Before using psychotropic medications
with the elderly there are several factors to consider, including whether or
not the client is physiologically and psychologically able to withstand such treatment.
The objective of this paper is to explore the psychotropic treatment of the
elderly population, including advantages and disadvantages. Common
physiological and psychological characteristics of the elderly will also be
discussed and an explanation of when and when not to medicate will be
presented, as well as the risks involved in both decisions. Finally, suggestions
for safer psychotropic practices and my personal views as a nursing home intern
will be presented.
Common Characteristics
of the Elderly
Physiological
Physiological changes that occur in the
aging human body can prove troublesome to older individuals taking medications.
Decreases in body water, lean masses, serum albumin, renal mass and liver blood
flow, as well as increases in body fat (especially in women) are the main
age-related changes affecting pharmacokinetics (Gareri et al., 2006). A study by Muller (1972, as cited in Ziance,
1979) found that the liver of an older person has a decreased capacity to
metabolize drugs into an inactive form prior to elimination by the kidneys. Physiological
changes can have a major impact on how well a person’s body can manage
mediations and how adverse the side effects can potentially be. Adverse side affects, which can be harmful
even fatal to older users, are 7 times more frequent in those people aged 70-79
as opposed to those 20-29 (Sadavoy, 2004).
Abnormal blood pressure can also be the cause of serious side effects,
including heart failure and potential death, in older people.
Psychological
Depression is one of the most common
mental health problems of older adults (Comer, 2007). A study by Flint (1994, as
cited in Comer, 2007) shows that generalized anxiety disorder is also very
common and experienced by up to 7 percent of all elderly persons. Various
life-related issues including: physical ailments, diseases, loss of property or
loved ones, and the inability to perform functions--just to name a few--can
cause depression and anxiety; the likelihood and frequency of life-related
issues occurring inevitably increases with old age. Dementia (especially
Alzheimer’s), for example, occurs late in life and can be very distressing and
confusing to those elderly persons developing the disorder. Such confusion and
stress can also develop into depression and anxiety. In Western society the
elderly are more likely than any other age group, including adolescents, to
attempt suicide and succeed (Comer, 2007). Loebel et al. (1991, as cited in
Comer, 2007) found that 44 percent of elderly people who commit suicide gave
some indication that their act was prompted by the fear of being placed into a
nursing home. With such a high number of suicides among the elderly it is
obvious that the issue needs addressed; use of psychotropics could very well be
the answer.
Psychotropic
Medication and the Elderly
Advantages
Reduction of cognitive ability due to
dementia can be troublesome and humiliating for elderly persons. Though there
are no medications at this time to prevent or reverse brain deterioration. A
study performed by Allard, Artero, and Ritchie (2003) has found that
antidepressants (other than benzodiazepines) show a significant positive effect
on primary memory, object naming, and performance in delayed free recall in
secondary memory. Given that the elderly client hasn’t reached a significant
cognitive decline associated with dementia, these positive effects on memory
could decrease any humility and feelings of worthlessness resulting from
cognitive incompetence.
Psychotic symptoms such as auditory and
visual hallucinations, delusions, paranoia, extreme irritation, aggression,
catatonia, as well as many others can be disabling to those who are afflicted. Some
symptoms, such as catatonia, can be so severe that the person virtually cannot
function at all. Antipsychotics are an indispensable tool available to all
physicians for controlling the symptoms of psychoses, schizophrenia,
schizoaffective disorders and behavioral disorders of demented patients (Gareri
et al., 2006). These medications, if used properly, give hope to those elderly
persons who would otherwise not be able to function properly, if at all,
without treatment.
Comer (2007) states that elderly people
who are depressed recover more slowly and less completely from impairments or
ailments, and those depressed elderly with high blood pressure are three times
at likely to suffer a stroke than older nondepressed individuals with the same
condition. If used carefully, psychotropics could potentially improve quality
of life for the elderly and have a positive impact on the number of suicides
among the population. Though at some point it is inevitable that everyone must
expire, the careful use of psychotropics has the potential to prevent the
elderly from feeling lifeless and perhaps even perform better daily until death
occurs naturally.
Disadvantages
As the human body grows older elderly
people commonly use various medications to counteract the decline of physical
and mental functioning. The more medications one takes, the higher the risk of
negative interactions. Katona (2001) gives a simple example of negative
interactions and explains that antacids, both prescribed and over-the-counter,
may decrease the absorption of benzodiazepines, which inadvertently reduces their
sedative side effect--an easily overlooked interaction. If the benzodiazepines
are being prescribed for insomnia and do not seem to be working then the dosage
will probably increase, not knowing the antacids are the cause. As a result of
high benzodiazepine doses, severe orthostatic hypotension, the most common
adverse autonomic side effect of antipsychotics (found in up to 75% of treated
patients), is likely to occur (Mackin, 2008). An elderly person taking
sedatives and antidepressants, especially high doses of antipsychotics, can
experience this sudden drop in blood pressure and become a greater risk for
falls (Furniss, Craig, & Burns, 1998) and heart failures. Falls can be
disastrous for elderly people, often causing broken bones or other internal
injuries; heart failure is more often fatal.
