Depression in the Elderly Dr Nick Clarke MD MRCPsych Consultant Old Age Psychiatrist Independent Practice North Downs Hospital, Caterham Nuffield Hospital, Tunbridge Wells November 21st 2018 Primary Care Update, Ardingly Show Ground drnicholasclarke.com

Learning - Antidepressants SAFETY NOTE Pre-treatment postural BP and QT interval check ECG advisable Trazadone 50mg ON max 300mg ON sedative and mild trycyclic drug - lower postural BP and slow urinary output/constipate/blur vision SSRI’s well known – titrate to maximum dose at 2 week intervals – response may be genetically specific SNRI’s equally well known – Mirtazapine 7.5mg ON is overly sedative and ineffective max 45mg ON Duloxetine can start at 20mg OM as Yentreve then 30mg OM max 60mgOM as Cymbalta nausea and withdrawal but neurogenic pain benefit Venlafaxine 37.5mg ON to 225mgON staging a comeback but palpitations, hypo- and hypertension monitoring Melatonin agonist Agomelatine (to avoid adverse effects) 25mg ON to 50mgON Serotonin dual agonist & RI Vortioxetine 2.5mg OD to max 20mg OD (Brintellix) NICE approved after failure of 2 antidepressants – cognitive benefits maybe

Learning- Mood Stabilisers and Enhancers WARNING FOR THE OVER 50’S ONLY not when pregnancy possible Pregabalin 25mg OD to 100mg BD (unlicensed) Carbamazepine 50mg OD to 300mg BD (Tegretol) (unlicensed & much used) Lamotrigine 25mg ON to 100mg BD in 25mg increments fortnightly (for rapid cycling BPD) Valproic Acid 250mg OD increased daily to 500mg TDS (Depakote) licensed Sodium Valproate 50mg OD to 100mg BD to (unlicensed) Quetiapine 25mg OD to 75mg BD/150mg ON(Seroquel) (licensed) Olanzapine 1.25mg ON to 20mg ON (Zyprexa) (licensed) Amisulpiride liquid 25mg ON to 100mg BD (low dose - unlicensed) Lithium carbonate 100mg ON titrated to plasma level 4-8 mmol/L (eg Priadel) (licensed)

What Problems Occur With Drug Treatment? BZ’s falls, sedation, confusion AP’s parkinsonism, falls, stroke risk AD’s anticholinergic/postural BP drop Li tremor, polyuria, dysmnesia, hypothyroidism, rarer renal impact, CNS toxicity

Caution from the Research Antipsychotic drugs may increase cerebrovascular risk Antidepressants and Antipsychotics may increase Alzheimer’s risk

National UK Atypical Antipsychotic Drugs in AD Review – ‘Cochrane’ Report Ballard & Waite Cochrane Database (2006) 1 risperidone and olanzapine treated patients had a higher incidence of serious adverse cerebrovascular events (including stroke), extra-pyramidal side effects and other important adverse outcomes. BUT those taking typical and atypical antipsychotics in AD were no more likely to decline cognitively than untreated patients (only baseline severity predicted decline). Higher drug mortality reflected age and severity. Six month cohort study (n=224) [Livingstone et al JNNP (2007) Laser-AD]

Elderly Consistent Users of Anti-Cholinergic Drugs Show Cognitive Impairment Ancelin BMJ (2006) the groups were a bit imbalanced ie 30 users and 297 nonusers ie users were older (81y vs 75y) tri & tetracyclic antidepressants, older chlorpromazine-type antipsychotics, antihistamines for sedation and allergy, anti Parkinson’s drugs, bladder antispasmodics, digoxin & codeine twice as many 80% users(80%) were diagnosed Mild Cognitive Impairment syndrome after 2y, compared to non-users (35%) age and drug use predicted MCI

Summary- Antipsychotic Drugs & Cholinergic Blockade (Richelson & Souder 2000) clozapine +++ olanzapine++ quetiapine twice risperidone risperidone, haloperidol, pimozide least +

Thank You Professor Paul Francis PhD WCARD Guy’s Hospital Dr Howard Bloom RCGP & Deanery Ramsay Healthcare