Psychiatric Annals

Guest Editorial Free

This issue: Geriatric Psychopharmacology

Theodore A. Stern, MD

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.


About the Guest Editor

Theodore A. Stern, MD, is the Ned H. Cassem Professor of Psychiatry in the field of Psychosomatic Medicine/Consultation at Harvard Medical School, Chief of the Avery D. Weisman Psychiatry Consultation Service, and the first Director of the Office for Clinical Careers at the Massachusetts General Hospital (MGH). He has focused his efforts at the interface of medicine and psychiatry as a clinician, a clinical researcher, and a teacher. Dr. Stern has mentored scores of residents at the MGH, has co-authored more than 400 peer-reviewed journal articles and book chapters, and has authored or edited 20 books (including MGH Comprehensive Clinical Psychiatry [1st and 2nd editions], the Massachusetts General Hospital Handbook of General Hospital Psychiatry [4th–6th editions], The MGH Guide to Primary Care Psychiatry [1st and 2nd editions], Psychiatry Update and Board Preparation [1st–3rd editions], Facing Cancer, and On the Edge of Life: Diary of a Medical Intensive Care Unit).

Dr. Stern is a Past-President of the Academy of Psychosomatic Medicine and he is the Editor-in-Chief of Psychosomatics; he also serves on the editorial boards of seven peer-reviewed journals. On four occasions he has won the coveted “Best Teacher Award” from the graduating residents at the MGH/McLean Hospital Psychiatric Residency Training Program and he has received the MGH Department of Psychiatry’s Award for Exceptional Mentorship in the Clinical Realm, as well as a Lifetime Achievement Award from the Society of Liaison Psychiatry, and the Thomas P. Hackett Award from the Academy of Psychosomatic Medicine (its highest honor).

Address correspondence to Theodore A. Stern, MD, Massachusetts General Hospital, 55 Fruit Street, Warren Building, Room 605, Boston, MA 02114; email:


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