disorder,
serotonin syndrome, and suicidal ideation.
Antipsychotic Medications
› Antipsychotic medications, typically given for psychotic
symptoms, are also frequently administered to manage
disruptive behavior and older adults with cognitive
impairment.
› Antipsychotic medications include both typical and atypical
drugs.
Older Adults Have Greater Risk…
› Typical antipsychotic medications have serious side effects
that can affect quality of life, including tardive dyskinesia,
acute extrapyramidal side effects, and neuroleptic malignant
syndrome.
› Tardive dyskinesia involves abnormal muscle movements in
the face, eyes, mouth, tongue, and limbs and can develop in
30% to 50% of patients, even at low drug dosages for short
periods of time. It can last for several years and, in some
cases, is irreversible even after the medication has been
discontinued.
Abnormal Involuntary Movements
› EPS include drug-induced parkinsonism, akinesia, dystonia,
and akathisia. Parkinsonism and akathisia consist of lack of or
slowed movement, depressed affect, salivation, expressionless
face, tremor, and shuffling gait.
› Dystonia is characterized by muscle rigidity, contracted neck
and eye muscles, and jaw and muscle soreness. Dystonic
reactions are less common in older adults for reasons that
remain uncertain.
› Akathisia is characterized by pacing and restlessness. Between
50% and 75% of all patients taking typical antipsychotic drugs
experience EPS; however, elderly patients are at higher risk for
drug induced parkinsonism and EPS than are younger patients.
Life-Threatening Side Effects
› Neuroleptic malignant syndrome involves high fever, rigidity,
altered consciousness, and autonomic system instability
including unstable hypertension, tachycardia, sweating, pallor.
› NMS can be potentially fatal if not recognized and treated.
› Conditions such as neurological illness, dehydration,
malnutrition, exhaustion, agitation, and organic brain disease
are considered risk factors that make older adults more
vulnerable to the development of neuroleptic malignant
syndrome.
Anticholinergic Effects
› Older adults are also more
susceptible to the
anticholinergic and
cardiovascular effects of typical
antipsychotic drugs.
› These include dry mouth,
constipation, blurred vision,
urinary retention, hypotension,
and cardiac conduction delay
(specifically Q-T prolongation).
Atypicals are Slightly Better…
› Atypical antipsychotic medications generally produce fewer of
the adverse effects commonly associated with the typical
antipsychotic medications.
› However black box warnings regarding the use of these
medications with older adults due to the cardiac and
cerebrovascular, mortality risks associated with their use in
patients with dementia should be considered.
No FDA Approved Medications for AD
› Other serious side effects include adverse cardiovascular
events, extrapyramidal symptoms somnolence, upper
respiratory infections, edema, urinary tract infections, and
fever.
› Although there is some controversy about the results of the
CATIE-AD study, these drugs are not approved for use in
patients with dementia.
So What are Some Safe Options?
› Nonpharmacological strategies for patients experiencing
psychosis to minimize agitation and disruptive behavior
include:
– Sensory enhancement (music therapy and aromatherapy)
– Socialization (reminiscence, simulated presence therapy)
– Social support and contact (talking with the person, video or audio
types of family members, pet therapy)
– Engaging activities (stimulation, activity and engagement)
– Relief from discomfort (pain, hearing or vision problems, positioning,
and addressing activity of daily living needs).
When Antipsychotics are Needed…
› When prescribed, the patient should be monitored for
oversedation, orthostatic hypotension, unsteadiness, and
extraparyramidal symptoms.
› Use of the AIMS (abnormal involuntary movements scale) is
recommended before treatment at baseline, at four weeks,
eight weeks, and every six months thereafter.
› They should be prescribed only when necessary, reviewed
regularly for continued need, and discontinued as soon as
possible.
Proceed With Caution…
› The introduction of psychotropic
medications in older adults
should be done with caution…
› Start low (1/2 to 1/3 of the usual
dose) and go slow.
› Documentation regarding the
reasons for prescribing and
continuing psychotropic
medications should be a part of
the patient's ongoing clinical
record.
Cover All the Bases
› Documentation should also be present indicating that other
potential causes of disruptive behavior, such as delirium, pain,
fatigue, hunger, incontinence, and infection, have been
explored.
› Close monitoring for side effects and documentation of both
pharmacological and nonpharmacological interventions,
including their effectiveness, is essential.
Pearls for Geriatric Prescribing
› Always investigate new symptoms to determine the root
cause. It could be a manifestation of a serious problem or an
adverse drug reaction.
› Determine if a medication is really needed. Sometimes a nonpharmacologic approach will work.
› Prescribe the lowest effective dose for the shortest period of
time.
› Review medications at each visit and don’t forget herbals,
vitamins, and other supplements.