Washington, DC: American Psychiatric Publishing, 2007
829 pages, $74.00 (hardcover)
Authors: Sandra A. Jacobson, Ronald W. Pies, and Ira R. Katz
In elderly patients there can be clinically important changes in medication disposition, altered sensitivity to medication's adverse effects, complicated medication interactions because of polypharmacy and multiple comorbidities, impaired ability to physiologically compensate for even minor "nuisance" effects such as sedation or nausea, and unique difficulties with adherence. These multiple age-related differences may influence the risk/ benefit ratio for treating psychiatric disorders—whether late-life depression, agitation in Alzheimer disease, or substance abuse.
The need to minimize risk and enhance outcome in the real world entails taking all these age-related complications into consideration. There can be tremendous heterogeneity between elderly patients in each of these areas, making medication management a challenge. Often, empirical evidence is lacking, and treatment choices have been based on inferences from clinical trials with younger patients. Given the differences among elderly patients, individually tailored treatments are required, which are guided by both a good evidence base and practical considerations. To assist in meeting the daunting challenge of medication management, the Clinical Manual of Geriatric Psychopharmacology is a valuable, up-to-date resource for any clinician who prescribes for elderly patients.
Following brief introductory reviews of adherence and basic clinical pharmacology, the chapters of this manual are organized into major medication and disorder categories. These begin with antipsychotics, antidepressants, and anxiolytics and end with treatments for movement disorders, cognitive disorders, and pain. Practical suggestions and guidelines are proffered. The basis for these suggestions is usually described—whether they are based on empirical geriatric studies, expert consensus guidelines, inferences from non-geriatric populations, or anecdotal observations.
This is not a textbook of late-life disease physiology, etiology, epidemiology, or neuropharmacology. Only brief mention is made about medications' putative mechanisms of action. Rather, this manual is clearly intended to be of practical and immediate use in answering clinical questions, such as which medication, at what dose, for how long, with what titration schedule, what interactions to consider, which laboratory tests to order, and what adverse effects to monitor for. The various medications in the modern psychiatric armamentarium, across a broad range of neuropsychiatric illnesses, are each specifically reviewed with these practical questions in mind.
Genetic variability in the cytochrome P450 2D6 enzyme is briefly mentioned, although no advice is given on genetic testing—specifically, whom to test and when. In addition, issues related to combining medication management with either psychotherapy or electroconvulsive therapy are not reviewed. Although the manual recommends that physicians be familiar with Medicare Part D and private drug plans, more attention could have been given to this and other practically relevant pharmacoeconomic issues.
Nonetheless, individual medication summaries, recommended treatment algorithms, several rating scales, and tables that list potential drug interactions all enhance the immediate utility of this manual as a reference. Worth reading by anyone who intends to treat elderly patients, the text expertly summarizes current clinical controversies, recommendations, and options.