ELUCIDATING ENIGMAS OF THE ELDERLY
From the West Coast Geriatric Psychiatric Conference, sponsored by the University of California, San Diego,
School of Medicine
| PSYCHOSIS TREATMENT —James B. Lohr, MD, Professor and Vice-Chair, Clinical Affairs, University of California,
San Diego, School of Medicine, Department of Psychiatry; San Diego Director, Veterans Affairs’ Veterans’
Integrated Service Network (VISN 22) Mental Illness Research, Education, and Clinical Center (MIRECC); and Executive
Director, UCSD Psychopharmacology Research Initiatives Center of Excellence (PRICE)
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| Psychosis in older patients: idiopathic psychotic disorders include schizophrenia, bipolar disorder, schizoaffective
disorder, psychotic depression, and delusional disorder (however, these disorders not always accompanied by psychotic
episode); other disorders that may be accompanied by psychosis include dementia and some medical conditions
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| Diagnostic assessment: carefully focused psychiatric history and examination, including mental status examination;
cognitive evaluation; focused neurologic examination; laboratory assessment, including complete blood count, urinalysis,
basic chemistry, and levels of any drug that patient takes for which levels available; thyroid measurements
(thyroid disease one of most common causes of nonresponse to medications); computed tomography (CT) not generally
useful, except where indicated; toxicology screen
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| Antipsychotic medications: evidence base lacking; medications that have been studied usually studied as monotherapy
in patients with no comorbid illnesses who do not take other medications; however, patients >70 yr of age
take average of 6 to 8 medications per day; consensus guidelines available for some situations, but often practitioner
must rely on his or her clinical experience in selecting antipsychotic medications and medication combinations
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 | Antipsychotics: usually divided into typical and atypical drugs, but speaker prefers terms “first generation” (typical)
and “second generation” (atypical)
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| First-generation medications: high-potency medications preferred in older patients because side effects of low-potency
drugs can be problematic; high-potency medications associated with movement-disorder problems, eg,
parkinsonism, tardive dyskinesia; because of side-effect profiles, first-generation antipsychotics used less frequently
in older patients; if patient has been on first-generation drug for long period, is doing well, and has minimal
side effects, no need to change; first-generation agents still used for acute psychosis and delirium and as
adjunctive drugs in patients not showing desired response to second-generation agent
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| Second-generation medications: generally associated with fewer extrapyramidal side effects and with less tardive
dyskinesia; may work more effectively than first-generation drugs on negative symptoms and possibly on cognitive
symptoms
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| Comparison trials: few that compare first-generation with second-generation medications; second-generation antipsychotics
do work in older patients, but studies unable to determine if they work better than first-generation
drugs in treating psychosis or cognitive symptoms; definite evidence that they work better in improving behavioral
problems that accompany dementia
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| Other trials: in schizophrenia and dementia, few clinical trials done, but those few seem to indicate second-generation
antipsychotics as efficacious as first-generation agents; however, no evidence to indicate any one agent better
than others; most differences relate to side effects
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| Specific medications: general rule of thumb says in older patients with schizophrenia, use half of dose used in
younger patients, and in patients with dementia, use quarter dose; clozapine—difficult to use in older adults;
speaker recommends starting at as low a dose as possible and planning on end dose in schizophrenia being half that
used in younger patients, and in dementia, about one quarter
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| Extrapyramidal symptoms (EPS): motor side effects that involve basal ganglia and cerebellum; antipsychotic-induced
EPS look just like other disorders of basal ganglia (eg, antipsychotic-induced parkinsonism looks just like
Parkinson’s disease); acute EPS—defined as those that develop within days to weeks of beginning or increasing
medication (tardive effects usually occur after months of beginning or increasing treatment, although in older patients,
some can develop as early as 1 mo); among acute EPS, akathisia most common; parkinsonism becomes
