ational Institute on Drug Abuse

SERVICES
RESEARCH («)

MONOGRAPH

 

SERIES
c

THE AGING PROCESS
~ AND

 

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
PUBLIC HEALTH SERVICE
ALCOHOL, DRUG ABUSE, AND MENTAL HEALTH ADMINSTRATION

PSYCHOACTIVE DRUG USE

>

 
''''The, Aging Process «,
and
Psychoactive Drug Use

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
Public Health Service
Alcohol, Drug Abuse, and Mental Health Administration

Services Research Branch
Division of Resource Development
National Institute on Drug Abuse
5600 Fishers Lane
Rockville, Maryland 20857

 

For sale by the Superintendent of Documents, U.S. Government Printing Office
Washington, D.C. 20402

Stock Number 017-024-00866-4
'' 

The Services Research Reports and Monograph Series are issued by
the Services Research Branch, Division of Resource Development,
National Institute on Drug Abuse (NIDA). Their primary purpose
is to provide reports to the drug abuse treatment community on
the service delivery and policy-oriented findings from Branch-
sponsored studies. These will include state-of-the-art studies,
innovative service delivery models for different client populations,
innovative treatment management and financing techniques, and

treatment outcome studies.

 

 

 

This report was produced under NIDA contract no. 271-75-1140, Work Order
No. 9 to the Stanford Reséarch Institute, Menlo Park, California 94025.

“aN

NS

a The material herein does not necessarily reflect the o inions, official policy,
y P Pp yi

i or position of the National Institute on Drug Abuse of the Alcohol, Drug

N\A Abuse, and Mental Health Administration, Public Health Service, U.S. De-
partment of Health, Education, and Welfare.

(Adm)

Publication No. ni9-81 3
Printed 1979

li
''FOREWORD PUBL

NIDA is concerned about the dangers of drug misuse or abuse by the elderly and is interested
in assisting in the development of prevention and treatment strategies. In 1975, as a result of
a NIDA-sponsored conference on Drug Use by the Elderly, it became evident that no systematic
attempt to organize, analyze, or evaluate the available data on the drug use problems of the
elderly had been undertaken. To gain a clear understanding of the drug-related problems of
the elderly, the Services Research Branch initiated, with the Stanford Research Institute (SRI),
a three-part study of the available literature.

The objective of the first phase of this study was to examine the literature on the physiological
and psychological changes attendent to the aging process and the relationship of these changes
to drug use. This section should prove to be of greatest value to those dealing directly with
the care of older persons.

The second phase of the study was designed to identify and synthesize information on the pat-
terns of use of psychoactive drugs by the elderly. This section reflects the difficulties of deal-
ing with this topic because of the discontinuous nature of the studies available and because of
the need for systematic research in this area. From the data that are available, it is difficult
to conclude that there is a substantial problem of drug misuse or abuse by the elderly. And
yet, the available data do indicate that the elderly are a major group in the consumption of pre-
scription and over-the-counter drugs, and that particular characteristics of the elderly--
increased incidence of diseases, polypharmacy, etc.--make them prone to drug misuse/abuse situ-
ations. Thus, the findings on use of psychoactive drugs by the elderly warrant a closer exami-
nation of the appropriateness of that use.

The third phase of the study sought to identify operating programs which have been established
to prevent and/or treat the problem of drug misuse or abuse by the elderly. As might be ex-

pected, it was revealed that there are few active programs in the area of specific intervention

and treatment of the elderly psychoactive drug user.

This monograph is composed of three separate reports, each presenting the findings of the three
phases of the study. Each report can be read as a separate document. In addition, two sets
of appendices are included, as well as an annotated bibliography. Appendix A contains a list
of researchers working in the subject area, and appendix B presents a list of programs designed
to intervene in psychoactive drug misuse/abuse by the elderly.

We hope that this monograph will serve as a helpful guide to interested clinicians, researchers,
or relevant governmental and community-based agencies who are responsible for providing assist-
ance to elderly individuals who may be experiencing problems related to drug use.

Michele M. Basen
Services Research Branch
Division of Resource Development

APR 17 1981
'' 

 

2 Ee

 

fndenee hee
''CONTENTS

FOREWORD

THE AGING PROCESS AND PSYCHOACTIVE
DRUG USE IN CLINICAL TREATMENT

Introduction
The Aging Process and Drug Use

Drug Treatment of Emotional
Disturbances or Mental Illness
Drug Treatment of Anxiety
Drug Treatment of Insomnia
Drug Treatment of Depression
Treatment of Physiologically Based Psychoses

Summary
References

PATTERNS OF PSYCHOACTIVE
DRUG USE AMONG THE ELDERLY

Introduction

Prescription Psychoactive Drugs
Patterns of Psychoactive Drug
Use Among the Elderly
Noncompliance, Improper Prescribing,
and Drug-Related Illness and Death

