Editorial Free

Geriatric Psychopharmacology: The Good, the Bad, and the Ugly

Jan Fawcett, MD

Abstract

This issue of Psychiatric Annals, guest edited by Dr. Theodore A. Stern, examines the topic of geriatric psychopharmacology. The articles focus on four major areas of high need and difficulty that are frequently encountered in elderly patients: (1) cognitive dysfunction, (2) geriatric pharmacology from the standpoint of pharmacokinetic and pharmacodynamic considerations, (3) the use of hypnotics in the elderly, and (4) the use of antipsychotics for neuropsychiatric symptoms of dementia. In each of these areas, the authors point out the needs, which are great, but in each area there are also serious problems with our existing treatments.

In the article “Geriatric Psychopharmacology: Pharmacokinetic and Pharmacodynamic Considerations,” by Drs. Andrew D. Carlo and Jonathan E. Alpert, they review the pharmacokinetic as well as the pharmacodynamic basis for the often increased sensitivity in geriatric patients. This article also discusses the basis for the great variability of sensitivity in these patients.

This reminded me of my recent work with pramipexole in treating resistant depressions (often electroconvulsive therapy failures) in geriatric patients who, in contrast to most studies, seemed to require and tolerate higher doses.1 Is this because we are losing dopamine cells as we age?

Oh yes, life goes on, long after the thrill of living is gone - John Mellencamp

The article “The Use of Hypnotics to Treat Sleep Problems in the Elderly” by Drs. Catherine McCall and John W. Winkelman points out both the need for and the risks of highly used sedatives. With increased risks of cognitive symptoms and suicide in a condition that we learn is so common, one wonders why we have not found effective hypnotics other than the benzodiazepine type that work on the gamma-aminobutyric acid system.

In “Antipsychotics for Neuropsychiatric Symptoms of Dementia—Safety and Efficacy in the Context of Informed Consent” by Drs. Kasia Gustaw Rothenberg and Ilse R. Wiechers, we learn that there are no drugs approved by the US Food and Drug Administration for neuropsychiatric symptoms in patients with dementia, particularly agitation. One wonders why there has been no pursuit of other agents besides the antipsychotic medications, which act as D2 blockers and are associated with significant risks to patients. When studies mentioned in the article “Psychopharmacologic Agents to Enhance Cognition in Alzheimer’s Disease” by Drs. Alireza Atri and Stern have shown that memantine (an anti-glutamaturgic drug) works in agitated, depressed patients and one study (not mentioned in this series) has shown that prazosin, an alpha-blocker, also exceeds placebo without major side effects2 in treating agitation in very elderly patients, we have to wonder why they are not further studied or even used by clinicians. The idea of an informed consent discussion with patients or their guardians would result in more directly facing the potential toxic effects of these medications versus the risks generated by an agitated state.

Upon reading the final article by Drs. Atri and Stern, I learned that an increasing volume of research supports giving a combination of donepezil and memantine to a patient with Alzheimer’s dementia, as it has no more and perhaps even fewer side effects than standard treatment.

Do we need more treatment studies sponsored by the National Institute of Mental Health or other government agencies to help clinicians address these issues in treating their patients as we are spending billions on research looking for the pathophysiologic mechanisms of these difficult to treat disorders? We’re all getting older (particularly me), and we need more effective and safer treatments for the major areas addressed in this series, because they are not going away. Also, as the population of the elderly increases, these problems will increase. Cheers!…

This issue of Psychiatric Annals, guest edited by Dr. Theodore A. Stern, examines the topic of geriatric psychopharmacology. The articles focus on four major areas of high need and difficulty that are frequently encountered in elderly patients: (1) cognitive dysfunction, (2) geriatric pharmacology from the standpoint of pharmacokinetic and pharmacodynamic considerations, (3) the use of hypnotics in the elderly, and (4) the use of antipsychotics for neuropsychiatric symptoms of dementia. In each of these areas, the authors point out the needs, which are great, but in each area there are also serious problems with our existing treatments.

In the article “Geriatric Psychopharmacology: Pharmacokinetic and Pharmacodynamic Considerations,” by Drs. Andrew D. Carlo and Jonathan E. Alpert, they review the pharmacokinetic as well as the pharmacodynamic basis for the often increased sensitivity in geriatric patients. This article also discusses the basis for the great variability of sensitivity in these patients.

This reminded me of my recent work with pramipexole in treating resistant depressions (often electroconvulsive therapy failures) in geriatric patients who, in contrast to most studies, seemed to require and tolerate higher doses.1 Is this because we are losing dopamine cells as we age?

Oh yes, life goes on, long after the thrill of living is gone - John Mellencamp

The article “The Use of Hypnotics to Treat Sleep Problems in the Elderly” by Drs. Catherine McCall and John W. Winkelman points out both the need for and the risks of highly used sedatives. With increased risks of cognitive symptoms and suicide in a condition that we learn is so common, one wonders why we have not found effective hypnotics other than the benzodiazepine type that work on the gamma-aminobutyric acid system.