Benzodiazepines, as well as any
antipsychotic, should not be used for sedative purposes in the elderly due to
serious adverse side effects. It is due to their sleep benefit, however, that
these medications tend to be misused. A study conducted by Furnis, Craig, and
Burns (1998) found a strong association between increased staffing on nursing
home night shifts and reductions in antipsychotic use, which suggests these
drugs were used as compensation for staff shortages. Also, if too many
antipsychotics are administered and serotonin levels become abnormally high,
then serotonin syndrome could emerge causing symptoms (confusion, agitation,
elation, irritability) that are rarely fatal but bothersome to the individual
(Katona, 2001).
Demented populations, especially the
elderly, are more likely to use a larger variety of substances (diuretics,
antipsychotics, antidepressants, anxiolytics, laxatives) and are at risk of
substantial exposure to inappropriate use of drugs (Giron et al., 2001;
Hosia-Randell & Pitkala, 2005). Psychotropics are commonly used in dementia
patients exhibiting psychotic-like symptoms such as hallucinations, delusion,
and aggression; however, there have been serious, even fatal, reactions within
this elderly sub-group. Research
conducted by Gareri et al. (2006) suggests increased cardiovascular events in
patients taking risperidone and olanzapine is the cause for restricting psychotropic
agents in this population. Allard et al. (2003) believe the cerebral changes in
dementia persons will be amplified with psychotropic use. McShane’s study (as
cited in Furniss et al., 1998) suggests neuroleptic drug use was associated
with an increased rate of cognitive decline in persons with dementia. If not
used carefully psychotropics can cause more damage to demented persons rather
than benefiting them.
It is fair to say that since the elderly
have evidence of higher rates of drug consumption, it seems quite likely that
they should also have higher rates of misuse or abuse (Whittington &
Peterson, 1979), especially those elderly individuals who are not placed in
nursing homes but are left to care for themselves. It is highly improbably that elderly individuals
with physical inabilities or mental deficits will be able to properly medicate
themselves. Devices have been implemented for home use to alert individuals
when to take their medications. Sometimes, however, these contraptions are just
confusing for the user, creating more serious problems from inappropriate
medication use.
Suggestions for
Safer Psychotropic Practices
Before medicating the elderly the
attending physician should always perform a preliminary physical to assist in
determining potential problems with adverse side affects. Once medications are determined
suitable and administered, the client should be monitored for side effects. If
side effects continue unnoticed, potentially fatal problems could result; therefore,
once medications are begun it is also necessary to perform routine checkups on
the elderly client to ensure that none of these side effects become serious or
life threatening. Initial monitoring is especially critical when the client is
using multiple medications simultaneously.
Mort and Aparasu (2002) suggest that consulting with a psychiatrist is
beneficial to decreasing inappropriate psychotropic use.
Even though second generation
antipsychotics decrease the likelihood of adverse side effects compared to
their traditional counterpart they are expensive and cannot be afforded by
everyone. When medicating the elderly, especially with traditional
antipsychotics, it is best to try and obtain an effective pharmacological
response with the lowest dose of drugs possible (Gareri et al., 2006). To help ensure elderly patients are not
overmedicated, the United States’ Congress initiated the Omnibus Budget
Reconciliation Act of 1987 (ORBA-87) in October 1, 1990, which mandates
regulation of antipsychotic drug use in nursing homes (Nursing Home Reform
Amendments) (Furniss et al., 1998; Garrard et al., 1995). Also, the Indiana
State Board of Health goes further to protect the elderly in nursing homes by
mandating that each client be reduced on psychotropic dosage 2 times a year
(McDaniel, 2009). If the doctor reports worsening symptoms after the dosage is
decreased then the medication can be reinstated as it previously was. If the
client’s symptoms do not seem to worsen then the medication amount is continued
at the reduced amount from then on.
The FDA has mandates a “black box
warning” put on all psychotropic medications, informing elderly users with
dementia that taking the medication increases risk of death. This warning
protects the pharmaceutical companies from any fault but what protects the
physician from malpractice suits should the family of a deceased dementia
patient pursue the matter in court? McDaniel (2009) explains that 77 out of 92
residents (84%) use psychotropic medication at Vermillion Convalescent Center
in Clinton, Indiana and as far as she knows the doctors use no consent forms
stating to the client that there are risks involved with the medication.
Conclusion
From the personal experience gained from interning
at Vermillion Convalescent Center in Clinton, Indiana, I have seen first-hand
the benefits psychotropic medications provide to the elderly; I have also seen
the negative. I understand how fragile elderly lives are and how susceptible to
adverse side effects they can be. I promote the use of psychotropics to improve
quality of life just so long as the treatment is precise and well maintained. I
believe the elderly clients and their families should be warned of potential
risks these medications can cause, not by a warning on a box or pill bottle but
by physicians themselves. Consent forms for psychotropic medications should be
established when dealing with the elderly so that the physician is protected
and to ensure a proper warning is issued. Psychotropic medications can change a
person’s life and there is no doubt that these medications will continue to be
used with the elderly. As geriatric research continues, methods for safely
administering these medications will surely become more precise.
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References
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