Dosage

• medication as an experimental trial

• stopping medication

Dosage

Some, but by no means all, medications need to be given at a lower dose in older people. Tricyclic antidepressants, for example, are often prescribed at very low doses in primary care for fear of their side-effects; arguably, these doses are ineffective. Newer antidepressants (e.g. SSRIs) are given at a standard dosage whatever the age of the patient, because they are tolerated better. Thus it is argued by some that SSRIs should be the first line of treatment for depression in old age, because they will be used in more effective dosage than the tricyclics.

Major tranquillizers should be given to older people in much lower doses than are prescribed for younger patients, especially when there is a degree of dementia. (For example, in a person with cognitive impairment 0.5 mg of risperidone daily may be sufficient to resolve paranoid symptoms.) Likewise, manic illness may respond to quite small doses (e.g. 1 mg of haloperidol twice daily), although in some cases the same dosage of major tranquillizers as in younger patients may be required. For lithium, the therapeutic range to be aimed at is 0.4 to 0.6 mmol/l rather than higher. The physical health of the patient, other illnesses, and other medications are relevant considerations. The best guides to medication are the manufacturers' literature, prior experience of the patient in earlier episodes of illness, and a careful trial with monitoring.

Medication as an experimental trial

Starting medication for any condition ought to be treated as the test of a hypothesis. There should be a plan, shared with the patient, setting out the following

1. how long the trial will last before a decision is made that the treatment is unsuccessful and should be ended;

2. which target symptoms will be monitored, and what records should be kept (by the patient or caregiver);

3. when progress will be reviewed;

4. what side-effects might be develop and which of these should alert the patient to stopping the drug and contacting the doctor;

5. what will follow if the trial succeeds;

6. what will be tried instead if the trial fails.

This approach to medication is particularly important for people with dementia. Often, because of confusion, lack of insight, and communication difficulties, a tentative diagnosis has to be based on scanty information. For example, a patient living in a nursing home who starts to show disturbed behaviour may have become depressed, but cannot describe the depressive symptoms. Clues to the diagnosis may come only from reports by the nursing staff (e.g. 'She never jokes with us now'). It is often valuable to try an antidepressant in these circumstances, which may result in a resolution of the symptoms. However, the trial must be set up carefully so that the medication is not thoughtlessly continued for months without review, because no one has asked whether it is helpful or not.

Stopping medication

The decision to withdraw medication should be taken as seriously as the decision to start. Stopping medication is especially valuable in two circumstances. First, it may contribute to confusion in delirum, particularly where a cocktail of medications has been built up over time. Second, patients reaching the terminal stages of dementia should have medication withdrawn gradually, to test whether it is still needed. In dementia drugs prescribed at an earlier stage to control behavioural syndromes are rarely, if ever, required for the entire course of the disease.

There are also two reasons for being cautious about stopping medication. First, some drugs have withdrawal effects (e.g. paroxetine and benzodiazepines). Second, medication that has been used prophylactically may falsely appear to be no longer needed—the stability of the patient's state may seem to demonstrate intrinsic health. For example, a patient can remain well for years on a low dose of antidepressant after a severe depressive episode, or on a low dose of antipsychotic after a schizophrenic illness has declared itself, until well-intentioned, careful, and thoroughly monitored withdrawal of the drug precipitates the return of the illness. There are times when it is better to leave well alone. The same may apply to a minority of patients who have been stable for years on a low dose of benzodiazepine for anxiety or insomnia.

Compliance

The view on this topic in younger age groups has moved away from considering the obedience of patients in following instructions (as the word 'compliance' appears to imply) to considering them as partners in their own treatment, for which the word 'concordance' is a happier choice. Where possible, older people should also be treated as partners in decisions about starting treatment and given information about the benefits (and disadvantages) that might be expected from it, so that they willingly assume responsibility for following the treatment through. However, in addition to willingness there has to be ability, and the ability of older people to take medication correctly is very easily impaired by physical causes (such as arthritic hands which cannot open child-proof packaging, or poor vision which misreads instructions), and by psychological causes, especially memory loss and temporal disorientation. When a patient is taking several different drugs for a number of conditions the problems are compounded. Therefore a psychiatrist (or other physician) who decides to use medication must decide whether the patient will need help in maintaining 'compliance', through suitable packaging and memory aids (such as calendar boxes), or whether responsibility for supervision or administration of the medication should be given to others. Families often take a long time to appreciate that their parent or grandparent, who has taken his or her tablets reliably for years, has started to miss or duplicate doses.

The feelings of a caregiver who is responsible for the medication taken by a patient with dementia, especially where medication is being used to control behavioural difficulties, also need to be understood. Medication prescribed on an 'as-needed' basis should be very carefully explained. The caregiver may have fears of the behaviour escalating out of control, or conversely of drugging the patient into stupor. She may experience guilt about meeting her own needs by medicating her relative, and these feelings will make it hard for her to judge when to give the medication.

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