Advances in Geriatric Psychopharmacology Discussed

Pharmacologic intervention on the C/L service was the focus of a workshop presented by Sandra Jacobson, M.D., coauthor of the clinical manual of geriatric psychopharmacology, 2nd edition, published by American Psychiatric Publishing. The workshop covered advanced practices of diagnosis and treatment involving a variety of syndromes—catatonia, neuroleptic sensitivity, serotonin syndrome, akathisia, and nonconvulsive status epilepticus—as well as issues such as psychotropic use in patients with hepatic or renal impairment, treatment of anxiety in patients with pulmonary disease, and the use of mood stabilizers in patients with secondary manic syndromes.

Each topic was introduced by a real-world clinical vignette, and then participants focused on specific diagnostic and treatment issues. In the discussion of catatonia, for example, the question was raised whether catatonia may be misdiagnosed as delirium. To make the diagnosis, the consultant has to be considering catatonia, because the classic motor signs have to be elicited. In addition, although EEG can be useful in distinguishing catatonia from delirium, EEG rarely is recommended by psychiatric consultants in current practice. Participants agreed that the treatment algorithms for delirium and catatonia diverge significantly, such that a wrong diagnosis could result in ineffective or even harmful treatment. The benzodiazepine challenge test was reviewed in detail.

In the discussion of akathisia, the role of anti-adrenergic drugs was explained using a model proposed by Loonen and Stahl in 2011. The point was made that anticholinergic drugs have no role in the treatment of this syndrome. For rapid control of severe akathisia, IV propranolol and benzodiazepines are recommended. For more routine treatment, oral propranolol, oral lorazepam, or clonidine are used. Newly proposed treatments hypothesized to work by a different mechanism—5HT2A antagonism—include trazodone and mirtazapine.

Also discussed was the need to establish a routine of evaluating hepatic and renal function of C/L patients before psychotropic medication is recommended, so that dosage and schedule adjustments can be made. Two quick methods for determining glomerular filtration rate and hepatic injury—the Web-based GFR (MDRD) calculator and Hy’s Law—were described.