Over-the-Counter Psychoactive Drugs
Summary and Conclusions
References

PSYCHOACTIVE DRUG MISUSE AMONG THE ELDERLY:
A REVIEW OF PREVENTION AND TREATMENT PROGRAMS

Introduction
Method

Programs That Monitor the Diagnosis, Prescription,
and Administration of Psychoactive Drugs
Introduction
The Role of Diagnostic Procedures and Pro-
grams in Reducing Psychoactive Drug Misuse

page

iii

OM PWW

12

14

17
17
18
20
31
36
38

40

43

43

44

44

44
''Contents (Continued)

The Role of Prescription and Administration
Controls in Reducing Psychoactive Drug Misuse
Alternative Methods of Drug Administration
Monitoring the Prescription and Use of Drugs
Drug Utilization Evaluation Programs

Summary

Programs Designed to Intervene in Psycho-
active Drug Misuse Among the Elderly
Programs
Summary

Conclusions
Programs That Monitor the Diagnosis, Pre-
scription, and Administration of Drugs
Programs Designed to Intervene in Psycho-
active Drug Misuse Among the Elderly
Trends

References

Selected Bibliography

ANNOTATED BIBLIOGRAPHY

APPENDIX A: RESEARCHERS INVOLVED IN PSYCHO-

ACTIVE DRUG USE BY THE ELDERLY

APPENDIX B: PROGRAMS SPECIFICALLY DESIGNED TO

INTERVENE IN PSYCHOACTIVE DRUG
MISUSE/ABUSE BY THE ELDERLY

vi

71

87

91
''THE AGING PROCESS AND PSYCHOACTIVE DRUG
USE IN CLINICAL TREATMENT

Barrie Piland

INTRODUCTION

With the growing size of the elderly popula-
tion, and the enactment of Medicare legislation
in 1965, increasing attention has been paid
to health care among the elderly. The rela-
tively slow development of geriatric medicine
as a specialization, however, underscores the
need to closely examine the unique physiologi-
cal changes associated with old age in order
to provide the best and most appropriate med-
ical care possible. In no instance is that

more true than in the case of psychiatric care,

especially when psychoactive drugs are used
as a form of treatment. The potential for
inappropriate use of psychoactive drugs
among elderly patients rests on two primary
bases: 1) diagnoses of psychiatric symptoms
that fail to take into account the unique phys-
iological, psychological, and sociological char-
acteristics of the older person may lead to
improper use of psychoactive drugs; and 2)
even when diagnoses are appropriate, the
prescribing of psychoactive drugs may not
adequately take into account the interaction
between the drug and the altered metabolic
capacities of the older person.

This chapter presents a description of some
of the major physiologic and psychologic
changes which accompany the aging process
and affect the employment of psychoactive
(psychotropic) agents in the geriatric popula-
tion. It provides a review of current thera-
peutic uses and utilization of psychoactive
drugs in the treatment of mental illnesses or
emotional disturbances occurring in the elder-
ly. It also reviews some physical changes

that contribute to emotional problems in the
aged.

A major focus is on the differences in psycho-
active drug dosages required by the elderly
population relative to younger age groups.
Some important drug interaction effects are
also reviewed. It is beyond the scope of this
paper to discuss modes of therapy which are
employed either concurrently with or alterna-
tive to psychoactive drug use.

The substantive portion of the paper is orga-
nized into three sections. The first section
presents a discussion of how the aging pro-
cess can alter the body's ability to process
and utilize various psychoactive drugs. The
second section is devoted to the use of psy-
choactive agents in the treatment of anxiety,
insomnia, depression, and physiologically
based psychosis in the elderly. The third
section provides a summary.

THE AGING PROCESS AND DRUG USE

The aging process produces alterations in
the human system which affect the absorption,
transport, tissue localization, metabolism, and
excretion of drugs. These physiologic changes
do not occur uniformly in persons of the same

‘chronologic age; they vary according to the

number and severity of chronic diseases and
pathological processes present in each individ-
ual (Salzman and Shader 1974). Therefore,
both biologic and chronologic age are impor-
tant considerations when administering drugs
to the elderly person (Lenhart 1976). In
addition, previous use of a variety of drugs
''may cause a predisposition to adverse drug
reactions over a long lifetime. Because of
the above factors, response to treatment with
drugs actually becomes more diverse with
increasing age (Lamy 1974). Despite the het-
erogeneity found in the elderly population,
however, certain changes are predictable in
kind, if not in degree, and have their effects
on the quantity and duration of drug avail-
able at the receptor site (Holloway 1974).

The central nervous system, which serves as
the receptor site for psychotropic agents, is
known to be the most sensitive in terms of
age-related altered responses to drug agents.
In addition to the accumulation of pigment,
decreases in nitrogen and phosphorous, and
increases in sulfur and lipids, the aging brain
undergoes a loss of neurons which varies ac-
cording to phylogenetic area. Resultant dis-
turbances in interaction and balance among
the various cerebral centers lead to deterior-
ation in integrated brain functions. This
unequal rate of neuron loss is primarily re-
sponsible for the altered reactivity and sensi-
tivity of the aged brain. Paradoxical or
abnormal reactions to drugs stem from an im-
paired central nervous system. It is known,
for instance, that in elderly patients the
action of stimulants is lessened whereas the
action of depressants is enhanced (Holloway
1974; Lamy 1974; Bender 1974; Salzman et
al. 1976; Salzman and Shader 1974).

