The Elderly

Psychiatric medications are frequently used by those over sixty-five years of age. Not only do the elderly experience anxiety, depression, psychotic disorders, and bipolar disorder, but they may also suffer from Alzheimer's disease and related cognitive difficulties. Many psychiatric medications can provide enormous benefit to the elderly: old age does not preclude the use of psychiatric medications. However, there are three issues pertinent to the issue of psychiatric drugs for the elderly that need to be taken into account. If you are over sixty-five, or are caring for an elderly person, it is important that you consider these issues to be sure that the kind and amount of medication are appropriate and beneficial.

Physiological Differences The elderly are more sensitive to the effects of medications than those under sixty-five. There is enhancement of some brain enzymes with aging and there is increased sensitivity of receptors in several neuro-

transmitter systems.

Drugs in elderly people tend to reach higher levels and last longer than in younger patients. There are two reasons for this. First, there is an increase in body fat composition and decreased muscle mass. Many drugs that are stored in fat tissue will be more widely distributed in the body and will take longer for the body to metabolize and excrete. Water-soluble drugs that are not stored in fat tissue, such as lithium, are distributed throughout a much smaller volume in the body and thus can reach higher tissue concentrations. Second, the liver enzymes that break down drugs decline with age, so that an elderly person takes longer to metabolize psychiatric drugs.

Side Effects Age-related changes in other body systems also make the elderly more sensitive to the side effects of many medications. For example, changes in the receptors of blood vessels make them much more vulnerable to experiencing low blood pressure from medications that are not particularly troublesome to younger people. The age-related decrease in bowel motility makes them more vulnerable to constipation from medications that have this tendency. Symptoms of prostatic enlargement may be significantly worsened by a wide variety of psychiatric medications. Gait and balance can be more easily affected by medications that would not be troubling to a younger person.

The increased sensitivity to impaired coordination and lower blood pressure renders the elderly at greater risk for experiencing complications from these side effects. They fall more and, as a result, have an elevated risk of hip fractures.8

Other Medical Problems The elderly are also more likely to experience other medical problems with the heart, liver, kidney, and other organ systems.

Many elderly people are on a wide variety of other medications because of these medical problems. These other medications can interact with psychiatric medications such that either one or both are increased or decreased in the body. The medications may also combine to contribute to side effects that would not be experienced in either one of them alone. For example, delirium can be caused by the addition of some psychiatric drugs to certain medical drugs when either one alone wouldn't cause significant difficulty.

Kidney and liver problems can lead to decreased metabolism of psychiatric drugs. This can increase the potency of a single dose when compared to someone without those medical problems.

Because of these differences, the maxim "Start low and go slow" is a good guide for the prescription of any psychiatric drug to people over the age of sixty-five. Exercise, relaxation techniques, establishment of a good social support system, and psychotherapy are important alternatives to consider in place of, or as an adjunct to, psychiatric medications.

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