The Art and Science of Psychopharmacology: Essential Tools for Treating Anxiety, Depression, Bipolar Disorder & Psychosis by Marie Susan

Author:Marie, Susan [Marie, Susan]
Language: eng
Format: epub
Publisher: PESI Publishing & Media
Published: 2020-06-09T16:00:00+00:00

In addition, older adults with bipolar disorders tend to have progressively less intense episodes of (hypo)mania. Instead, they are more likely to experience predominant depressive episodes and can be frequently misdiagnosed as having major depressive disorder (which then leads to inappropriate treatment). The importance of accurate treatment cannot be understated, as lifelong, poorly treated or untreated mood disorders are associated with poorer cognitive functioning and earlier cognitive decline (James et al., 2018).

The three recommended top-line agents for the treatment of bipolar disorders in older adults are lithium, Lamictal, and Depakote. When lithium is used, older adults tend to do well with slightly lower levels (0.4-0.6 mEq/l), and for those over the age of 80, the maximum level is 0.7 mEq/l. Additionally, the dose needed to get a therapeutic level decreases with age. For example, clients in their eighties require approximately 30 percent of the dose they needed in their thirties (Rej et al., 2014). Depakote dosing is not as affected by aging, and the required dose may remain similar to what worked and provided a therapeutic blood level in younger years.

Seroquel (quetiapine) is a second-tier medication used for the treatment of bipolar disorders in older adults, and it is the best of the atypical agents for this population. The other atypicals are not commonly used because these medications are associated with a very high rate of movements disorders, such as dystonia and tardive dyskinesia (see Chapter 4 ). Although medications like Cogentin® (benztropine) are used to treat movement disorders caused by atypical agents, they also have a heavy anticholinergic burden that can worsen cognitive impairment in older adults. Because Seroquel has a low potential to cause movement disorders, it is the preferred choice of the atypicals. Unfortunately, it can wreak havoc on blood sugar levels, which can be problematic for those with diabetes.

Across all classes of medications, lower doses may be needed when treating older adults to avoid sedation or cognitive impairment, though older adults tend not to be so vulnerable to akathisia. Benzodiazepines are not recommended in older adults, even as an add-on to other mood stabilizers, because of its associated risk of falls and memory impairment (see Chapter 5 for more information on benzodiazepines).

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