The sedative effect of many psychotropic
agents is also more pronounced in older than
in younger persons. This is probably due
to increased central nervous system sensitiv-
ity, to decreased brain capacity, or both
(Salzman and Shader 1974). When fewer ac-
tive cells are present to act as receptors,
the dose per milligram of active tissue is in-
creased, presenting difficulties in determining
the amount of drug being absorbed and util-
ized (Lenhart 1976). The aging central nerv-
ous system is also especially vulnerable to
cerebral hypoxia resulting from hypotension
and vascular disease (Holloway 1974). Oxy-
gen consumption, a measure of cerebral metab-
olism, decreases with age and is probably
the result of arteriosclerosis (Salzman and
Shader 1974). With increasing age there is
an accompanying decrease in total systemic
perfusion. A reduction in cerebral blood flow
occurs normally with aging but is quite pro-
nounced in the cerebral arteriosclerotic indi-
vidual (Holloway 1974). A wide variation in
the clinical effect of psychotropic drugs stems
from alterations in cerebral metabolism
(Salzman and Shader 1974).

Venous congestion in elderly patients, due to
reduced cardiac reserves, reduced cardiac
output, and frequently diminished vascular

elasticity associated with local atherosclerosis,
serves to increase the circulation time of
drugs, thus impairing their distribution and
often delaying their excretion. Diminished
cardiac output causes blood flow redistribu-
tion to the cerebral and coronary circulation
at the expense of peripheral flow to the kid-
ney and liver (Lenhart 1976; Salzman and
Shader 1974; Baker 1974; Bender 1974).

A diminished arterial flow can hamper absorp-
tion of orally administered agents by reducing
the number of available active cells, thus
causing a reduction in the size of the absorb-
ing surface. It also reduces the availability
of enzymes necessary for maintaining trans-
port mechanisms in the gastrointestinal tract.
In this manner passive absorption across the
intestinal epithelial membrane is reduced
(Stotsky 1970; Bender 1974). Other factors
related to the aging process also interfere
with absorption. The reduction in mainly
intracellular fluid volume, due to generalized
loss of body weight, may alter absorption
because of the accompanying increased sodium
and decreased potassium levels (Lenhart 1976).
The diminished acidity of gastric juice affects
the degree of solubility and state of ionization
of drugs, and a slowed stomach emptying time
influences the rate at which drugs absorbed
mainly from the intestine are made available
to the duodenum (Holloway 1974; Lamy 1974).

Drug action is also affected by changes in
blood components. Serum albumin levels

frequently decline in the elderly so that

protein-bound drugs are forced to compete
for binding sites. This increases the ratio
of free to bound drugs and results in en-
hanced drug toxicity. Both benzodiazepine
antianxiety agents and tricyclic antidepres-
sants are enhanced in this manner (Salzman
and Shader 1974; Salzman et al. 1976; Lamy
1974).

Aging is accompanied by the replacement of
functional tissue by fat, varying in increase
from 18 to 36 percent in men and from 33 to
48 percent in women from age 18 to 35 years
old. Psychotropic agents, which are mainly
highly lipid soluble compounds, tend to be
drawn by and subsequently to become local-
ized in body fats. As mentioned above, cen-
tral nervous system tissue increases in lipids
with aging. Storage of lipid soluble drugs
results either in their decreased intensity or
increased duration of effect before they slow-
ly return to circulation (Holloway 1974;
Lenhart 1976; Stotsky 1970).

Unlike drugs of low lipid solubility, which
are promptly excreted through a kidney with
healthy glomerular filtration, the highly lipid
soluble agents must be reabsorbed by the
''renal tubule and then converted to less lipid
soluble metabolites (Bender 1974). Most psy-
chotropic agents are converted to water-
soluble compounds, often in the form of a
glucuronide or sulfate conjugate, before excre-
tion by the kidneys or other organs (Friedel
and Raskind 1976), The rate at which this
process occurs is another major determinant
of the duration of activity such drugs have
through the regulation of the serum or plasma
level of these agents (Stotsky 1970). This
biotransformation procedure is centered in
the microsomal fraction of the liver cells and
is dependent upon the level of enzyme activity
in this area. Evidence strongly suggests
that there is a varying reduction in microsomal
metabolism with increasing age. Either be-
cause of a decrease in the rate of synthesis
or because of an alteration in enzyme struc~
ture, the activities of several circulating en-
zymes, such as cholinesterase, are diminished
(Lamy 1974; Lenhart 1976).

The aging kidney experiences reductions in
renal blood flow, glomerular filtration, and

tubular secretory capacity. The functional
decrement may range from 20 percent to 50
percent in relatively healthy older persons,
and only a few persons 70 years and older

are without some degree of renal pathology.
Diminished hepatic and renal function can

each prolong the plasma half-life of drugs

with a resultant increasing risk of drug tox-
icity and drug interactions (Lamy and Vestal
1976; Bender 1974; Lamy 1974).

