PSYCHOTROPIC MEDICATION IN THE GERIATRIC POPULATION
In the geriatric population, the use of psychotropic drugs is strictly regulated by the recommendations of the Omnibus Budget Reconciliation Act. Because some individuals in the geriatric population receive primary care in nursing homes, these recommendations are designed to fit the drug needs of this population and also guide clinicians in drug administration. Nonpharmacological options, including psychotherapy, are considered to be the first option of treatment in this population, with the exemption of individuals with dementia. Psychotropic
drugs contraindicated for use in nursing homes under the OBRA regulation include amobarbital (Amytal), amobarbital- secobarbital (Tuinal), aspirin-butalbital-caffeine (Fiorinal), butabarbital (Butisol), pentobarbital (Nembutal), secobarbital (Seconal), meprobamate (Miltown), glutethimide (Doriden), and ethchlorvynol (Placidyl). Table 5 summarizes psychotropic drugs that are classified as drugs with a high potential for severe outcomes in the geriatric population.
Table 5: Psychotropic Drugs With a High Potential for Severe Outcomes Drug Type Drugs Comments Psychotropics Amitriptyline (Elavil)
Strongly anticholinergic and sedating
Barbiturates More side effects than most sedative–hypnotic drugs; should not be used except to control seizures (phenobarbital) Long-acting benzodiazepines Long half-life and hence prolonged sedation; associated with an increased incidence of falls and fractures Doxepin (Sinequan) Strongly anticholinergic and sedating Meprobamate (Miltown) Highly addictive and sedating
Analgesics
Meperidine (Demerol)
Not effective when administered orally; metabolite has an anticholinergic profile
Pentazocine (Talwin)
Confusion and hallucinations more common than with other narcotics
Miscellaneous
Antispasmodic agents (gastrointestinal)
Highly anticholinergic with associated toxic effects
Chlorpropamide (Diabinase)
Serious hypoglycemia possible because of the drug's prolonged half-life
Digoxin (Lanoxin)
Decreased renal clearance; doses should rarely exceed 0.125 mg, except when treating arrhythmias
Methyldopa (Aldomet)
Causes bradycardia and exacerbates depression
Ticlopidine (Ticlid)
More toxic than aspirin
Table 6 summarizes medications classified as having a high potential for less severe outcomes in the geriatric population. Table 6: Psychotropic Drugs With a High Potential for Less Severe Outcomes Drug Type Drugs Comments Analgesics Indomethacin (Indocin)
More central nervous system side effects than any other nonsteroidal anti- inflammatory drug
Propoxyphene (Darvon)
Few advantages over acetaminophen and has narcotic side effects
Antihypertensives
Beta-blockers
Can cause problems in patients with asthma or chronic obstructive pulmonary disease; may precipitate syncope because of negative inotropic and chronotropic effects
Reserpine
Can cause depression, sedation, and orthostatic hypotension
Miscellaneous
Antihistamines
Highly anticholinergic
Cyclandelate (Cyclospasmol)
Generally ineffective for dementia or any other condition
Dipyridamole (Persantine)
Frequently causes orthostatic hypotension; of benefit only in patients with artificial heart valves
Ergoloid mesylates (Hydergine)
Generally ineffective for dementia or any other condition
Muscle relaxants
Increased cholinergic activity, sedation, and weakness
Trimethobenzamide (Tigan)
Least effective antiemetic and can cause extrapyramidal symptoms
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