more common as patients become older and can be difficult to differentiate from Parkinson’s disease; dystonia
only EPS less common in elderly, may be confused with seizure
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| Tardive dyskinesia: more significant in older patients than in younger; often considered more problematic by practitioners
than by patients, who often do not notice they have it; tends to involve distal muscles, whereas Huntington’s
disease involves all muscle groups; tardive dystonia most difficult to treat subtype of tardive dyskinesia; definitive
risk factor for tardive dyskinesia is age; more controversial risk factors include length of time patient has been
treated, alcohol abuse or dependence, development of EPS earlier on, medical comorbidity, female sex, and presence
of mood disorder; of younger patients on first-generation drugs, 33% to 66% have improvement in tardive
dyskinesia when drug stopped; unknown if this applies to second-generation drugs or to older patients
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| 2004 consensus guidelines: delirium—no consensus for first-line therapy; determine cause of delirium and treat
that; for second-line treatment, risperidone received highest ratings, 0.75 to 1.75 mg/day; dementia with agitation
and delusions—first-line treatment antipsychotic monotherapy; not clear if same therapy should be used in absence
of delusions; second-line treatment mood stabilizer with antipsychotic, both in small doses; schizophrenia—
second-generation antipsychotics favored over first-generation; in older patients, doses for schizophrenia higher
than those for other psychoses; mood disorders—for first-line treatment of patients with psychotic major depression,
combination of antipsychotic and antidepressant; selective serotonin reuptake inhibitors (SSRIs) favored over
other classes of antidepressants; antipsychotics not recommended for nonpsychotic depression, even in presence of
severe agitation; antipsychotics recommended for psychotic mania, but not for mild mania; drug interactions—
carbamazepine interferes with metabolism of many other drugs and with its own metabolism
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| ALCOHOL USE AND ABUSE IN OLDER ADULTS —Tamara Wall, PhD, Associate Professor of Psychiatry, University
of California, San Diego, School of Medicine, La Jolla
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| Introduction: once alcohol consumed, rapidly distributed throughout body, where it affects virtually every organ
system; effects of alcohol vary with age, and same dose of alcohol given to person of similar sex and body weight
results in higher blood alcohol level in older person than in younger; liver, which metabolizes majority of alcohol,
becomes less efficient with age, contributing to increased sensitivity to or decreased tolerance for effects of alcohol
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| Alcohol in elderly: most people decrease alcohol consumption as they become more sensitive to its effects; those who
do not decrease consumption at higher risk for neurocognitive impairment and other problems; people ≥55 yr of age
consume most prescription drugs, and multiple prescriptions not uncommon, increasing risk for adverse reactions
with alcohol; older people have longer washout periods than younger; currently >100 prescription and nonprescription
medications known to interact adversely with alcohol; medical disorders can contribute to adverse alcohol reactions
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| Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV): recognizes 2 primary alcohol-related
disorders, alcohol abuse and alcohol dependence; alcohol abuse—characterized by maladaptive pattern of
use that leads to adverse consequences, including problems with family, friends, work, legal problems, and recurrent
use in physically hazardous situations, and substance-related problems must occur in 12-mo period; alcohol
dependence—requires patient’s meeting 3 of 7 criteria in 12-mo period; withdrawal vs tolerance—withdrawal
typically experienced by those with more severe dependence, tolerance by those with less severe; DSM-IV says
people with withdrawal or tolerance have alcohol dependence, but speaker thinks this is not well supported by evidence;
she also opines that DSM-IV criteria may not be relevant to many older adults
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| Epidemiology: in United States, ≈10% meet criteria for alcohol abuse or dependence in general population, and 2%
to 8% in community samples; however, among inpatients, ≈20% of people admitted for medical diagnosis meet criteria,
≈30% of those admitted for psychiatric diagnosis, and ≈20% of those admitted to nursing homes
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| Patterns of drinking: different between younger and older people; while daily drinking common, older folks typically
consume smaller amount each day; medical problems more commonly associated with alcohol disorders
among older people, and those that should arouse concern include frequent falls, trauma and fractures, hypertension,