Homeostatic capability declines with increasing
age. The adjustments of secondary systems
and their effect on drug activity are dimin-
ished and only a small change is needed to
create disequilibrium in one or several pro-
cesses. The aged population's impaired capac-
ity to handle orthostatic stress, for example,
can be further taxed by the administration
of phenothiazines and antidepressants. Pos-
tural hypotension is very often the result
(Bender 1974; Baker 1974; Holloway 1974).
Abnormal chain or paradoxical drug reactions
can stem from an impaired reserve capacity
of tissues that are less able to withstand tem-
perature changes as well as fluid and electro-
lyte loss (Lenhart 1976; Baker 1974).

Generally, the combined effects of aging on
the various systemic functions act to slow
down or impair the body's processing of psy-
chotropic drugs; accordingly, these agents
have a prolonged action time before they are
eliminated from the system, although the de-
gree of variation differs among individuals.
Also, the wastage of muscle tissue and subse-
quent fat substitution which accompanies
aging results in a decrease in total body vol-
ume. Both factors indicate the necessity for

lower dosage levels (Hall 1975; Baker 1974;
Freeman 1974).

Finally, the practice of polypharmacy in treat-
ing elderly patients is common and is brought
about by multiple pathologic conditions occur-
ing with a myriad of symptoms. However,
this practice may invite an increase in ad-
verse drug reactions as well as decreased
compliance (Davison 1975).

In summary, changes in the central nervous
system, arterial and venous flow, blood com-
ponents, the ratio of functional tissue to fat,
renal flow, and homeostatic capability can
have significant effects on the metabolism and
elimination of drugs in elderly patients. The
specific nature of the effects those factors
may have will depend upon the characteristics
of individual drugs, drug groups, and drug
combinations.

DRUG TREATMENT OF EMOTIONAL
DISTURBANCES OR MENTAL ILLNESS

DRUG TREATMENT OF ANXIETY

Anxiety is a common reaction to the various
problems and dilemmas accompanying the aging
process and may coexist with feelings of de-
pression. Anxiety may be manifested in hypo-
chondriasis or it may be the cause of agitated
or hostile, aggressive behavior. A chronically
anxious state can add to the severity of de-
pression, insomnia, and behavioral reactions
as well as have a worsening effect upon con-
current physical disease states (Lifshitz and
Kline 1970).

Antianxiety agents, such as minor tranquil-
izers or anxiolytics are a group of chemically
heterogeneous compounds that produce similar
clinical effects and that possess, in varying
degrees and frequently in combination, anxi-
ety-relieving, sedative, and skeletal muscle-
relaxant properties (Fann et al. 1976; Markoff
et al. 1974). It should be noted that hypnot-
ics, or sleep-producing agents, are to a con-
siderable degree interchangeable with anti-
anxiety agents in their effect, depending on
dosage level. They share the pharmacological
property of central nervous system depression
whereby progressively larger doses, the
amount varying from agent to agent, can lead
to drowsiness, sleep, and finally a coma state
(Greenblatt and Shader 1974a).

Although not ideal agents, the benzodiazepine
derivatives are considered the most effective
of all currently available anxiolytics (i.e.,
anxiety-reducing agents) for both young and
old patients and have replaced barbiturates
''and the propanediols (e.g., meprobamate and
tybamate) as the antianxiety agents of choice.
Chlordiazepoxide (Librium), diazepam (Valium),
and oxazepam (Serax) are the most frequently
used benzodiazepines (Markoff et al. 1974;
Greenblatt and Shader 1974b; Salzman et al.
1976). Each of the derivatives possesses, in
varying degrees, anticonvulsant, sedative-
hypnotic, anxiolytic, and muscle-relaxant ef-
fects (Ayd 1975). They have moderate ad-
diction potential, and overdoses usually do
not result in serious poisoning. When used
to treat anxiety they are less apt to cause
undesired drowsiness than equivalent doses
of either barbiturates or meprobamate
(Greenblatt and Shader 1974a). However,
elderly persons are more susceptible to their

“ sedative side effects (Salzman et al. 1976).
Another advantage of the benzodiazepine
derivatives is that, unlike barbiturates, they
do not alter the blood levels of concomitantly
administered tricyclic agents, which are some-
times needed during initial treatment of endog-
enous depression (Shader 1976). Certain
side effects that accompany central nervous
system depression are more dangerous for
elderly persons. Muscle weakness and ataxia
are especially threatening to a population more
predisposed to falls. Dysarthria (difficulties
in speech articulation) may also occur. Older
persons are also more vulnerable to a paradox-
ical reaction associated with the use of Librium,
sometimes referred to as "Librium rage." As
the name suggest, irritability and hostility
are somehow increased (Lenhart 1976; Appleton
1976). Diazepam may have the strongest
antidepressant effect of these agents, at least
for elderly males with mild anxious depres-
sions (Salzman et al. 1976; Fann and Wheless
1975). Fairly recent findings about oxazepam
suggest that it may offer unique benefits to
the elderly population. It, unlike chlordiaze-
poxide and diazepam, is rapidly biotransformed
to an inactive product, and because it does
not accumulate and build up toxic effects, it
is the more appropriate drug choice for
chronic therapy (Greenblatt and Shader 1974a;
Merlis and Koepke 1975),

