Dr Ryan Fuller, psychogeriatrician based in Johannesburg, recently presented on the impact of Covid on older people’s mental health. This webinar was made possible by Dr. Reddy’s and the following article is based on his presentation.
To watch the replay click here. https://event.webinarjam.com/go/replay/348/vo34ob8wcvxa61sg.
If you watch the replay and would like a CPD certificate, email John.firstname.lastname@example.org
There is a consensus that the Covid-19 pandemic affects not only physical, but also mental health and well-being. This is changing the priorities of psychiatrists and other mental health professionals.
Principles of old age psychiatry
Mental health problems are common in this patient population, permeated by acute stress reaction / adjustment disorder (such as when an elderly person’s children emigrate), depression, and dementia.
Less common in the elderly are bipolar disorder, schizophrenia and severe obsessive compulsive disorder.
Geriatric syndromes include:
- Intellectual impairment
- Immune deficiency
- Impaired vision and/ or hearing
The following are known as the ‘geriatric giants’ because of their prominence in this patient population:
- Urinary tract infections.
The ageing trajectory is affected by acute illnesses on the background of chronic diseases.
Approximately 50% of Covid patients have neurological symptoms. Covid could possibly enter the brain via the olfactory bulb, through the optic tract or via the blood-brain barrier.
Different groups of patients are likely to be affected by different mechanisms, with different degrees of brain fog, delirium, and post-covid syndrome.
Non-specific presentations are mistaken for ageing and acopia or ‘social problems’, but usually persistent distress has underlying pathology.
Multiple pathologies usually present and there are several causes of varying degrees for a given symptom or problem. Many minor interventions may yield major benefits.
Pharmacotherapy in the older patient
Escitalopram, agomelatine and vortioxetine have been shown to be more effective and more tolerable than all other antidepressants in head-to-head, placebo-controlled studies. Network meta-analysis of 522 trials (116 477 patients) compared 21 antidepressants.
In our practice, we find that escitalopram and venlafaxine are effective for anxiety and major depression. It is usually starting dose 37.5mg twice a day, titrated slowly up to 150mg daily.
Caution: Reversible dose-dependent blood pressure changes and skin rash.
There are many different options and we tend to start with selective serotonin reuptake inhibitor (SSRI)-based therapy (escitalopram 5-10mg nocte/ venlafaxine 150mg mane (severe anxiety)/ fluoxetine 20mg mane (vascular dementia).
Avoid tricyclics and consider the sedating vs neutral vs activating options. Antidepressants are generally stopped if no response after 3/12 weeks. Side effects include falls/dizziness/drug interactions, and tend to be more effective earlier on in the disease course.
Clonazepam: 0.25 – 2mg divided doses, maximum 4mg daily.
Caution: Falls, oversedation, aspiration.
Note: ALL benzodiazepines (BZ) increase the risk of falls and delirium. Shorter-acting BZ are more unpredictable.
Melatonin: 2mg 2hrs before sleep
Caution: None, well tolerated.
Note: ALL Hypnotics (Z drugs) increase the risk falls, delirium.
Sleep hygiene should be attempted for all patients.
Valproate: 200mg up to 1200mg daily, divided doses, can be given in liquid format (5ml = 200mg)
Caution: Oedema, electrolyte imbalances.
Note: Other mood stabilisers have higher autophagy index and are more unpredictable.
Anticonvulsants (Maudsley Guidelines)
Carbamazepine, sodium valproate, lamotrigine, topiramate and gabapentin:
- Trials showed no convincing evidence advocating routine use
- 10% of patients with Alzheimer’s disease (AD) may have occult seizures with variable post-ictal confusional periods. Anticonvulsants may stop seizures and reduce post-ictal confusional states.
- Aggression may respond to carbamazepine but there is a high risk of skin rash, falls, syncope, and sedation.
- Sodium valproate is clinically best at <800mg/day for agitation, but there is oedema risk.
Quetiapine: Low dose, 12.5mg nocte, often divided doses, maximum 150mg daily.
Caution: Oversedation, swallowing problems, Parkinsonism and other extrapyramidal movement disorders with antipsychotic medications (EPSE).
Olanzepine: Low dose, 2.5mg, divided doses, maximum 20mg daily.
Caution: Oedema, oversedation, glycaemic control, especially if used with valproate.
Haloperidol: Low dose, 2.5mg nocte, often divided doses, maximum 10mg daily.
Caution: Oversedation, swallowing problems, Parkinsonism and other EPSE.
Risperidone: Avoid. Relatively high risk for sudden death, cardiac, cerebral events, EPSE, and falls.
Brexpiprazole: 0.5 to 2mg a day divided doses. This offers potential promise, is far less sedating and is associated with fewer EPSE.
Why consider antipsychotics in the older person?
- Behavioural and psychological symptoms of dementia.
- Hyperactive delirium.
- Delusional disorders in older persons.
- Pre-morbid schizophrenia.
- Agitated or resistant mood disorders.
- Palliative care.
Antipsychotic medications’ risk compared to placebo:
- 1.7 times higher risk of sudden death.
- 2-3 times higher risk of falls and hip fractures.
- Up to 4.5 times higher risk of pneumonia.
- Up to 5.7 times higher risk of stroke.
- Up to 2-3 times higher risk of developing parkinsonism or other rarer disorders of muscle stiffness.
EU recommendations when prescribing antipsychotics:
- Psycho-educate – Patient, caregiver, staff
- Obtain valid consent (family or next of kin)
- Start low, go slow, check frequently
- Current thinking favours first-line use of acetylcholinesterase inhibitors (AChEIs)
- Use of antipsychotics must be on individual merit.
Management of vascular risk factors:
- Anti-coagulants/anti-platelets (such as rivaroxaban) for stroke prevention where clinically indicated – no empiric use.
- Anti-hypertensives – aggressive management of midlife and young-old patients, in old-old and oldest-old hypotension should be avoided.
- Hypoglycaemics for diabetes – aim for 4-12, particularly avoiding hypoglycaemia.
- Statins for atheroembolic stroke prevention.
- Anaemia – haemoglobin range 13-16g% is best.
- Hypoxia – therapy with oxygen and CPAP.
It’s not all about medication. Evidence-based enhancement should be considered too. Craniosacral therapy (CST) is a gentle hands-on technique that uses a light touch to examine membranes and movement of the fluids in and around the central nervous system. Relieving tension in the central nervous system promotes a feeling of well-being by eliminating pain and boosting health and immunity. Cognitive behaviour therapy is less effective.
Psychotherapy is difficult but possible and family (systemic) therapy is essential.