As the year's end and various gatherings of family and friends approach, it is important to engage and observe the older members of our communities. For older adults, year's end can trigger the memories of loved ones who have since died and the memories of their past vitality and roles in the family and workforce. For some older adults, the end of the year can also trigger the recognition that they are no longer as independent as they once were. The loss of the ability to drive, the “family home” being downsized, the income once enjoyed, among other losses may all be at the forefront of the minds of older adults as they reminisce about years gone by.
Psychiatric nurses and other mental health professionals may see an increase in older adults being referred for treatment, particularly for the treatment of depressive symptoms. There are some unique challenges inherent in coordinating the care of older adults, and health care professionals must seek the most appropriate psychosocial/psychotherapeutic and psychopharmacological treatments.
Epidemiology of Mental Health Issues and Treatments
According to the World Health Organization (2016):
- The global population of older adults, identified as those older than 60, is anticipated to double in the next three decades, comprising approximately 22% of the world's population.
- Approximately 15% of older adults have a psychiatric illness and approximately 7% have a disabling neuropsychiatric illness.
- Dementia and depression are the most common neuropsychiatric disorders.
- Approximately 4% of older adults are affected by anxiety disorders.
- Substance use disorders impact 1% of older adults.
- Twenty-five percent of deaths attributable to self-harm occur among individuals 60 and older.
Not only must the above statistics be considered when treating the mental health concerns of older adults, but there are also unique considerations when contemplating the psychopharmacological treatment of the aging population:
- Individuals between ages 65 and 79 take an average of 14 prescriptions per year; those ages 80 to 84 take an average of 18 prescriptions per year (Task Force on Aging Research, 2009).
- A Canadian study of older adults, with a mean age of 81 and an average of 15 medications taken daily, found approximately nine drug-related adverse events per patient (Farrell, Szeto, & Shamji, 2011).
- In the United States, approximately 30% of older adult hospitalizations are attributed to adverse drug events (Task Force on Aging Research, 2009).
- More than 20% of older adults have been prescribed at least one high-risk medication (HRM) and approximately 5% have been prescribed more than two HRMs (Qato & Trivedi, 2013).
With these pharmacological concerns, it is especially important for prescribing psychiatric advanced practice nurses (APNs) to update, review, and cross-reference older patients' lists of medications—prescription, over-the-counter (OTC), samples, vitamins, supplements, among others—at every appointment. In addition, the American Geriatric Society's (AGS, 2015a) Beers Criteria for potentially inappropriate medication use in older adults must be consulted at every appointment to improve medication selections that will reduce the risk of falls, confusion, and adverse events, and ensure safe prescribing based on renal dosage adjustments and potential for drug–drug interactions.
Prescribing Considerations for Older Adults
It is well known that older adult patients have decreased ability to metabolize some psychopharmacological agents (Schatzberg, Cole, & DeBattista, 2010) routinely used to treat depression, anxiety, and psychosis. As individuals age, lower serum protein levels may contribute to an increase in the levels of free drug, which may in turn lead to increased side effects, including extrapyramidal symptoms and movement disorders among other central nervous system events (Schatzberg et al., 2010). According to the AGS 2015 Beers Criteria (AGS, 2015b), the key recommendations include the monitoring of creatinine clearance, as opposed to estimates of glomerular filtration, which over-estimate creatinine clearance and may result in elevated or inappropriate drug-dosing levels (Beizer & Semla, 2016). In addition, caution is warranted when augmenting psychotropic agents to improve response with lithium, thyroid, and testosterone therapies. Lithium levels may quickly become toxic due to reduced renal excretion; and lithium may contribute to further cognitive impairment (Ellison, 2015). Supplementation of antidepressant agents with thyroid hormone may contribute to adverse cardiac events, and using testosterone to increase the effectiveness of psychotropic agents may adversely affect the liver and prostate (Ellison, 2015).
