Less May be More When it Comes to Prescribing Drugs for Seniors
By BECKY GILLETTE
If you're lucky enough to live long, you've been through a few things such as the death of loved ones. There can be pain leading to taking potentially addictive drugs, and challenges such as cancer, heart disease, financial problems and cognitive decline. It is easy to see how someone could end up with depression, anxiety and insomnia.
Old age is not a protective factor against mental illnesses or substance abuse, said Daniel S. Boyd, MD, a psychiatrist at Lakeside Behavioral Center in Memphis.
“People seek treatment at any age,” said Boyd, who is medical director at one of the largest free-standing psychiatric hospitals in the nation with 364-beds. “With the loss of friends and family, you can see people develop an addiction to alcohol after the age of 60 who had no previous problem. Maybe their spouse died and they turned to alcohol to deal with it. And we don’t metabolize alcohol as well when we get older.”
Older adults may be less likely to acknowledge having depression, a problem exacerbated by the social isolation of the Covid-19 pandemic. People were cut off from their families. They often also had work socialization taken away from them when they had to work at home.
As people age, social determinants get more complicated. At the same time they lose friends, family and colleagues, they get more complicated medically, too.
“That gets tricky, tricky, tricky,” Boyd said. “It is so easy to do polypharmacy with the elderly. It is like once someone of any age overdoses, everything is different going forward. You worry, ‘Could they overdose on this drug? Could they overdose on that drug? What would things look like if they overdosed on this prescription?’ You have to carefully consider what other drugs could help but might also be harmful.”
Boyd’s approach with the elderly is that every drug is guilty until proven innocent. He believes less is more. The more drugs you add to the soup, the more problems there are with drug interactions and complications like how the drug affects other medical illnesses and how the medical illnesses impact the metabolism of the new drug.
“It gets pretty murky,” he said.
Alzheimer's disease was the fifth-leading cause of death among people age 65 and older in 2021, and the costs of caring for people living with dementia are projected to reach $360 billion in 2024 and nearly $1 trillion in 2050, according to the Alzheimer’s Association. About ten percent of people over age 65 are estimated to have Alzheimer’s, the most common form of dementia.
“Unfortunately, the drugs for dementia are so weak,” Boyd said. “The drugs for dementia got approved not because they made anyone better but because people got worse more slowly. So that is pitiful. It is pretty disappointing. I remember in the 1990s I was somewhat excited about the treatment of dementia. They came out with Cognex, which is no longer used, and they came out with Aricept, Exelon, Razadyne and Namenda. We had five drugs come out in ten years, so we thought this was going to be great. Then in the 20-year period since, there has been one disappointment after another for the treatment of dementia.
“Investors lost a lot of money funding drug trials that failed. No new oral medications have been approved. There have been some intravenous drugs approved that have been controversial about the approval process, safety risks, high cost and concerns about accessibility and effectiveness.”
Boyd said when people with mental illnesses get old, that sometimes changes the way their mental illness needs to be managed. Older people may have been on drugs that were effective for many years but no longer work.
“The drugs may work okay until they developed multiple medical problems,” he said. “So that gets tricky, as well.”
Boyd said most classes of medications prescribed for mental illnesses were invented between 1948 and 1963; pretty much everything after that has been children and grandchildren of the original drugs.
Depression is one of the most common mental health issues impacting an estimated 8.3 percent of adult Americans and an increasing number of children. Boyd said the three legs of the stool for the treatment of depression are psychotherapy, exercise and antidepressants.
“It we could put exercise into a pill, it could sell pretty well based on its benefit profile,” Boyd said. “The big daddy of all treatments for severe depression is electroconvulsive therapy. That is our ace in the hole.”
At Lakeside’s 37-acre campus, there are both inpatient and outpatient programs. Boyd said a huge part of what they do is get the diagnosis right.
“Bipolar type one is probably one of the easiest diagnoses we ever make,” he said. “Bipolar type two is one of the hardest to identify or rule out. There can be low grade versions of it.”
The newest building on the campus is the geriatric building, where the number one diagnosis is dementia. The East Unit building is primarily for schizophrenia. The Landing Unit building is focused on treating depression or bipolar disease.
There is also an addiction building for people with any type of substance addictions with the most common being opiates, especially fentanyl, alcohol, and stimulants, including cocaine and crystal meth.
Lakeside Behavioral Center takes most forms of government and private insurance. Patients may not need to be hospitalized for a long time. For example, once patients have detoxed from a drug, they don’t need 24-hour nursing care and may progress to a residential level of care or partial hospitalization program (PHP), which is six hours a day and then later intensive outpatient (IOP) at three hours a day. PHP and IOP are offered on the main campus in Bartlett as well as facilities in East Memphis and Jackson.
With most states now legalizing medical marijuana, many older Americans have turned to cannabis for pain relief or treatment of PTSD. But there are concerns about Cannabis Use Disorder.
“Thankfully it is not scary like fentanyl, but a minority of people get psychologically addicted to it,” Boyd said. “Marijuana is much stronger than in the past, and some people get paranoid on marijuana. A problem is that people sometimes now get fentanyl or crystal meth put in their marijuana purchased on the black market. If you get crystal meth in it, it can make you psychotic. With too much fentanyl, you stop breathing. Once something is legal, people think it is safe. Tobacco and alcohol are legal, but it doesn’t mean they are safe. For that matter, cocaine used to be in Coca-Cola and at one time, heroin was over-the-counter.”