Specific treatments

Psychotropic drugs (see Chapter 23) should be used in small starting doses because of the following facts:

• Metabolism and excretion are slow.

• Both therapeutic effects and unwanted effects may be found with low doses.

• Medical conditions necessitating caution in drug use may be present.

• Interactions with other medication may occur.

Forgetfulness and other factors may lead to poor compliance, so single-drug therapy in once-daily dosage is desirable. The prescriber should become familiar with a small number of preparations and their unwanted effects, make a special effort to gain the trust of the patient, and pay great attention to explanation and detail. For example, someone with severe arthritis of the hands may not be able to take tablets dispensed in a 'blister pack'; and a change in colour of tablet, or from tablet to capsule, may be especially worrying for an elderly person.

Antidepressants: either tricyclics or SSRIs may be used. Tricyclics are cheaper, have predictable unwanted effects, and can be started at very low doses. Some authorities recommend drugs of secondary tricyclic structure, such as nortriptyline, because anticholinergic and hypotensive effects are less than with tertiary tricyclics such as amitriptyline.

The major advantage of the SSRIs is their lack of toxicity in overdosage. However, they frequently cause worsening in anxiety and gastrointestinal upset, although it is not possible to predict which patients will be affected. Lithium is used in prophylaxis of depression and mania. Sedatives for use in psychosis or agitation include the following:

• Promazine is an effective sedative but weak antipsychotic.

• Haloperidol is often effective in doses as low as 1 mg, but it has marked Parkinsonian side-effects.

• 'Atypical' antipsychotics, such as olanzepine and risperidone, have, since the last edition of this book, come and gone for use in the elderly. They rapidly became popular on introduction, because of a perceived reduction in extrapyramidal side-effects. However, it has now become clear that olanzepine and risperidone are associated with an increased risk of stroke in elderly patients with dementia, and the CSM has advised that risperidone and olanzepine should not be used for treating behavioural symptoms of dementia.

• Hypnotics and 'minor' tranquillizers were overprescribed in the past, creating a large population of elderly long-term users. However, it is possible that the pendulum has swung too far against these drugs; provided they are used judiciously in line with British National Formulary recommendations, they remain a safe and effective treatment for transient neurotic states such as insomnia after bereavement.

ECT (see Chapter 24) may be used if the patient is fit for anaesthetic, and is often better tolerated than antidepressant drugs, but many patients need long-term drug prophylaxis also.

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