As depression and anxiety are not uncommon diagnoses among the older adult population, treatment of these disorders is anything but routine. Commonly prescribed selective serotonin reuptake inhibitor (SSRI) and serotonin norepinephrine reuptake inhibitor antidepressant agents are not without adverse effects in older adults, in particular, hyponatremia and bleeding are significant complications and require active monitoring (Ellison, 2015). The risk of seizure activity related to the prescribing of bupropion, especially the immediate and sustained release formulations, continues for older adults, just as for the younger population. It is important to note that many of the Medicare Part D and Medicaid prescription drug benefits programs will not authorize the extended release formulations of bupropion; thus, it is important to consider alternative medication therapies to reduce risk to older adults. In addition, tricyclic antidepressant agents and monoamine oxidase inhibitor are generally avoided in older adults due to their anticholinergic effects, orthostatic hypotension, and the risks of cardiac arrhythmias and hypertensive crisis.
Although it may appear that the pharmacological treatment of affective psychiatric disorders in older adults may be a futile undertaking with the multiple risk factors, impaired renal and hepatic metabolism, and medical comorbidities, options are still available. Mirtazapine may be an option given its anxiolytic properties, as well as its sedating side effects and stimulation of appetite. Insomnia, anorexia, and nervousness are not uncommon complaints voiced when treating older adults, thus this agent may address all three of these issues. With care, SSRI antidepressant agents (e.g., sertra-line, citalopram, escitalopram) for the treatment of depression in older adults are generally considered safer choices (Ellison, 2015) than their counterparts; however, caution must be noted regarding citalopram and escitalopram due to the reports of cardiac arrhythmia and prolonged QT wave when used at higher doses (Ellison, 2015). Psychostimulant agents, such as methylphenidate and amphetamine salts, typically used in the treatment of attention-deficit/hyperactivity disorder (Leahy, 2017a), may present another viable treatment for depression in older adults. In a review of the use of methylphenidate in the older adult population, Swartzwelder and Galanos (2016) noted approximately 20 studies, involving hundreds of individuals older than 60, dating back to the 1950s. The take-away from these collective studies was that the literature and research supports the clinical efficacy and safety profile of the psychostimulant methylphenidate as a treatment option to address depression, apathy, executive functioning deficits, and even the prevention of falls in individuals 70 and older, even in patients older than 100 (Swartzwelder & Galanos, 2016).
Prescribing for Insomnia in Older Adults
Sleep is often elusive for older adults, and many reach for OTC anti-histamine products often advertised to promote sleep. A 2017 study of adults 65 and older found that approximately 60% inappropriately use products containing the antihistamines diphenhydramine or doxylamine to improve sleep and were unaware of the safety risks associated with OTC medications (Abraham, Schleiden, & Albert, 2017). The anticholinergic effects of these agents can contribute to urinary retention, constipation, cognitive impairment, blurred vision, as well as sedation (Aga & Mago, 2017), and are listed among the medications to avoid on the AGS 2015 Beers Criteria (AGS, 2015b). Per the AGS 2015 Beers Criteria, the “Z-drugs”—zolpidem, zaleplon, and eszopiclone—are also to be avoided; however, these benzodiazepine receptor agonists have less incidence of daytime sleepiness, orthostatic hypotension, respiratory depression, and retrograde amnesia compared to benzodiazepine agents, which contribute to increased risk of falls and fractures, confusion, and significant cognitive impairment in older adults (Aga & Mago, 2017; AGS, 2015a). Caution should be used, in general, when prescribing the “Z-drugs” due to the class effect of delirium, sleepwalking, fractures, and other serious injuries (Aga & Mago, 2017). OTC melatonin may be one of the most effective and safest sleep aides for the treatment of insomnia in older adults, as it does not contribute to sedation; however, there can be tremendous, up to 10-fold or more, variability in the bioavailability of OTC melatonin products, thus some may not work as well as others (Aga & Mago, 2017).
Antipsychotic agents, both first and second generation, have a black box warning related to the increased risk of mortality in older adults with dementia-related psychosis (Leahy, 2017b), and should therefore also be used with caution as they may exacerbate the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and/or hyponatremia (AGS, 2015a). Hyponatremia and SIADH are characterized by confusion, disorientation, change in mental status, delirium, ataxia, hyporeflexia, tremor, muscle weakness, and Cheyne-Stokes respiration (Thomas, 2017), thus it may be difficult to determine if these symptoms are related to an adverse medication event, a new manifestation of an undiagnosed condition, or the general process of aging.
