Kimby Barton, MSc
Assistant Editor, Geriatrics & Aging
- What is the best treatment for agitation and aggression?
- Should cognitively impaired individuals be allowed to determine their own course of treatment?
- What are the best methods for improving cognition in patients with dementia?
- What are the most widely prescribed antidepressants in elderly patients?
These are a few of the topics that were addressed by keynote speakers at the recent conference on psychogeriatrics held at the Baycrest Centre for Geriatric Care. Approximately 200 physicians, nurses, social workers, physiotherapists and occupational therapists attended the conference and took part in the workshops.
Dr. Nathan Hermann (of Sunnybrook and Women's College Health Sciences Centre) opened up the program with his summary of recent studies on the pharmacologic management of agitation and aggression in elderly patients. Dr. Hermann presented data on the effects of typical and atypical antipsychotics, anticonvulsants, b-blockers, hormone therapy, cholinergic therapy and behavioural therapy. According to Dr. Hermann, there has been a move away from the use of typical antipsychotics such as haloperidol and/or thioridazine because they have numerous and unpleasant adverse effects. The most troubling of these are the extrapyramidal side effects that include akathisia, tardive dyskinesia and Parkinsonism. Dr. Hermann's talk was well summarized by a recent study of a randomized controlled trial comparing the effects of treatment with haloperidol (a typical antipsychotic) with treatment with trazodone (an atypical antidepressant), and comparing the results of these treatments with the results of behavioural intervention. In the 149 Alzheimer's disease patients treated over 6 weeks there was no significant difference found between the three treatment groups. Clearly, it must be concluded that although we have made many major advances in the treatment of AD, we have a long way to go.
There are many serious ethical dilemmas facing physicians who treat patients suffering from dementia. A physician must decide whether a cognitively impaired patient is capable of determining his/her own course of treatment. The physician must also balance the needs of this patient against the needs of the patient's caregiver(s). Dr. Carole Cohen (of Sunnybrook and Women's College Hospital) discussed some of the serious issues facing physicians in this position, as well as the difficulties physicians may have in coping with their own fear and frustration in the face of a patient's cognitive impairment. Another interesting point was the recently-raised ethical question about whether or not to enroll a patient in a clinical trial. Is it ethical to place a cognitively impaired patient in a drug trial? If that patient is enrolled, what if he/she is placed in a placebo control group? Should current studies even contain placebo controls, or should they be restricted to measuring the effectiveness of one drug against another? Dr. Cohen concluded her discussion with some guidelines for ethical decision-making. She stressed the need to take a thorough patient history, to involve the patient in the decision-making process, to develop a foundation for basic values, to learn to classify ethical dilemmas, and to enable the physician to identify his/her own fears and frustrations and get help from other people when necessary. This final point is particularly important, as advice from clinicians and colleagues who may have faced similar dilemmas and dealt with similar fears can be invaluable.
"Improving cognition and delaying disease progression are very different," stated Dr. Robert van Reekum (of Baycrest's Centre for Geriatric Care) in the introduction to his presentation on the role of cognitive-enhancing drugs in the treatment of dementia. A variety of drugs have been investigated for their effects in improving cognition in patients with dementia, although realistically only a few have met with real success. Dr. van Reekum pointed out the benefits to and limitations of, a variety of pharmacologic agents including acetylcholinesterase inhibitors, substances that influence neuronal metabolism, anti-inflammatories and estrogen treatment. One very promising result comes from the finding that 1000 IU of synthetic a-tocopherol (vitamin E), taken twice daily, actually delayed negative outcomes. However, he was quick to point out that this study had some flaws in methodology and needs to be replicated and that more research is needed to determine if lower doses of vitamin E will work with the same efficacy. He ended by suggesting that combination therapies and earlier detection and prevention may lead to better treatments in the future.
Dr. Alastair Flint (of the Toronto Hospital and Queen Elizabeth Hospital) ended the session by discussing recent advances in the treatment of mood disorders in the elderly. Dr. Flint stated that there has been a steady increase in the number of prescriptions written for antidepressants for elderly patients from 1993 to 1999, and this increase is mostly due to an increased demand for selective serotonin reuptake inhibitors (SSRIs). These tend to be the most popular prescriptions for elderly patients because they are safe, easy to use, have no cardiotoxic effects, no problematic anticholinergic side effects and are not fatal when taken alone in an overdose. When starting, elderly patients are generally prescribed half the regular adult dose. However, for patients who are not responding to treatment, augmentation of the current treatment is a good option. Substituting with another antidepressant or using electroconvulsive therapy is also possible. Dr. Flint also discussed the problem of noncompliance in elderly patients. Some of this noncompliance may be due to the fact that the side effects of many antidepressants tend to peak in the first few weeks of treatment. He suggested that adding educational messages including such statements as 'take every day' or 'do not discontinue use without consulting a physician' might increase compliance.