macrocytosis, peripheral neuropathy, depression, insomnia, loss of libido, late-onset seizure disorder, confusion
(which can masquerade as dementia), poor nutrition, incontinence, diarrhea, myopathy, inadequate self-care,
congestive heart failure, and adverse interactions of alcohol with prescription or nonprescription medications; individuals
who smoke more likely to drink than people who do not smoke (80% to 90% of people in treatment for alcohol
use disorder found to smoke; no negative impact associated with trying to quit both simultaneously)
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| Clinical course in older adults: drop in alcohol intake considerable among people >75 yr of age, possibly due to increase
in health problems seen in later years and to increased proportion of women in older age groups (throughout
lifespan, men 3 to 4 times more likely than women to have alcohol use disorders); studies identify early-onset alcohol
use disorder and late-onset (some studies use 40 yr of age as cutoff, others use 60 yr of age); early-onset types
represent ≈66% of older people with alcohol use disorder, typically drink more, have more severe dependence,
more financial, legal, and social problems, and more likely to have family history of alcoholism than late-onset
types; women more likely to have late-onset alcohol use disorder; late-onset alcohol use disorder often precipitated
by environmental factor or by life event (eg, loss of spouse, retirement, divorce, or separation); people with alcohol
use disorder die 10 to 15 yr earlier than those without; leading causes of death are accidents, suicide, heart disease,
infectious disease, chronic liver disease, cirrhosis, pancreatitis, and cancer; mortality for alcoholics >60 yr of age 2
to 3 times higher than for nonalcoholics; 50% of elderly in community with alcohol abuse or dependence also report
depression, which tends to be more protracted than in people without; study found that alcohol abuse in people >60
yr of age increases risk for late-onset psychotic symptoms by 8 times in men and by 3 times in women
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| What can be done? older patients underrepresented in alcohol-treatment programs, due in part to cultural bias that
older adults do not abuse alcohol and drugs; in addition, symptoms of alcohol disorder may be mistaken for problems,
such as neurocognitive impairment, that are more common in older people; gamma-glutamyl transferase
(GGT) first liver enzyme induced by alcohol; GGT test has 70% to 80% sensitivity in patients who regularly consume
>6 alcoholic drinks per day; screen all patients for alcohol use disorder, using any of several questionnaires
available; patients expect physicians and other health care providers to give sound advice about alcohol consumption;
research shows that ≈30% of people with alcohol-related problems reduce their consumption if offered brief
intervention by health care provider; brief interventions—several formalized, but all have some elements in common;
immediately after positive screen, share results with patient in supportive and nonconfrontational manner;
present information in neutral and objective way; ask if patient understands; invite patient to tell you about his or
her drinking (disarm patient by starting with, “What are the good things about your alcohol use?” ask about bad
things second); provide feedback and advice and supplement it with behavior modification technique or self-help-
directed bibliotherapy; follow up with phone call or appointment, during which behavioral change reinforced; educate
all patients about common myths about alcohol, eg, using it improves sleep or sexual performance; refer patient
for detoxification if necessary (hospitalization may be needed for older patient, particularly if he or she has
other medical problems); focus initial treatment on motivating patient, encouraging him or her to enter and continue
in treatment program; refer patients to alcohol rehabilitation program such as Alcoholics Anonymous
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Educational Objectives
| The goal of this program is to educate the listener about treating psychosis and alcohol use disorders in the elderly.
After hearing and assimilating this program, the clinician will be better able to:
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| 1. Determine the underlying cause of psychosis in older patients.
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| 2. Discuss the effects that first-generation and second-generation antipsychotics have on elderly patients and how
they differ from the effects on younger patients.
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| 3. Distinguish between extrapyramidal effects due to medications and those due to a disease process.
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| 4. Describe the differences in how alcohol affects older and younger individuals.
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| 5. Incorporate a brief screen for alcohol use disorders for all patients.
