George T. Grossberg, MD Samuel W. Fordyce Professor Director, Geriatric Psychiatry
• • • •
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine St. Louis, Missouri
Disclosures
Mr. Deardorff reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Grossberg is a consultant/speaker for Acadia, Accera, Actavis/Allergan, Avanir, Baxter, Daiichi Sankyo, Forest, GE, Genentech, Lilly, Lundbeck, Novartis, Otsuka, Roche, and Takeda and serves on safety monitoring boards for EryDel, Merck, and Newron. His department at Saint Louis University receives research support from Cognoptix and Janssen.
Treatment of anxiety disorders—such as panic disorder, social phobia, or GAD—generally starts with SSRIs or SNRIs. Although benzodiazepines are commonly used for anxiety in older adults,56 these drugs are associated with a high rate of adverse effects: increased risk of agitation, falls, impaired cognition, and possibly dementia.57 In general, reserve benzodiazepines for treating acute episodes of severe anxiety in this population.
A particularly prevalent source of anxiety in LTC is fear of falling, which may affect up to 50% of residents and cause them to restrict their activities.58 Interventions such as CBT, exercise, or tai chi may be beneficial, although supporting evidence is lacking.
Pain and sleep management
Addressing pain. Age-related changes in pain perception and difficulty in reporting pain likely contribute to under-recognition of pain in LTC residents. Two useful methods to recognize their pain are to:
observe for pain behaviors, such as facial expressions (grimacing and brow lowering), vocalizations, and body movements (clenched fists)
solicit reports from nurses and other caregivers.59
Self-report may be a reliable indicator of pain for individuals with mild-to-moderate NCDs. Observational pain scales, such as the Pain Assessment Checklist for Seniors with Limited Ability to Communicate, may be useful in severe NCDs.60
The AGS recommends acetaminophen as initial pharmacotherapy to manage persistent pain.61 NSAIDs may be another option, but caution is warranted for patients with acid-peptic disease or chronic kidney disease. Opioids may be considered for severe pain, but otherwise avoid using them.
Sleep disturbances are common in LTC because of physiologic changes associated with aging (altered circadian rhythm), comorbidities (depression), and environmental factors.62 A strong association appears to exist between insomnia and use of sedative-hypnotic drugs, and the AGS Beers Criteria recommend avoiding non-benzodiazepine receptor agonists and benzodiazepines when treating insomnia in older adults.9
Assess factors that may contribute to sleep disturbances, including medications and use of caffeine or alcohol. Have the resident or caregiver document sleep patterns in a sleep diary.
Consider administrating medications at different times (eg, switch donepezil from bedtime to morning) or replace with alternatives (switch from the more anticholinergic amitriptyline to nortriptyline). Ensure that residents engage in physical activity and have at least 30 minutes daily exposure to sunlight.
In addition to behavioral interventions and CBT, treatment in older adults can involve melatonin—which has mixed evidence—or sedating antidepressants, such as mirtazapine or trazodone, in patients with comorbid depression.
Bottom Line
Address psychiatric conditions in older adults in long-term care with thorough assessments and coordination of psychosocial and environmental interventions. Use pharmacotherapeutic agents judiciously because aging, polypharmacy, and multiple comorbidities increase the risk of adverse events.
Related Resources
Palatino LT StdDesai AK, Grossberg GT. Psychiatric consultation in long-term care: a guide for health care professionals. Baltimore, MD: The Johns Hopkins University Press; 2010.
Palatino LT StdThe American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173(5):543-546.
