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F. Implementation of Pharmacological Treatments

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Use nonpharmacological approaches first for nonemergency situations and avoid polypharmacy when possible.

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In general, use low starting doses, small dose increases, and long intervals between dose increases.

  • Elderly individuals have decreased renal clearance and slowed hepatic metabolism, which alters the pharmacokinetics of many medications. Moreover, because elderly individuals may have multiple coexisting medical conditions and therefore may take multiple medications, it is important to consider how these general medical conditions and associated medications may interact to further alter the absorption, serum protein binding, metabolism, and excretion of the medication.

  • Some patients may ultimately need doses as high as would be appropriate for younger patients.

  • See Tables 2, 3, 4, and 5 for usual doses and side effects for commonly prescribed first-line medications.

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Table Reference Number
Table 2. Cholinesterase Inhibitors and Memantine
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Table Reference Number
Table 3. Second-Generation Antipsychotics
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Table Reference Number
Table 4. Antidepressants
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Table Reference Number
Table 5. Medications to Treat Sleep Disturbance
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Be cautious about medication side effects that may pose particular problems for elderly patients and those with dementia.

  • Anticholinergic side effects (e.g., from antipsychotics, antidepressants, diphenhydramine) are problematic in individuals with dementia and can also exacerbate coexisting cardiovascular disease, prostate or bladder disease, or other general medical conditions. Anticholinergic medications may also lead to worsening cognitive impairment, confusion, or even delirium.

  • Elderly patients, especially if suffering from dementia, are more prone to falls and associated injuries because of orthostasis.

  • Medications associated with central nervous system (CNS) sedation (e.g., benzodiazepines) may worsen cognition, increase the risk of falls, and put patients with sleep apnea at risk of additional respiratory depression.

  • Use of antipsychotics may be associated with worsening cognitive impairment, oversedation, falls, tardive dyskinesia, and neuroleptic malignant syndrome, as well as with hyperlipidemia, weight gain, diabetes mellitus, cerebrovascular accidents, and death. The elderly, particularly those with Parkinson's disease or dementia with Lewy bodies, are especially sensitive to extrapyramidal side effects.

Table Reference Number
Table 2. Cholinesterase Inhibitors and Memantine
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Table 3. Second-Generation Antipsychotics
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Table 4. Antidepressants
Table Reference Number
Table 5. Medications to Treat Sleep Disturbance

References

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