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Treatment Considerations in Old Age Psychiatry

• Psychotropic medication use in older adults requires careful consideration to ensure effectiveness and minimize adverse effects.
• Pharmacokinetics and pharmacodynamics of drugs are significantly altered in the elderly.
• Comorbid illnesses leading to polypharmacy increase the risk of drug interactions and drug-induced problems.
• Older adults are more susceptible to increased frequency and severity of side effects, such as stroke with antipsychotic drugs or bleeding with SSRIs.
• Older adults may exhibit a delayed therapeutic response.

Physical Age-Related Changes and Pharmacokinetics

• Slower drug absorption may occur in older adults due to poor intestinal motility, leading to a slower onset of action.
• Increased volume of distribution is observed due to changes in physical constitution, with older adults having more body fat, less body water, and less albumin.
• Drugs tend to have a higher duration of action.
• Reduced renal function with age, losing 35% of function by age 65 and 50% by age 80 can lead to lower drug excretion.
• Dosage monitoring and reduction are often required in older adults.

Other Aspects to Consider

• High risk of drug interactions must be considered when using psychotropic medication in old age.
• Small dose changes may cause toxicity or loss of therapeutic action due to a lower therapeutic index, requiring careful management of drugs with lower therapeutic indices.
• Lithium for bipolar should only exceptionally be used in older adults.
• Inhibitors or inductors of hepatic metabolizing enzymes, such as SSRIs, erythromycin, and carbamazepine, can alter the metabolism of other drugs.

Physical Examination and Monitoring

• Physical examination, including vital signs, weight, blood pressure, and pain severity measurements, is essential before prescribing medications.
• Certain antipsychotics like olanzapine or quetiapine can cause weight increases, requiring careful treatment selection in obese patients.
• Side effects of antipsychotics like tardive dyskinesia and Parkinsonism (tremor or psychomotor retardation) should be considered.

Principles for Prescribing Psychotropic Medication

• Start slow, go slow, beginning with minimal doses, titrating slowly upwards, and monitoring tolerance and response.
• Keep pharmacological regimes simple to reduce side effects and drug interactions
• Expect latency of drug response due to pharmacokinetic and pharmacodynamic changes.
• All patients started on psychotropic medication require physical examination, medication review, potential drug interactions consideration, and basic blood and urine tests if symptomatic.

Things to Avoid

• Avoid treating side effects with medication, dose augmentation , antipsychotics and dementia due to high stoke and cardiac risk and motor side effects like Parkinsonism
• Avoid medication with anticholinergic side effects and very sedative medications as they lead to falls Drugs with very long half life as they are potent inhibitors of hepatic metabolising enzymes that could interact with other drugs, particularly in the context of polypharmacy.

Mental Capacity Assessment

• Mental capacity assessment is needed when someone lacks the capacity to make decisions about their care.
• The Mental Capacity Act protects and empowers individuals who may lack mental capacity.
• The Act promotes safeguards decision making within a legal framework for all those over 16 years old.
• Capacity assessment is needed with evidence of impairment that prevents the person from making a specific decision when they need to.
• The Mental Capacity Act defines four main criteria for assessing decision capacity:
  • Understanding relevant information, retaining that information, using it to weigh up a decision, and communicating the decision.

Factors Affecting Decisional Capacity

• Dementia is a prominent illness affecting decisional capacity.
• Emotional factors like paranoid delusions or severe hopelessness can also impair capacity.
• Presence of these conditions do not necessarily mean that a person lacks the capacity to decide.
• An individual may retain capacity to decide financial but lack capacity for medical decisions.
• Lack of capacity is not static, requiring assessment to be specific in time.

Treatment and Care Strategies

• Community level primary mental health care for older people is crucial.
• Focus on long-term care of older adults with mental disorders and provide caregiver education, training, and support.
• Early identification and screening, promoting prevention and psychosocial interventions.
• CBT and social inclusion programs can combat mental illness.

Optimising Management

• Early diagnosis and optimal management includes optimising physical and mental health.
• Attention to functional ability, well-being, and identification of physical comorbidities.
• Management of challenging behaviours such as, BPSD and dementia.
• Enhance care and support that are exposed to burnout.
• Promotional active and healthy aging in older adults, with supporting individuals' security and freedom.
• Developing targeted health and social programs that deal with old age abuse, stigma and ageism need to be considered by policy makers and health care providers, to improve the quality of life in older people.

Future Healthcare Challenges

• Increase training for health professionals in providing care for older people.
• Enhance prevention and management strategies of chronic diseases.
• Design sustainable policies for long-term and palliative care.
• Develop age-friendly services, settings and cities.