The use of antihistamines, such as hydroxy-
zine (Vistaril, Atarax), as either antianxiety
agents or as hypnotics, particularly in elderly
patients, is inadvisable. These agents, metab-
olized by the liver, have anticholinergic effects
that can produce the already described symp-
toms of atropine-like toxicity. Their nonspe-
cific sedative effects are only a secondary
pharmacologic property (Greenblatt and Shader
1975; Greenblatt and Miller 1974; Modell 1974).
The propanediols, such as meprobamate (Mil-
town) and tybamate (Tybatran), are another
group with questionable efficacy and safety
in the control of anxiety. Meprobamate usage
can easily lead to addiction, and overdoses

can cause serious poisoning (Greenblatt and
Shader 1974b).

Barbiturates are a poor drug choice when an
antianxiety effect is needed. Their efficacy
in this area is highly variable and often inade-
quate as their effect is to produce a general
central nervous system depression which has
little focus on anxiety (Greenblatt and Shader
1974a).

DRUG TREATMENT OF INSOMNIA

Insomnia, a very common complaint of elderly
patients, is typified by symptoms such as
increased time required to fall asleep, fre-
quent nightly awakenings, increased frequency
of dreaming, lighter sleep, and an increase
in total bed time with an accompanying de-
crease in total sleep time. Findings of all-
night electroencephalographic recordings sup-
port the notion that stages of deep sleep
diminish steadily in their intensity with ad-
vancing age (Amin 1976). Oxazepam, because
of characteristics described earlier, is thought
by some to be helpful for complaints centering
around restlessness at night and/or early
morning awakening; it is rapidly absorbed
and has a relatively short duration of action.
Use of oxazepam is contraindicated in cases
where patients have been chronic barbiturate
or other soporific users since previous experi-
ence with those drugs diminishes the effective-
ness of ordinary doses of oxazepam (Ayd 1975).
Dosage levels are best administered in accord-
ance with the tolerance of each individual
patient.

Barbiturates have serious limitations when
used as hypnotics for elderly patients. Ha-
bituation and addiction can easily occur at
doses only slightly higher than prescribed,
and intentional or unintentional overdose can
easily cause deep coma and death. Through
possible depression of folic acid and vitamin
B-12 levels, they may cause depression, toxic
psychosis, and apparent dementia. Their use
is contraindicated during pneumonias or cere-
brovascular episodes due to their depressant
effect on vital brainstem centers. Their ten-
dency to accumulate and produce toxic delirium
makes them a poor choice for patients with
impaired renal function (Greenblatt and Shader

1974a; Morrant 1975; Dawson-Butterworth
1970). All barbiturates, but especially
phenobarbital, accelerate liver microsomal

metabolism of drugs (such as certain of the
antipsychotic phenothiazines, the tricyclic

antidepressants, warfarin, coumarin, and di-
phenylhydantoin), resulting in a lowering of
their clinical effects (Fann 1976; Ayd 1975).

The piperidinedione hypnotics, glutethimide
(Doriden) and methyprylon (Noludar), are
''similar to barbiturates in chemical structure
and should also be avoided; glutethimide is
likely to cause cerebellar signs and osteo-
malacia due to vitamin D deficiency, as well
as being extremely difficult to treat in over-
dose situations (Morrant 1975; Dawson-
Butterworth 1970). It also accelerates liver
microsomal metabolism, and addiction can eas-
ily occur (Greenblatt and Miller 1974). Bar-
biturates, glutethimide, and methyprylon are
potent REM depressors, and withdrawal may
lead to REM rebound with intensified insomnia
and nightmares. REM rebound in elderly pa-
tients is particularly undesirable, since angi-
nal attacks and cardiac arrhythmias, as well
as confusional episodes with vivid hallucina-
tions, occur. with greater frequency during
REM sleep. Patients experiencing REM re-
bound symptoms may return to drug use as
a source of relief and in this manner build
up dependency (Modell 1974; Amin 1976;
Greenblatt and Miller 1974).

The quinazolone derivative methaqualone
(Quaalude) also causes intense REM depres-
sion, as well as physiological addiction when
administered in essentially therapeutic doses.
Lately it has been recognized as a drug pos-
sessing strong abuse potential, and there is
some evidence that it accelerates liver micro-
somal metabolism (Fann and Wheless 1975;
Modell 1974; Greenblatt and Miller 1974).

Chloral hydrate, predecessor to the barbitur-
ates and in use for over a century, does not
appear to depress REM sleep, although some
reports are conflicting. It acts fairly quickly
with rapid metabolism in the liver as well as
other tissues; therefore, it is only contrain-
dicated in'cases where renal or hepatic disease
are marked and in patients with severe car-
diac disease. This and other chloral deriva-
tives are seldom abused or utilized in cases
of intentional overdose, possibly because of
their gastric irritant properties. These are
the only hypnotics that can cause protein-
binding displacement, leading to an increased
concentration of the pharmacologically active
unbound faction of the displaced drug. This
results in a transient potentiation of the other
protein-bound drugs. When a chloral deriva-
tive is concomitantly administered with warfar-
in or bishydroxycoumarin, transient excessive
hypothrombinemia can occur. Similar interac-
tions with drugs such as diphenylhydantoin,
phenylbutazone, or imipramine could potentially
occur but are as yet inadequately documented
(de Groot 1974; Morrant 1975; Modell 1974;
Greenblatt and Miller 1974).

