The treatment of mental health conditions in the elderly population presents a range of concerns and potential complications. These concerns are not limited to adverse side effects; advanced age often brings metabolic and functional changes that necessarily affect medication response. Research on these problems is currently less than adequate. While there is no simple answer to the issue of how to address mental health issues in an aging population, there are some general best practices to consider for the most commonly occurring situations.
One of the more typical complications for elderly individuals is treatment-resistant depression. By one estimate, up to 40% of depressed, elderly people respond poorly to first-line treatments. Despite uncertain clinical evidence, doctors often prescribe a combination antidepressant treatment for elderly patients who fail to improve when administered a single psychotropic drug, or monotherapy. Unfortunately, the combination treatment approach to poor medication response often leads to further problems. Multiple drug treatments add stress to the body’s major organs, a particular concern among the elderly. Individual responses to these combination approaches are unpredictable, and there is no compelling evidence that the risk outweighs the rewards.
So-called “off label” prescriptions are another serious issue for elderly people and their primary care physicians. The classic case of off-label usage is the prescription of antipsychotic drugs for the treatment of behavioral symptoms related to dementia. At present, there’s scant evidence that antipsychotics represent a safe or effective treatment for elderly individuals with dementia. Risperdal (risperidone) has been shown to manage aggression in dementia, but is less effective with other symptoms. Indeed, studies have shown that atypical antipsychotic medications actually increase the risk of cardiac arrest, stroke, and death in the elderly.
In some instances, the failure to diagnose a mental health condition and prescribe an appropriate treatment can be just as damaging as improper prescription. In elderly individuals with cognitive decline, the symptoms of depression are too easily missed. Likewise, comorbid health conditions, such as major illness or injury, can mask underlying mood disorders. It’s important for attending physicians to always consider mental status and mood in their elderly patients, as the prevalence of depression and anxiety in this population is at least as great as the general population.
Psychotropic drugs carry drug-specific warnings about potentially dangerous side effects or drug-drug interactions, and these risks are amplified in the elderly. With the baby-boom population currently entering retirement, it is critical that future clinical research focus on the safe, effective treatment of mental health conditions in persons over age 65.
Abarno, A., Alderman, C., Hogan, J., & Loutchkina, D. (2012). Psychotropic drug-related problems in the elderly. Aging Health, 8(2), 147.
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