MHM Magazine

36 | MENTALHEALTHMATTERS | Issue 3 | 2021 MHM THE RULE OF THUMB When medicating an elderly patient, the procedures are similar to that of a younger patient so always start low, go slow, and review frequently. Elderly patients are more sensitive to side-effects and should be prescribed ¹⁄2 to ¹⁄3 of a standard adult dose. Polypharmacy is usually indicated. Medication regimes should be supervised and reviewed at least every three months. MORBIDITY IN THE ELDERLY Sleep Disturbance 35% Impaired ADL 34% Somatic Complaints 27% Decreased Subjective Cognition 25% Depression 15% Dementia 8% CAUSES OF NEUROPSYCHIATRIC SYMPTOMS (NPS) Medical Disorders Pain, constipation, infection, cardiac failure * the best laxative for elderly patients is Senna (Soflax) 1 – 4 tablets at 17:00 Psychiatric Disorders Depression, dementia, delirium Environmental Effects A new caregiver, having hair washed Medication Side- effects Anti-cholinergic properties, benzodiazepines CAREGIVER PSYCHO- EDUCATION Taking the time to psycho-educate caregivers is crucial and enables further monitoring of patients’ wellbeing. Elderly patients in care, with or without delirium, are fluctuating quite markedly due to COVID-19 restrictions. Psycho- educating caregivers so that they can identify mood fluctuations, times of the day that are more difficult for the patient as well as sleep and eating patterns is key to successful managed treatment. ANTIDEPRESSANTS If there is even a hint of a mood condition, sadness – cognitive symptoms – rather prescribe an antidepressant with sedating agents. Start low, go slow, and review frequently – always titrate upwards in small increments. It’s important to note that there is an 80% relapse rate in elderly patients who don’t stay on treatment for at least two years. Avoid the use of tricyclics, and benzodiazepines, in the elderly. Treating depression after a relapse is far more challenging. Venlapaxine XR (Effexor) in the morning is showing success in dosages of 150 to 225 mg. ANTIDEPRESSANTS Sedating agents: Citalopram (Cipramil) 10 – 30 mg Mirtazapine (Remeron) 15 – 30 mg Agomelatine (Valdoxane) 25 – 50 mg Escitalopram (Cipralex) 5 – 10 mg Sertraline (Zoloft) 50 – 150 mg ACUTE SEDATION AND BENZODIAZEPINES While there are numerous methods and older combinations that work, the superior method overall is lorezapam. Ideally, patients should be medicated before bed so their circadian rhythms are not disrupted. Haloperidol is still frequently used but is far too strong for the elderly and wreaks havoc on circadian rhythms. Ziprasidone (10mg) works very well in private practice. Among the hypnotics, benzodiazepines should, as a rule, be avoided. Elderly patients are sensitive to daytime somnolence, disruption of circadian rhythms, emotional lability, confusion, incoordination ataxia, and memory impairment. Elderly patients are already at high risk for falls and one in seven falls results in hip fracture. Of those, one in seven results in death. It should take at least a year to wean an elderly patient off a benzodiazepine while converting to a different agent. Reduce dose by ¹⁄4 or ¹⁄3 and maintaining that for several months before reducing again. Melatonin can be used for mild cases of sleep disturbance. The “Z medications” (zolpidem, zopliclone) are preferred for stronger cases. It’s important to note that should you have an elderly patient with treatment-resistant psychosis, it’s critical to refer to a specialist. The COVID-19 pandemic and its resulting social constraints has seen many elderly patients in private practice “acting out”. At times, an anxiolytic is required. However, these should be used with discretion as they act on the gabba system and the potential for addiction is similar to benzodiazepines. NON-BENZODIAZEPINE a. Melatonin Melatonin (Citcadin) 2mg – 60 to 90 minutes before sleep b. Benzodiazepine-related Zolpidem (Stilnox) 5 – 10mg / Stilnox MR 12.5 mg Zopiclone (Imovane) 3.75 – 7.5 mh c. Antidepressants Citalopram (Cipramil) 10 – 20 mg (1 in 20 will not be sedated) Mirtazepine (Remeron) 7.5 – 15 mg Agomelatine (Valdoxan) 25 mg at night d. Neuroleptics Chlorpromazine (Largactil) 25 mg Olanzepine (Zyprexa) 24 mg given at 17:00 Quetiapine (Seroquel) 25 mg at night NEUROLEPTICS The use of antidepressants in Alzheimer’s patients with a Mini- Mental State Exam (MMSE) of 22 and lower remains questionable. Patients with first-time onset of depression and/or anxiety in their 50s ultimately are diagnosed with Vascular Depression. Many people with dementia develop signs of depression, such as feelings of low self-esteem and confidence, tearfulness and appetite, concentration and memory problems. The apathy of depression should be treated with cognitive enhancers and neuroleptics rather than antidepressants in long-term, augmented treatment. As a matter of course, elderly patients become emotionally depleted as the day wears on and at around 17:00 / 18:00 fall into a soft delirium, what we call ‘sundowners’. In order to intercept this, evening doses of medication should be given at 17:00. Once an elderly patient is delusioning, a neuroleptic is required. Bear in mind