In “Antipsychotics for Neuropsychiatric Symptoms of Dementia—Safety and Efficacy in the Context of Informed Consent” by Drs. Kasia Gustaw Rothenberg and Ilse R. Wiechers, we learn that there are no drugs approved by the US Food and Drug Administration for neuropsychiatric symptoms in patients with dementia, particularly agitation. One wonders why there has been no pursuit of other agents besides the antipsychotic medications, which act as D2 blockers and are associated with significant risks to patients. When studies mentioned in the article “Psychopharmacologic Agents to Enhance Cognition in Alzheimer’s Disease” by Drs. Alireza Atri and Stern have shown that memantine (an anti-glutamaturgic drug) works in agitated, depressed patients and one study (not mentioned in this series) has shown that prazosin, an alpha-blocker, also exceeds placebo without major side effects2 in treating agitation in very elderly patients, we have to wonder why they are not further studied or even used by clinicians. The idea of an informed consent discussion with patients or their guardians would result in more directly facing the potential toxic effects of these medications versus the risks generated by an agitated state.

Upon reading the final article by Drs. Atri and Stern, I learned that an increasing volume of research supports giving a combination of donepezil and memantine to a patient with Alzheimer’s dementia, as it has no more and perhaps even fewer side effects than standard treatment.

Do we need more treatment studies sponsored by the National Institute of Mental Health or other government agencies to help clinicians address these issues in treating their patients as we are spending billions on research looking for the pathophysiologic mechanisms of these difficult to treat disorders? We’re all getting older (particularly me), and we need more effective and safer treatments for the major areas addressed in this series, because they are not going away. Also, as the population of the elderly increases, these problems will increase. Cheers!

References

  1. Fawcett J. An uncontrolled series of the effects of high dose pramipexole in treatment resistant disorders. Am J Psychiatry. 2015; (submitted)
  2. Wang LY, Shofer JB, Rohde K, et al. Prazosin for the treatment of behavioral symptoms in patients with Alzheimer disease with agitation and aggression. Am J Geriatr Psychiatry. 2009;17(9):744–751. doi:10.1097/JGP.0b013e3181ab8c61 [CrossRef]
Authors

Jan Fawcett, MD, is a Professor, Department of Psychiatry, University of New Mexico School of Medicine. He was chairperson of the DSM-5 Mood Disorders Task Force.

Address correspondence to Jan Fawcett, MD, via email: psyann@Healio.com. 

10.3928/00485713-20150626-01

This issue of Psychiatric Annals, guest edited by Dr. Theodore A. Stern, examines the topic of geriatric psychopharmacology. The articles focus on four major areas of high need and difficulty that are frequently encountered in elderly patients: (1) cognitive dysfunction, (2) geriatric pharmacology from the standpoint of pharmacokinetic and pharmacodynamic considerations, (3) the use of hypnotics in the elderly, and (4) the use of antipsychotics for neuropsychiatric symptoms of dementia. In each of these areas, the authors point out the needs, which are great, but in each area there are also serious problems with our existing treatments.

In the article “Geriatric Psychopharmacology: Pharmacokinetic and Pharmacodynamic Considerations,” by Drs. Andrew D. Carlo and Jonathan E. Alpert, they review the pharmacokinetic as well as the pharmacodynamic basis for the often increased sensitivity in geriatric patients. This article also discusses the basis for the great variability of sensitivity in these patients.

This reminded me of my recent work with pramipexole in treating resistant depressions (often electroconvulsive therapy failures) in geriatric patients who, in contrast to most studies, seemed to require and tolerate higher doses.1 Is this because we are losing dopamine cells as we age?

Oh yes, life goes on, long after the thrill of living is gone - John Mellencamp

The article “The Use of Hypnotics to Treat Sleep Problems in the Elderly” by Drs. Catherine McCall and John W. Winkelman points out both the need for and the risks of highly used sedatives. With increased risks of cognitive symptoms and suicide in a condition that we learn is so common, one wonders why we have not found effective hypnotics other than the benzodiazepine type that work on the gamma-aminobutyric acid system.

In “Antipsychotics for Neuropsychiatric Symptoms of Dementia—Safety and Efficacy in the Context of Informed Consent” by Drs. Kasia Gustaw Rothenberg and Ilse R. Wiechers, we learn that there are no drugs approved by the US Food and Drug Administration for neuropsychiatric symptoms in patients with dementia, particularly agitation. One wonders why there has been no pursuit of other agents besides the antipsychotic medications, which act as D2 blockers and are associated with significant risks to patients. When studies mentioned in the article “Psychopharmacologic Agents to Enhance Cognition in Alzheimer’s Disease” by Drs. Alireza Atri and Stern have shown that memantine (an anti-glutamaturgic drug) works in agitated, depressed patients and one study (not mentioned in this series) has shown that prazosin, an alpha-blocker, also exceeds placebo without major side effects2 in treating agitation in very elderly patients, we have to wonder why they are not further studied or even used by clinicians. The idea of an informed consent discussion with patients or their guardians would result in more directly facing the potential toxic effects of these medications versus the risks generated by an agitated state.

