In the United States, 14 percent of adults are 65 or older, and the growing numbers in this population far exceed the number of psychiatrists specializing in treating them. Thus, PCPs and family medicine practitioners are increasingly shouldering the load for treating older adults. In addition, geriatric social workers and licensed professional counselors provide a bulk of the non-medical care to this group. Here are 5 tips and suggestions for working with older clients:
Communicating With Them
Some degree of hearing loss is often prominent in older people, rendering them at least somewhat compromised during medical appointments and treatment planning sessions. Such circumstances can have them feeling left out and passed over, in favor of a family member who can hear much better and who takes the lead in discussions. Many geriatric patients have complained to me about being spoken about as if they’re not even in the room, which can be humiliating, while eroding feelings of autonomy and independence.
Make it a point to always include older adults in any discussions, regardless of how well they hear. Face them directly, speak a bit louder, but not so loud that they feel they’re being shouted at. Incorporate gestures to make key points and leave them with reading material that references the issues you addressed verbally.
Rely On The Old Adage
If you’re doing medication management, you’re aware that older people undergo substantive changes in drug metabolism and eventual excretion from the body – so you’ll want to adjust your prescribing plans to accommodate for these changes. Slower metabolism results in increased blood levels of many medications. Drugs affected include the antipsychotics Abilify, Zyprexa and Seroquel; most benzodiazepines and trazodone. To avoid possible toxicity, it’s best to prescribe smaller doses more frequently, as opposed to bigger doses all at once.
Advancing age is also often accompanied by a decline in kidney function, slowing the elimination of many medications, resulting in higher serum levels. So, taking these age-related concerns into account brings attention to the old adage to “start low, and go slow.” However, older clients still require at least some dosage increases, so this adage instead should be “start low, go slow, and keep on moving.”
Screen For Depression
Many cases of depression in elderly folks go unnoticed and undetected because of complicating factors linked to general medical conditions such as dementia, autoimmune disease, and Parkinson’s disease. And even when diagnosed, a mere one-third of older people with MDD are managed with antidepressants. This is unfortunate because antidepressants are effective in older people, and have robust antisuicide effects accompanying their mood improvement effects in this population. The Geriatric Depression Scale (GDS) is a fine screening tool and can be administered quickly. It’s available via a simple Google search, and comes in 5, 15, and 30 question formats – all with a yes or no answer structure.
Avoid Benzodiazepines
I have never been on the anti-benzodiazepine bandwagon that is quite common now among many practitioners – particularly outside psychiatry. It is undeniably true though, benzodiazepines pose potentially significant risks when used in older adults. All of the benzos and “Z”-drugs (Ambien, Sonata, Lunesta) increase the risk of cognitive difficulties, delirium, falls, and motor vehicle accidents. They do have a place in treatment-resistant panic and generalized anxiety, seizure disorders, and as an adjunct to anesthesia procedures. Often, prescribers – typically outside of psychiatry – employ them in treating older people, and they should be discontinued.
What To Use; What To Avoid
A general principle is to avoid medications that trigger the emergence of orthostatic hypotension, daytime sedation or sleepiness, and cardiac arrhythmias for sure. A tried and true dosing strategy is to begin at half the usual starting dose and increase to the least effective dose after a couple of weeks, as tolerated. And of course, conduct a review of the drug regimen to determine whether anything else can be deprescribed over time.
Older adults need a more targeted approach to medication management due to pharmacokinetic changes, heightened sensitivity to certain drugs, and adverse effects.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.