Depression in the Elderly Dr Nick Clarke MD

Depression in the Elderly Dr Nick Clarke MD MRCPsych Consultant Old Age Psychiatrist Independent Practice North Downs Hospital, Caterham Nuffield Hospital, Tunbridge Wells November 21 st 2018 Primary Care Update, Ardingly Show Ground drnicholasclarke. com

Learning - Antidepressants SAFETY NOTE Pre-treatment postural BP and QT interval check ECG advisable Trazadone 50 mg ON max 300 mg ON sedative and mild trycyclic drug - lower postural BP and slow urinary output/constipate/blur vision SSRI’s well known – titrate to maximum dose at 2 week intervals – response may be genetically specific SNRI’s equally well known – Mirtazapine 7. 5 mg ON is overly sedative and ineffective max 45 mg ON Duloxetine can start at 20 mg OM as Yentreve then 30 mg OM max 60 mg. OM as Cymbalta nausea and withdrawal but neurogenic pain benefit Venlafaxine 37. 5 mg ON to 225 mg. ON staging a comeback but palpitations, hypo- and hypertension monitoring Melatonin agonist Agomelatine (to avoid adverse effects) 25 mg ON to 50 mg. ON Serotonin dual agonist & RI Vortioxetine 2. 5 mg OD to max 20 mg OD (Brintellix) NICE approved after failure of 2 antidepressants – cognitive benefits maybe

Learning. Mood Stabilisers and Enhancers WARNING FOR THE OVER 50’S ONLY not when pregnancy possible Pregabalin 25 mg OD to 100 mg BD (unlicensed) Carbamazepine 50 mg OD to 300 mg BD (Tegretol) (unlicensed & much used) Lamotrigine 25 mg ON to 100 mg BD in 25 mg increments fortnightly (for rapid cycling BPD) Valproic Acid 250 mg OD increased daily to 500 mg TDS (Depakote) licensed Sodium Valproate 50 mg OD to 100 mg BD to (unlicensed) Quetiapine 25 mg OD to 75 mg BD/150 mg ON(Seroquel) (licensed) Olanzapine 1. 25 mg ON to 20 mg ON (Zyprexa) (licensed) Amisulpiride liquid 25 mg ON to 100 mg BD (low dose - unlicensed) Lithium carbonate 100 mg ON titrated to plasma level 4 -8 mmol/L (eg Priadel) (licensed)

What Problems Occur With Drug Treatment? BZ’s AP’s AD’s Li falls, sedation, confusion parkinsonism, falls, stroke risk anticholinergic/postural BP drop tremor, polyuria, dysmnesia, hypothyroidism, rarer renal impact, CNS toxicity

Caution from the Research Antipsychotic drugs may increase cerebrovascular risk Antidepressants and Antipsychotics may increase Alzheimer’s risk

National UK Atypical Antipsychotic Drugs in AD Review – ‘Cochrane’ Report Ballard & Waite Cochrane Database (2006) 1 risperidone and olanzapine treated patients had a higher incidence of serious adverse cerebrovascular events (including stroke), extra-pyramidal side effects and other important adverse outcomes. BUT those taking typical and atypical antipsychotics in AD were no more likely to decline cognitively than untreated patients (only baseline severity predicted decline). Higher drug mortality reflected age and severity. Six month cohort study (n=224) [Livingstone et al JNNP (2007) Laser-AD]

Elderly Consistent Users of Anti-Cholinergic Drugs Show Cognitive Impairment Ancelin BMJ (2006) §the groups were a bit imbalanced §ie 30 users and 297 nonusers §ie users were older (81 y vs 75 y) §tri & tetracyclic antidepressants, older chlorpromazine-type antipsychotics, antihistamines for sedation and allergy, anti Parkinson’s drugs, bladder antispasmodics, digoxin & codeine §twice as many 80% users(80%) were diagnosed Mild Cognitive Impairment syndrome after 2 y, compared to non-users (35%) §age and drug use predicted MCI

Summary- Antipsychotic Drugs & Cholinergic Blockade (Richelson & Souder 2000) clozapine +++ olanzapine++ quetiapine twice risperidone, haloperidol, pimozide least +

Thank You Professor Paul Francis Ph. D WCARD Guy’s Hospital Dr Howard Bloom RCGP & Deanery Ramsay Healthcare