The treatment of psychiatric symptoms in the older adult population is complex. Not only must older adults' medical diagnoses and lists of prescription, over-the-counter, vitamins/supplements, and other medications be considered, but caution must be exercised when exploring the potential pharmacological treatment of depression, anxiety, insomnia, and psychosis in this population. The AGS 2015 Beers Criteria Pocket Guide (AGS, 2015b) is readily available as a resource that every prescribing practitioner should have accessible when prescribing for older adults.
Prescribing psychiatric APNs must be sure to check for potential drug– drug interactions when issuing prescriptions to older adults. Although the obstacles to treating this population may appear daunting, prudent, responsible, cautious practice should be exercised to ensure patients achieve improved functionality, maintain safety and reduction of risks, and enhance their quality of life. Finally, as another year closes, as health care providers who attend to the physical, emotional, and social needs of others, it is important to remember to care for ourselves, while observing those around us who may be in greater need of our services when reflecting on their life's accomplishments.
- Abraham, O., Schleiden, L. & Albert, S.M. (2017). Over-the-counter medications containing diphenhydramine and doxylamine used by older adults to improve sleep. International Journal of Clinical Pharmacology, 39, 808–817. doi:10.1007/s11096-017-0467-x [CrossRef]
- Aga, V. & Mago, R. (2017). Best medicines for sleep in older patients? Retrieved from https://simpleandpractical.com/hypnotics-elderly-older-adults
- American Geriatrics Society. (2015a). American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 63, 2227–2246. doi:10.1111/jgs.13702 [CrossRef]
- American Geriatrics Society. (2015b). A pocket guide to the AGS 2015 Beers criteria. Retrieved from https://www.mnhospitals.org/Portals/0/Documents/patientsafety/Delirium/AGS_2015_BEERS_Pocket-PRINTABLE.PDF
- Beizer, J.L. & Semla, T. (2016, May2). Beers criteria: Navigating the challenges of geriatric care. Retrieved from http://www.wolterskluwercdi.com/blog/beers-criteria-navigating-challenges-geriatric-care
- Ellison, J.M. (2015, May14). Recognizing and treating geriatric mood disorders. Retrieved from http://www.psychiatrictimes.com/bipolar-disorder/recognizing-and-treating-geriatric-mood-disorders
- Farrell, B., Szeto, W. & Shamji, S. (2011). Drug-related problems in the frail elderly. Canadian Family Physician, 57, 168–169.
- Leahy, L.G. (2017a). Attention-deficit/hyperactivity disorder: A historical review (1775 to present). Journal of Psychosocial Nursing and Mental Health Services, 55(9), 10–16. doi:10.3928/02793695-20170818-08 [CrossRef]
- Leahy, L.G. (2017b). Medication safety: What nurses should know about black box warnings. Journal of Psychosocial Nursing and Mental Health Services, 55(6), 11–15. doi:10.3928/02793695-20170519-01 [CrossRef]
- Qato, D.M. & Trivedi, A.N. (2013). Receipt of high risk medications among elderly enrollees in Medicare advantage plans. Journal of General Internal Medicine, 28, 546–553. doi:10.1007/s11606-012-2244-9 [CrossRef]
- Schatzberg, A.F., Cole, J.O. & DeBattista, C. (Eds.). (2010). Manual of clinical psychopharmacology (7th ed.). Washington, DC: American Psychiatric Publishing.
- Swartzwelder, B.A. & Galanos, A.N. (2016). Methylphenidate use in the elderly population: What do we know now?Consultant, 56, 994–997.
- Task Force on Aging Research. (2009). Medications & errors. Retrieved from http://www.medscape.com/viewarticle/847187_2
- Thomas, C.P. (2017). Syndrome of inappropriate antidiuretic hormone secretion. Retrieved from http://emedicine.medscape.com/article/246650-overview
- World Health Organization. (2016). Mental health and older adults. Retrieved from http://www.who.int/mediacentre/factsheets/fs381/en