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Adjusting Psychopharmacologic Treatment for Geriatric Patients

September 13, 2020

(Part 1 of 4)

In this video, Psych Congress 2020 presenter Marc E. Agronin, MD, shares strategies that mental health clinicians can use to adjust psychopharmacologic treatment and dosages for geriatric patients.

Dr. Agronin presented "The Top Dos and Don’ts in the Psychopharmacologic Treatment of Geriatric Patients: Focus on Dementia and Late-Life Depression and Anxiety" at the virtual conference.

Read the transcript:

Hi. My name is Dr. Marc Agronin. I'm a geriatric psychiatrist, and I've practiced at Miami Jewish Health since 1999. I work there as the senior vice president for Behavioral Health, and also as the chief medical officer for MIND Institute at Miami Jewish Health, which is one of Florida's official memory disorder centers.

My specialty is working with individuals with neurocognitive disorders, with a focus on Alzheimer's disease, looking at ways to treat the disorder itself, to help them with all the associate psychiatric issues, and also to conduct some of the latest clinical trials to try to slow down the course of Alzheimer's disease.

The use of psychopharmacologic medications in late life is important because we see all of the same psychiatric conditions, and we don't want to minimize treatment. That being said, it's important to keep in mind several basic principles.

First of all, the older body and the older brain might be more sensitive to medications, and might have sometimes less predictable responses to medications than we might see in younger individuals.

It warrants really getting to know the person, their medical background, potential drug side effects that may be really difficult for them, such as sedation in someone who's very frail or has a history of falling, and all the potential drug‑drug interactions.

We usually fall back on this mantra I'm sure everyone is familiar with, called start low, go slow, which basically means, start at the lowest necessary dose, titrate slowly to make certain you're monitoring how they're tolerating this, and do it one medication a time so you know what's going on.

I always add to this, “but go,” because it's important to keep pushing the medication until you actually get a therapeutic response. What we don't want to do is hold back on the medication and not get a full response, and so someone is still suffering from symptoms. I would add, if the medication is not working, we don't want to stop it abruptly. We want to taper it slowly.

These are the basic principles that we use in late life. We still use most of the same medications. I would just advise anyone working with older patients to be familiar with something called the Beers Criteria.

This is a list for what are known as potentially inappropriate medications to use in older adults. It was developed initially in 1991 by Dr. Mark Beers, who was a prominent geriatrician.

Since 2011, the American Geriatric Society has taken over revising the list, updating it, and basing these recommendations on both consensus and evidence‑based approaches to ensure that we all understand what medications might pause a greater risk in older individuals along the lines of some of the principles that I outlined earlier.

I think if you follow these principles, you're aware of Beers Criteria, you're judicious in your dosing, but at the same time, you also make certain you treat to effect, you'll do very well in terms of working with older adults.

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