Variations in psychopharmacology for elderly and children

VARIATIONS IN PSYCHOPHARMACOLOGY FOR

ELDERLY AND CHILDREN

AHMED ELAGHOURYEgyptian & Arab Boards in Psychiatry

Abbassia Hospital for Mental Health, MOH

Cairo, Egypt

Pre assessment in elderly

• Current medical problems / medications

• Exam: physical & mental

• Labs: esp LFT & KFT

• Drug interactions: esp warfarin with Enz Inhib

• POTENTIALLY INAPPROPRIATE PRESCRIBING: Beers Criteria 2012 ( free / in apps)

• Smartphone apps: your “peripheral brain”

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Anticholinergic Activity (AA)

• Familiarize yourself with one of the following:

– Beers criteria

– STOPP criteria

– FORTA criteria

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American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012 Apr;60(4):616-31. doi: 10.1111/j.1532-5415.2012.03923.x. Epub 2012 Feb 29. Review. PubMed PMID: 22376048; PubMed Central PMCID: PMC3571677.

Gallagher P, O'Mahony D. STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers' criteria. Age Ageing. 2008 Nov;37(6):673-9. doi: 10.1093/ageing/afn197. Epub 2008 Oct 1. PubMed PMID: 18829684.

Kuhn-Thiel AM, Weiß C, Wehling M; FORTA authors/expert panel members. Consensus validation of the FORTA (Fit fOR The Aged) List: a clinical tool for increasing the appropriateness of pharmacotherapy in the elderly. Drugs Aging. 2014 Feb;31(2):131-40. doi: 10.1007/s40266-013-0146-0. PubMed PMID: 24353033; PubMed Central PMCID: PMC3907693.

Beers criteria: by drug

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Beers criteria: by diagnosis

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Neuropsychiatric symptoms of dementia

• One of these symptoms is observed in up to 90% of pts of dementia

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• Nonpharmacologic therapy: environmental

• AntiChEIs: Rivastigmine, Donepezil

• Antipsychotics: Olanzapine, Risperidone, Quetiapine

• Antidepressants: Citalopram

• AEDs: CBZ, VPA, GBP, LMT

• Analgesics

• Physical restraint

• Avoid: BZD, AntiH

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• Depression: Citalopram & Sertraline

• Insomnia: Trazodone, Melatonin

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Suggested durations of antipsychotic treatment

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Children variations

• Dose by body weight

• Consider rapid metabolism esp AEDs

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Minimum age to start: Rough lines

• Amphetamine, Chlorpromazine, Thioridazine, Haloperidol, Risperidone, Benztropine, Clonazepam, Diazepam, Carbamazepine, ( ? Valproate), Oxcarbazepine, Lamotrigine, Gabapentin, Topiramate: May start at Preschool age

• MPH, Atomoxetine, Imipramine, Fluoxetine, Sertraline, Fluvoxamine, Trazodone: NOT BEFORE School age

• All others: At adolescent age

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Disorders associated with aggressive or violent behaviors

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Greydanus DE, et al: Pediatric and Adolescent Psychopharmacology. 2008, Cambridge University Press

• Off label prescribing:

– Very common in children

– Identify target symptoms

– Manage adverse effects

– Second opinions

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