Upon reading the final article by Drs. Atri and Stern, I learned that an increasing volume of research supports giving a combination of donepezil and memantine to a patient with Alzheimer’s dementia, as it has no more and perhaps even fewer side effects than standard treatment.

Do we need more treatment studies sponsored by the National Institute of Mental Health or other government agencies to help clinicians address these issues in treating their patients as we are spending billions on research looking for the pathophysiologic mechanisms of these difficult to treat disorders? We’re all getting older (particularly me), and we need more effective and safer treatments for the major areas addressed in this series, because they are not going away. Also, as the population of the elderly increases, these problems will increase. Cheers!…

This issue of Psychiatric Annals, guest edited by Dr. Theodore A. Stern, examines the topic of geriatric psychopharmacology. The articles focus on four major areas of high need and difficulty that are frequently encountered in elderly patients: (1) cognitive dysfunction, (2) geriatric pharmacology from the standpoint of pharmacokinetic and pharmacodynamic considerations, (3) the use of hypnotics in the elderly, and (4) the use of antipsychotics for neuropsychiatric symptoms of dementia. In each of these areas, the authors point out the needs, which are great, but in each area there are also serious problems with our existing treatments.

In the article “Geriatric Psychopharmacology: Pharmacokinetic and Pharmacodynamic Considerations,” by Drs. Andrew D. Carlo and Jonathan E. Alpert, they review the pharmacokinetic as well as the pharmacodynamic basis for the often increased sensitivity in geriatric patients. This article also discusses the basis for the great variability of sensitivity in these patients.

This reminded me of my recent work with pramipexole in treating resistant depressions (often electroconvulsive therapy failures) in geriatric patients who, in contrast to most studies, seemed to require and tolerate higher doses.1 Is this because we are losing dopamine cells as we age?

Oh yes, life goes on, long after the thrill of living is gone - John Mellencamp

The article “The Use of Hypnotics to Treat Sleep Problems in the Elderly” by Drs. Catherine McCall and John W. Winkelman points out both the need for and the risks of highly used sedatives. With increased risks of cognitive symptoms and suicide in a condition that we learn is so common, one wonders why we have not found effective hypnotics other than the benzodiazepine type that work on the gamma-aminobutyric acid system.

In “Antipsychotics for Neuropsychiatric Symptoms of Dementia—Safety and Efficacy in the Context of Informed Consent” by Drs. Kasia Gustaw Rothenberg and Ilse R. Wiechers, we learn that there are no drugs approved by the US Food and Drug Administration for neuropsychiatric symptoms in patients with dementia, particularly agitation. One wonders why there has been no pursuit of other agents besides the antipsychotic medications, which act as D2 blockers and are associated with significant risks to patients. When studies mentioned in the article “Psychopharmacologic Agents to Enhance Cognition in Alzheimer’s Disease” by Drs. Alireza Atri and Stern have shown that memantine (an anti-glutamaturgic drug) works in agitated, depressed patients and one study (not mentioned in this series) has shown that prazosin, an alpha-blocker, also exceeds placebo without major side effects2 in treating agitation in very elderly patients, we have to wonder why they are not further studied or even used by clinicians. The idea of an informed consent discussion with patients or their guardians would result in more directly facing the potential toxic effects of these medications versus the risks generated by an agitated state.

Upon reading the final article by Drs. Atri and Stern, I learned that an increasing volume of research supports giving a combination of donepezil and memantine to a patient with Alzheimer’s dementia, as it has no more and perhaps even fewer side effects than standard treatment.

Do we need more treatment studies sponsored by the National Institute of Mental Health or other government agencies to help clinicians address these issues in treating their patients as we are spending billions on research looking for the pathophysiologic mechanisms of these difficult to treat disorders? We’re all getting older (particularly me), and we need more effective and safer treatments for the major areas addressed in this series, because they are not going away. Also, as the population of the elderly increases, these problems will increase. Cheers!

References

  1. Fawcett J. An uncontrolled series of the effects of high dose pramipexole in treatment resistant disorders. Am J Psychiatry. 2015; (submitted)
  2. Wang LY, Shofer JB, Rohde K, et al. Prazosin for the treatment of behavioral symptoms in patients with Alzheimer disease with agitation and aggression. Am J Geriatr Psychiatry. 2009;17(9):744–751. doi:10.1097/JGP.0b013e3181ab8c61 [CrossRef]

Jan Fawcett, MD, is a Professor, Department of Psychiatry, University of New Mexico School of Medicine. He was chairperson of the DSM-5 Mood Disorders Task Force.

Address correspondence to Jan Fawcett, MD, via email: psyann@Healio.com. 

References

  1. Fawcett J. An uncontrolled series of the effects of high dose pramipexole in treatment resistant disorders. Am J Psychiatry. 2015; (submitted)
  2. Wang LY, Shofer JB, Rohde K, et al. Prazosin for the treatment of behavioral symptoms in patients with Alzheimer disease with agitation and aggression. Am J Geriatr Psychiatry. 2009;17(9):744–751. doi:10.1097/JGP.0b013e3181ab8c61 [CrossRef]
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