The benzodiazepine flurazepam has little ef-
fect on REM sleep, and like chloral hydrate,
only minimally accelerates liver microsomal
metabolism. In terms of abuse and overdos-

age it may be the least hazardous of all the
hypnotics. It does produce a reduction in
slow-wave sleep, however. Insomnia associ-
ated with hyperthyroidism and uremia is
accompanied by a reduction in slow-wave
sleep, and flurazepam may further complicate
this type of insomnia. It is possible that
flurazepam could produce cumulative or resid-
ual clinical effects. Its major metabolite,
which possesses significant central nervous
system depressant activity, accumulates sig-
nificantly and remains in the blood for sev-
eral days after drug therapy termination
(Amin 1976; Greenblatt and Miller 1974).

DRUG TREATMENT OF DEPRESSION

Depression, when appearing in older persons,
shares many characteristics of the illness ex-
perienced by younger persons. In both old
and young, depression has an episodic nature,
a tendency to remit, and a potential for favor-
able immediate outcome (Prange 1973; Epstein
1976), although depression may vary in sever-
ity and duration. In cases of situational or
reactive depression, a person may be respond-
ing to a temporary loss or rejection; the fail-
ure of the depressive syndrome to spontane-
ously remit after a year or more can be an
indication of pathology (Greenblatt and Shader
1975). In cases of endogenous depression,
the onset of depression may occur without
obvious cause or sufficient basis. to explain
the severity of symptoms (Greenblatt and
Shader 1975).

Depression in elderly patients is often mis-
diagnosed. Incontinence, confusion, disori-
entation, and apathy are symptoms in both
senility and depression (Fann and Wheless
1975). Undernutrition, which can result from
a depressed, apathetic state, is often the
cause of a confusional state (Epstein 1976).
A worsening depression can produce signs of
retardation, memory defect, and. cognitive
impairment. Moderate to severe depressions,
with minimal organic brain disease, are often
misdiagnosed as chronic brain disease accom-
panying either cerebral arteriosclerosis or
senile brain disease (Fann and Wheless 1975;
Epstein 1976).

Depression in elderly patients may be unrec~-
ognized as well as misdiagnosed. The clinical
picture for these patients more typically lacks
the dramatic presentation of a younger de-
pressed person. An air of apathy, inertia,
introversion, self-deprecation, and unwilling-
ness to communicate are often regarded as
normal behavior for'an elderly person. Even
when depression is identified it is often
thought of as a normal or realistic response
to the physical and emotional stresses accom-
panying aging (Hodkinson 1975). Endogenous
''or manic-depressive disorders coinciding with
chronic physical illness can be overlooked
and left untreated in this manner (Epstein
1976).

Approximately 20 percent of the population
65 years and older suffers from some form of
‘psychiatric disorder, and it is important to
realize that functional disorders, whether pre-
cursors to chronic brain disease or not, pre-
dominate in those over age 70. The greater
incidence of depression with advancing age
is not surprising. The aged population suf-
fers the loss or diminution of occupation, in-
come, status, health, and loved ones at a
time in life when adapting and coping abilities
are also diminished due to cerebrophysiologic
changes. Sociopsychologic changes which
accompany advancing years constitute a more
frequent exposure to depression-precipitating
circumstances. The elderly person is called
on to cope when recuperative ability, resili-
ence, energy, and general homeostatic capac-
ity are reduced. Reactive depressions to
illness, bereavement, and other losses are
common, but many older persons ‘also have
had a history of recurring depressive episodes
throughout their life. Also, latent or existent
neurotic conditions can be aggravated by old
age (Fann and Wheless 1975),

From the above, it can be concluded that the
depressed older individual can have a variety
of symptoms emanating from a wide range of
conditions and circumstances. Prompt treat-
ment can be essential for elderly persons be-
cause the illness may be severe, prolonged,

and likely to recur. The risk of suicide is

considerable, and attempts by elderly persons
are often successful (Young 1972).

Treatment of depresion in elderly persons is
generically similar to treatment of younger
patients. Antidepressant drugs are the major
treatment choice for moderate and severe de-
pressions. Accurate diagnosis is essential |
for appropriate treatment choice. Endogenous
depression may be manifest on a constant
basis or it may be only one phase of a "bi-
polar" affective (manic-depressive) disease;
psychomotor agitation and hyposomnia are
characteristic of the former, while psycho-
motor retardation and hypersomnia character-
ize the latter (Greenblatt and Shader 1975;
Shader 1976). Middle-aged or elderly patients
with endogenous depression may have one or
more of the following characteristics: pro-
longed or severe symptoms; a history of de-
pressive episodes; a family history of similar
symptomatology; no obvious precipitating
cause; anorexia or weight loss; early morning
awakening; and sexual disinterest or dysfunc-
tion (Greenblatt and Shader 1975). Prompt
and energetic treatment of endogenously de-

pressed elderly patients is particularly imper-
ative because the condition can last for ‘2
years or longer. It is also accompanied by a
high suicide risk, potential malnutrition, and
subsequent permanent memory impairment and
the incurring of an acute confusional state
(Kral 1976).

