Given the fact that the percentage of people qualifying for geriatric status is rapidly increasing (by up to 25% in developed countries over the next few decades), and that adults older than age 65 years receive the lion’s share of prescriptions each year (and develop 2 to 3 times the number of adverse effects from medications), it should not be a surprise that an entire issue of Psychiatric Annals would be devoted to geriatric psychopharmacology.
Although most practitioners evaluate and treat large numbers of elderly patients for a wide variety of complaints (eg, depression, anxiety, sleep disturbances, agitation, psychosis, cognitive impairment), familiarity does not always translate into competence or expertise. Therefore, we have gathered seasoned clinicians, researchers, and teachers to review state-of-the-art knowledge and practice methods on topics relevant to geriatrics and to geriatric psychiatry.
This issue begins with an informed discussion entitled “Geriatric Psychopharmacology: Pharmacokinetic and Pharmacodynamic Considerations” by Drs. Andrew D. Carlo and Jonathan E. Alpert. They provide a cogent discussion of the impact of absorption, distribution, metabolism, and excretion on psychopharmacology, with special emphasis placed on age-related changes. Their review sets the stage for the articles that follow.
Next, Drs. Catherine McCall and John W. Winkelman present “The Use of Hypnotics to Treat Sleep Problems in the Elderly.” They note that one-third of all elderly individuals suffer from difficulties with sleep; moreover, as age advances, such problems become even more prevalent. However, because many sleep problems are secondary to comorbid medical conditions, their review of the etiologies of sleep disturbances is particularly relevant. They also present an approach to the management and assessment of sleep problems. Both pharmacologic (eg, use of benzodiazepine receptor agonists, melatonin receptor agonists, tricyclic antidepressants, phenylpiperazine antidepressants, noradrenergic and serotonergic antidepressants, sedating antipsychotics, and orexin antagonists) and nonpharmacologic (eg, use of relaxation therapy, bright light therapy, exercise, massage, cognitive-behavioral therapy, and enhanced sleep hygiene) interventions are detailed and discussed.
Then, Drs. Kasia Gustaw Rothenberg and Ilse R. Wiechers present “Antipsychotics for Neuropsychiatric Symptoms of Dementia—Safety and Efficacy in the Context of Informed Consent.” Such neuropsychiatric symptoms (especially agitation and psychosis) are present in essentially all individuals afflicted with dementia at some point in the course of their illness; these disturbances disrupt behavior and cognition, and have an enormous impact on the patients, their caregivers, and on the health care system. They review the approach to diagnosis, prognosis, and treatment, and discuss the risks and benefits associated with the use of antipsychotics in dementia, as well as the alternatives.
Finally, Dr. Alireza Atri and I distill the data on “Psychopharmacologic Agents to Enhance Cognition in Alzheimer’s Disease.” Because cognitive impairment dramatically alters interactions, independence, behavior, health, and quality of life for affected individuals and their care providers, this review of US Food and Drug Administration-approved anti-Alzheimer’s disease medications (eg, acetyl cholinesterase inhibitors and N-methyl-D-aspartate receptor antagonists) should prove informative and useful when deciding when, which, how much, and for how long to use these agents.
It is our sincere hope that the presentation of these topics, conditions, and problems is readable, informative, and helpful to you and to your patients.