General considerations in the treatment of older psychiatric patients Medication and physical frailty

Older patients are much more susceptible to the unwanted effects of both psychotropic and non-psychotropic medication. In addition to side-effects specified in data sheets and pharmacopoeias confusion is common with almost any drug and patients prescribed several are at extra risk. Confusion may be the direct result of a drug, say amitriptyline, or indirect, as when antibiotics cause diarrhoea and electrolyte imbalance. In prescribing psychotropic agents for elderly people, certain principles need to be observed:

1. keep the number of drugs to a minimum and prescribe only when the patient's condition clearly indicates it;

2. monitor the patient's progress regularly and cancel a medication that is no longer necessary—neuroleptics prescribed for a psychotic depressive illness are sometimes forgotten and continued far too long after remission;

3. the starting dose may need to be lower, sometimes much lower, the time taken to achieve the therapeutic dose generally longer, and the therapeutic dose smaller than for a younger adult.

For example only, amitriptyline or imipramine may be given to a physically fit young man of 30 years of age at a starting dose of 50 to 75 mg and increased over 2 weeks to 200 mg. For a frail woman in her eighties or nineties the starting dose may be as low as 10 mg and be increased over 3 to 4 weeks to no more than 50 to 75 mg. A few older patients tolerate the same doses as younger adults but most require much less. The important point is that dosing has to be carefully and individually tailored.

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