The tricyclic antidepressants currently are
the preferred drug agents for treatment of
endogenous depression, followed by the gen-
erally less effective and more toxic monoamine
oxidase (MAO) inhibitors (Young 1972;
Greenblatt and Shader 1975; Lifshitz and Kline
1970; Fann and Wheless 1975; Fann 1976;
Markoff et al. 1974; Medical Letter on Drugs
and Therapeutics 1975), The tricyclics have,
since their introduction in 1958, retired the
MAO inhibitors to a fairly minor role (Fann
and Wheless 1975; Frazier 1976; Fann 1976).
The tricyclics act to block the neuronal up-
take into presynaptic nerve endings, thus
having direct action on sympathomimetic
amines in the brain (e.g., norepinephrine)
and indirect action on catecholamine-releasing
substances (e.g., tyramine). Although both
the tricyclics and MAO inhibitors specifically
act on the biology of amines, the former has
little inhibitory effect on monoamine oxidase
(Frazier 1976). A wide variety of tricyclics
are currently available in the United States.
Some are nonsedating, such as protriptyline,
imipramine, desipramine, and nortriptyline,
and are more appropriate for treating retarded
or withdrawn depressions characterized by
hypoactivity and hypomentation. Those with
a sedative effect, such as amitriptyline or
doxepin, are more therapeutically ap propriate
for treating agitated or hyperactive depres-
sive states (Fann and Wheless 1975; Fann
1976; Hollister 1976). With the exception of
protriptyline, which acts as a stimulating
drug, all possess anxiolytic properties which
are of great help when endogenous depression
is accompanied by anxiety. Excepting the
more potent protriptyline and nortriptyline,
all possess about equal potency on a milligram
basis and a narrower, barely threefold, dose
range, compared to the larger ranges of
other psychotropic drugs (Prange 1973).
There is considerable lag time, usually from
1 to several weeks, before tricyclic antidepres-
sants attain a sufficient blood level for thera-
peutic results (Fann 1976; Greenblatt and
Shader 1975; Fann et al. 1976). The lag time
can be interpreted as a serious drawback in
the treatment of extremely depressed, strongly
suicidal patients (Fann 1976; Hollister 1976).
Attempts to shorten this period through simul-
taneous administration of stimulant compounds
or thyroid hormones and androgenic agents,
as well as parenteral administration (i.e., of
amitriptyline and imipramine), are either con-
sidered not promising for a routine practice
''or evidence is indeterminate concerning their
effectiveness.

It is generally recommended that dosage levels
of tricyclic antidepressants begin at a lower
level and increase at a more gradual rate when
administered to elderly persons (Fann 1976).
However, a strictly rigid adherence to this
recommendation could sometimes prevent older
patients from receiving a sufficiently high,
yet still tolerated therapeutic level (Prange
1973). Genetic differences in the ability to
concentrate tricyclics do exist and it is wise
to routinely monitor patient blood levels
(Frazier 1976). Prescription amounts of tri-
cyclics should never exceed roughly a week's
supply at one time, as overdoses are often
fatal. Elderly patients deemed suicidal or
forgetful should not be allowed to self-
administer these agents (Hollister 1976;
Schmidt 1974). The affinity of tricyclics for
tissue and plasma proteins makes them nearly
impossible to dialyze in emergency situations
(Frazier 1976).

The potential side effects of the tricyclics
are numerous. They, along with all antipsy-
chotic agents as well as antiparkinsonian
drugs, possess anticholinergic properties
which can produce atropine-like effects, among
these a central anticholinergic confusional
reaction which occurs more commonly in elder-
ly patients. Symptoms are a marked disturb-
ance of short-term memory, disorientation,
impaired attention, anxiety, and visual and
auditory hallucination (Davis 1974; Hollister
1976). This deliriform psychotic state is
often mistakenly interpreted as an increase
in psychiatric symptoms, and dosage levels
are elevated still further (Fann 1976). The
elderly, due to a diminution of liver metab-
olism rates, are particularly vulnerable to
peripheral anticholinergic effects as well
(Prange 1973). A dry mouth, often consid-
ered the least dangerous atropine effect, can
cause problems with dentures, can increase
the wearing away of the gingiva and natural
teeth, and if severe enough can cause acute
parotitis. Another effect, the inhibition of
bowel motility, can lead to constipation, fol-
lowed by fecal impaction and paralytic ileus.
Micturition can easily develop into acute reten-
tion of the urine, and both urinary and bowel
problems can worsen anxiety in compulsive
patients. Paralysis of visual accommodation
can aggravate unsuspected and untreated
cases of narrow-angle glaucoma. These drugs
are particularly hazardous in patients with a
history of seizures, urinary retention, pro-
static hypertrophy, increased intraocular pres-
sure, narrow-angle glaucoma, or intestinal
obstruction (Greenblatt and Shader 1975; Fann
1976; Morrant 1975; Schmidt 1974; Hodkinson
1975). Mydriasis as well as tachycardia can

