Hi there! I'm a geriatric psychiatrist, so my input is mainly for patients 65 and up.
1) If you are thinking about starting a benzodiazepine for anxiety and/or sleep, please think again. It is not standard of care and benzodiazepines are on the AGS Beers List of Potentially Inappropriate Medications for Use in Older Adults. There a number of more appropriate options and if you end up referring to me, I'm going to taper them off any benzodiazepines. My go to medications for generalized anxiety disorder and panic disorder in older adults are sertraline 25 mg po daily x 2 weeks, then increase to 50 mg po daily thereafter or escitalopram 5 mg po daily x 2 weeks then increase to 10 mg thereafter. I avoid citalopram since max dose in older adults is 20 mg and I usually need a wider dose range. I also avoid paroxetine given high anticholinergic burden. Buspar is also good for generalized anxiety disorder. If someone needs something for breakthrough anxiety I usually go off-label with very low dose trazodone (like 12.5 mg), low dose gabapentin (100 mg po TID prn anxiety) or if the person is a really healthy 65 with no medical problems, low dose hydroxyzine (like 10 mg).
2) For sleep, please don't use temazepam in older adults or benzodiazepines just for sleep. Also, remember the maximum dose of zolpidem in older women is 5 mg po QHS. I'm not opposed to very short term courses (think 1-2 weeks) of lunesta 1 or 2 mg or low dose sonata in patients without risk factors for falls or cognitive impairment. I like to use low dose doxepin (3 to 6 mg) if no contraindication because it is NOT on the Beers List. Some people do well on ramelteon, but insurance usually requires a prior authorization. Mirtazapine is good for those who also have depression or are losing weight, but remember that it is actually the most sedating at the lowest doses (so if using for sleep, 7.5 mg is more sedating than 15 mg). I do tend to use a lot of trazodone in people without contraindications with pretty good effectiveness.
3) I don't really prescribe stimulants given my demographic, so I can't really comment on that aspect.
I do require a controlled substances agreement be signed and random urine drug screens at least once per year. I also agree that either the PCP OR the psychiatrist should be managing the psychotropic medications and not both. You get into a "too many cooks in the kitchen" situation and in the end it isn't good for the patient. What I've seen happen is patients end up on 2 different SSRIs at high doses-1 from the PCP and 1 from the psychiatrist and I've seen 1 case of serotonin syndrome from this happening.
Also, please, if you are going to start a benzodiazepine, please do not use alprazolam. I beg of you. It has a really short half life and patients end up withdrawing in between doses. This withdrawal looks like increased anxiety symptoms which leads to dose increases and then you get patients on some ridiculously high doses of alprazolam. In psychiatry, we typically use low dose clonazepam or low dose lorazepam. Diazepam has such a long half life that I don't use it in older adults, but for younger folks you are probably ok.
Thank you, PCPs for all you do for our shared patients. Y'all are amazing 🙂.
I share all of these sentiments. I primarily work in geriatrics. I've not had success getting low dose doxepin covered by insurance. I normally use 10 mg. This dose is still low enough to avoid anticholinergic side effects. Evidence shows patients do not develop tolerance to this med. Doxepin is actually one of the best-researched meds for insomnia with long-term data establishing its safety and efficacy. Edit: It can cause weight gain.
I have used citalopram, up to 30 mg, in dementia patients with agitation. There is strong evidence in the literature to support this, in my opinion. I've also had good success treating insomnia in dementia patients with Belsomra. It is FDA indicated for this, and can improve cognition. It's much much safer than z-drugs. As it acts on orexin receptors, does not cause significant respiratory depression, making it safe in patients on opiods or benzos.
Lastly, please avoid high dose fluoxetine in the elderly, particularly in the elderly that are frail. It increases fall risk. Because it's active metabolite, norfluoxetine, has a half life of 2 to 3 weeks, this combined with slower metabolism can cause it to build up in the system, magnifying its adverse affects. It can be activating at high doses, making anxiety worse instead of better. Conversely, in healthier geriatric patients, it's long half life makes it a good choice for depression in patients that sometimes forget to take their meds, at lower doses. It's long half life means any significant discontinuance syndrome is avoided.
Be aware serotonin inhibits platelet function and increases bleeding risk. The risk is even higher with concomitant NSAIDSs. There's some evidence that SSRIs inhibit, via a complex pathway that's not completely understood, the brains ability to regulate or resist arterial blood flow. This increases the risk of hemorrhaging and stroke in the geriatric population.
I've found duloxetine to be well-tolerated and often use it in patients with radicular or neuropathic pain. Avoid this med in advanced liver disease.
Definitely weigh the risk vs benefit of any SSRI, taking into account their comorbidities.
In my anecdotal experience, pregabalin is better tolerated in the elderly than gabapentin.
Regarding doxepin, amitriptyline, etc. (any TCA), patient selection is important. Avoid in patients at risk of committing suicide. TCAs are highly lethal in overdose due to cardiac toxicity. For this reason, I do not fill 90 day supplies of TCAs. I only do a 30 day supply with refills.
