Clinical Manual of Geriatric Psychopharmacology This page intentionally left blank Clinical Manual of Geriatric Psychopharmacology Sandra A. Jacobson, M.D. Assistant Professor, Department of Psychiatry and Human Behavior, Brown Medical School, Providence, Rhode Island Ronald W. Pies, M.D. Clinical Professor of Psychiatry, Tufts University School of Medicine, Boston, Massachusetts Ira R. Katz, M.D. Professor of Psychiatry and Director, Section of Geriatric Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania Washington, DC London, England Note: The authors have worked to ensure that all information in this book is accurate at the time of publication and consistent with general psychiatric and medical standards, and that information concerning drug dosages, schedules, and routes of administration is accurate at the time of publication and consistent with standards set by the U.S. Food and Drug Administration and the general medical community. As medical research and practice continue to advance, however, therapeutic standards may change. Moreover, specific situations may require a specific therapeutic response not included in this book. For these reasons and because human and mechanical errors sometimes occur, we recommend that readers follow the advice of physicians directly involved in their care or the care of a member of their family. Books published by American Psychiatric Publishing, Inc., represent the views and opinions of the individual authors and do not necessarily represent the policies and opinions of APPI or the American Psychiatric Association. Copyright © 2007 American Psychiatric Publishing, Inc. ALL RIGHTS RESERVED Manufactured in the United States of America on acid-free paper 11 10 09 08 07 5 4 3 2 1 First Edition Typeset in Adobe’s Formata and AGaramond. American Psychiatric Publishing, Inc., 1000 Wilson Boulevard, Arlington, VA 22209-3901, www.appi.org Library of Congress Cataloging-in-Publication Data Jacobson, Sandra A., 1953– Clinical manual of geriatric psychopharmacology / by Sandra A. Jacobson, Ronald W. Pies, Ira R. Katz. — 1st ed. p. ; cm. Includes bibliographical references and index. ISBN 1-58562-252-4 (pbk. : alk. paper) 1. Geriatric psychopharmacology—handbooks, manuals, etc. I. Pies, Ronald W., 1952– . II. Katz, Ira R. III. Title. [DNLM: 1. Psychotropic Drugs—pharmacokinetics. 2. Psychotropic drugs—therapeutic use. 3. Aged—psychology. 4. Aging—metabolism. 5. Mental Disorders—drug therapy. 6. Psychopharmacology— methods. QV 77.2 J17c 2007] RC451.4.A5J334 2007 615’.78—dc22 2006025880 British Library Cataloguing in Publication Data A CIP record is available from the British Library. Contents 1 The Practice of Geriatric Psychopharmacology. 1 Introduction. .1 Maximizing Therapeutic Effects . .2 Improving Treatment Adherence. .8 Minimizing Adverse Effects and Drug Interactions . .12 Chapter Summary. .25 References. .25 2 Basic Psychopharmacology and Aging . 27 Introduction. .27 Pharmacokinetics and Aging . .28 Drug Half-Life . .52 Pharmacodynamics and Aging . .53 Chapter Summary. .55 References. .55 3 Antipsychotics . 59 Introduction. .59 Pharmacokinetics . .61 Pharmacodynamics and Mechanism of Action . .62 Drug Interactions . .66 Indications . .66 Efficacy . .69 Clinical Use . .70 Adverse Effects . .84 Antipsychotic Treatment of Selected Syndromes and Disorders . .109 Chapter Summary. .119 References. .120 Specific Drug Summaries. .129 4 Antidepressants . 141 Introduction. .141 Pharmacokinetics . .144 Pharmacodynamics and Mechanism of Action . .150 Drug Interactions . .154 Efficacy . .155 Clinical Use . .161 Adverse Effects . .182 System-Specific Adverse Effects. .187 Antidepressant Treatment of Selected Syndromes and Disorders . .204 Chapter Summary. .223 References. .224 Specific Drug Summaries. .237 5 Mood Stabilizers . 259 Introduction. .259 Pharmacology . .261 Drug Interactions . .268 Efficacy . .279 Clinical Use . .280 Adverse Effects . .291 System-Specific Adverse Effects. .295 Treatment of Selected Disorders and Syndromes. .301 Chapter Summary. .311 References. .312 Specific Drug Summaries. .319 6 Anxiolytic and Sedative-Hypnotic Medications . 329 Introduction. .329 Pharmacokinetics . .332 Pharmacodynamics and Mechanisms of Action . .338 Drug Interactions . .340 Indications . .342 Efficacy . .343 Clinical Use . .344 Adverse Effects . .355 Treatment of Selected Syndromes and Disorders . .360 Chapter Summary. .379 References. .380 Specific Drug Summaries. .389 7 Treatment of Substance-Related Disorders. 403 Introduction. .403 Basic Pharmacology of Ethanol. .407 Alcohol-Related Disorders . .408 Nicotine-Related Disorders . .434 Abuse and Misuse of Prescribed Drugs . .441 Chapter Summary. .455 References. .456 Specific Drug Summaries. .465 8 Treatment of Movement Disorders . 477 Introduction. .477 Abnormalities of Movement . .478 Treatment of Selected Movement Disorders and Syndromes. .485 Chapter Summary. .513 References. .514 Specific Drug Summaries. .521 9 Medications to Treat Dementia and Other Cognitive Disorders. 543 Introduction. .543 Evaluation of the Cognitively Impaired Elder. .544 Medications Used to Treat Dementia . .550 Treatment of Specific Dementing Diseases and Other Cognitive Syndromes. .561 Treatment of Selected Behavioral Disturbances in Dementia . .580 Chapter Summary. .587 References. .588 Specific Drug Summaries. .599 10 Analgesic Medications . 607 Introduction. .607 Pain and the Mechanisms of Analgesia . .608 Indications for Analgesics. .609 Pharmacology of Major Analgesic Medications . .610 Drug Interactions . .618 Efficacy of Analgesics and Adjuvants. .619 Clinical Use of Analgesics and Adjuvants . .627 Adverse Effects of Analgesics by Class . .636 System-Specific Adverse Effects. .637 Treatment of Selected Pain Syndromes Affecting Elderly Patients . .645 Nonpharmacologic Therapies . .655 Chapter Summary. .657 References. .658 Specific Drug Summaries. .661 Index . 679 1 The Practice of Geriatric Psychopharmacology Introduction Few areas of current psychiatric practice present a challenge quite as daunting as that of geriatric psychopharmacology, which is complicated not only by the effects of normal aging but by medical disease and coad- ministered medications. Elderly patients often present with subclinical syndromes or symptoms that are modified by comorbid disease or partial treatment. Since the psychotropic regimen for an individual patient may be a composite of prescriptions from the hospital, clinic, and long-term- care facility, there may be duplicate medications (e.g., two antipsychot- ics), drug interactions may be significant, dosing may be inappropriate (e.g., inadequate dose of an antidepressant because of lack of titration), or dosing schedules for various medications may be out of synchrony..