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Suggested Reading
Babor TF, Higgins-Biddle JC, Monteiro MG: AUDIT—The Alcohol Use Disorders Identification Test—
Guidelines for Use in Primary Care. Available at http://www.who.int/substance_abuse/publications/alcohol/en. Accessed
December 7, 2005; Brennan PL, Schutte KK, Moos RH: Pain and use of alcohol to manage pain: prevalence
and 3-year outcomes among older problem and non-problem drinkers. Addiction 100:777, 2005; De Deyn PP et al: A
randomized trial of risperidone, placebo, and haloperidol for behavioral symptoms of dementia. Neurology 53:946,
1999; Dufour M, Fuller RK: Alcohol in the elderly. Annu Rev Med 46:123, 1995; Dunn LB, Jeste DV et al: Enhancing
comprehension of consent for research in older patients with psychosis: a randomized study of a novel consent
procedure. Am J Psychiatry 158:1911, 2001; Fleming M: Identification and treatment of alcohol use disorders in
older adults. In: Gurmack AM, Atkinson R, Osgood NJ, eds. Treating Alcohol and Drug Abuse in the Elderly. New
York, NY: Springer Publishing, 2002: 85; Jeste DV et al: Management of late-life psychosis. J Clin Psychiatry 57
(Suppl 3):39, 1996; Jeste DV et al: Risk of tardive dyskinesia in older patients. A prospective longitudinal study of
266 outpatients. Arch Gen Psychiatry 52:756, 1995; Jeste DV, Lohr JB et al: Conventional vs. newer antipsychotics
in elderly patients. Am J Geriatr Psychiatry 7:70, 1999; Kane JM, Woerner M, Lieberman J: Tardive dyskinesia:
prevalence, incidence, and risk factors. J Clin Psychopharmacol 8(4 Suppl):52S, 1988; Katz IR et al: Comparison of
risperidone and placebo for psychosis and behavioral disturbances associated with dementia: a randomized, double-
blind trial. Risperidone Study Group. J Clin Psychiatry 60:107, 1999; Letizia M, Reinbolz M: Identifying and managing
acute alcohol withdrawal in the elderly. Geriatr Nurs 26:176, 2005; Liberto JG, Oslin DW, Ruskin PE: Alcoholism
in the older population. In: Carstensen LL, Edelstein BA, Dornbrand L, eds. The Practical Handbook of
Gerontology. Thousand Oaks, CA: Sage Publications, Inc.; 1996:324; McManus DQ, Arvanitis LA, Kowalcyk BB:
Quetiapine, a novel antipsychotic: experience in elderly patients with psychotic disorders. Seroquel Trial 48 Study
Group. J Clin Psychiatry 60:292, 1999; McMurtray A et al: Early-onset dementia: Frequency and causes compared
to late-onset dementia. Dement Geriatr Cogn Disord 21:59 2005; Nelson JC: Increased risk of cerebrovascular adverse
events and death in elderly demented patients treated with atypical antipsychotics: what’s a clinician to do? J
Clin Psychiatry 66:1071, 2005; Onen SH et al: Alcohol abuse and dependence in elderly emergency department patients.
Arch Gerontol Geriatr 41:191, 2005; Regier DA et al: Comorbidity of mental disorders with alcohol and other
drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA 264:2511, 1990; Street JS et al:
Olanzapine treatment of psychotic and behavioral symptoms in patients with Alzheimer disease in nursing care facilities:
a double-blind, randomized, placebo-controlled trial. The HGEU Study Group. Arch Gen Psychiatry 57:968,
2000; Woerner MG et al: Prospective study of tardive dyskinesia in the elderly: rates and risk factors. Am J Psychiatry
155:1521, 1998; Zuccala G et al: Gruppo Italiano di Farmacoepidemiologia nell’Anziano Investigators. Dose-related
impact of alcohol consumption on cognitive function in advanced age: results of a multicenter survey. Alcohol
Clin Exp Res 25:1743, 2001.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported nothing to disclose.
Drs. Lohr and Wall were recorded at The West Coast Geriatric Psychiatry Conference, held February 10-13, 2005, in
San Diego, and sponsored by the University of California, San Diego, School of Medicine. The Audio-Digest Foundation
thanks the speakers and UCSD for their cooperation in the production of this program.
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