also occur (Medical Letter on Drugs and Ther-
apeutics 1975). Dryness of the mouth, along
with two other common side effects, drowsi-
ness and blurred vision, seems to wear off
relatively soon after treatment initiation
(Schmidt 1974). It is worth mentioning that
the sedating antidepressants as well as the
antipsychotics can indirectly cause broncho-
pneumonia in elderly patients by causing up-
right motionless daytime dozing with resultant
decrease in respiratory efficiency (Morrant
1975). .

 

When tricyclics are first administered they
also exert a hypotensive effect, causing a
danger of orthostatic hypotensive episodes
which can easily lead to falls and subsequent
injuries in frail older patients. Particularly
when cerebral or myocardial ischemia is pres-
ent, a sudden drop in blood pressure can
produce serious infarctive lesions (Young 1972;
Fann 1976; Morrant 1975). Great caution must
be used in administering tricyclics to such
patients, and especially to those with a his-
tory of arrhythmias. Tricyclics are known
to produce changes. in the EKG, such as a
lengthened Q-T interval and the production
of prominent U-waves. Thus ventricular
repolarization is prolonged and the falling of
a ventricular premature contraction on this
extended period may set off ventricular tachy~
arrhythmias. Evidence exists that death from
arrhythmias can occur in overdose situations
involving patients with cardiac disease. The
use of these drugs only rarely precipitates
congestive heart failure and cardiomyopathy.
All patients with any preexisting cardiac
disease or abnormalities should be given a
base-line electrocardiogram before tricyclic
administration is begun and elderly patients
in particular should be carefully screened
(Lutz and Wayne 1976; Hollister 1976). Par-
kinsonian syndrome manifestations such as
tremor or akathisia (inability to sit still) can
develop on high dosage levels of tricyclics.
The best treatment is to lower the dosage
level (Morrant 1975; Prange 1973). ' All major
side effects of the tricyclics can be relieved
by terminating their use (Schmidt 1974).

Patients on tricyclics who are taking antihy-
pertensives such as guanethidine (Ismelin) |
and bethanidine, which block the adrenergic
neuron, will experience a reversal of the anti-
hypertensive’ effect 12 hours or more after
tricyclic administration (Morrant 1975; Davis
et al. 1973; Fann 1976; Fann 1973; Greenblatt
and Shader 1975). The norepinephrine pump
in the adrenogenic neuron membrane is
blocked by the tricyclics so that guanethidine
is not carried to its active site within the
neuron. Although all tricyclics at least par-
tially antagonize this agent, some evidence
suggests that doxepin may do so only
''minimally. Because the antihypertensive
agent methyldopa (Aldomet) does not utilize
the norepinephrine pump for transport to the
neuron, its activity is not affected by the tri-
cyclic compounds (De Groot 1974; Prange 1973;
Greenblatt and Shader 1975).

The activity of tricyclics is potentiated by
thyroid hormone and by the enzyme inhibitor
methylphenidate, the latter inhibiting micro-
somal enzymes and thereby slowing tricyclic
metabolism with a resultant rise in tricyclic
blood levels. Recently these combinations
have been used to enhance the effect of tri-
cyclics, but their efficacy and safety is still
questionable, Secobarbital induces enzymes,
with a resultant lowering of tricyclic blood
levels. Major tranquilizers and estrogens
also inhibit metabolism. Results from studies
on how tricyclic drugs alter the metabolism
of other agents are contradictory and incon-
clusive (Shader 1976; Greenblatt and Shader
1975; Frazier 1976). However, pertaining to
their effects on absorption, it is known that
by reducing gastrointestinal motility they de-
lay or reduce the absorption of phenylbuta-
zone and levadopa. Both the tricyclics and
the antipsychotic agents called phenothiazines
increase their own absorption by decreasing
gut motility. Through their slowdown of the
gastric emptying process they may, in turn,
enhance the absorption of digoxin (Hall 1975;
MacLennan 1974; Greenblatt and Shader 1975).

It should be noted that in the case of severely
agitated or markedly paranoid depressed pa-
tients, or those with suspected schizophrenia,
it may be necessary to treat with a tricyclic
and an antipsychotic drug combination
(Schmidt 1974). One of the phenothiazines,
thioxanthenes, or butyrophenones is appropri-
ate but must be used with extreme caution
due to the combined anitcholinergic properties
of these drugs (Fann and Wheless 1975; Kral
1976; Schmidt 1974). Amitriptyline and per-
phenazine are the most commonly prescribed
combination for this purpose (Shader 1976).

The MAO inhibitors, e.g., isocarboxazid, par-
gyline, phenelzine, and trancylcypromine,
although seldom the initial treatment choice
for elderly patients, are sometimes successful
in severe depressions where treatment with
tricyclics has failed to gain desired results
(Fann 1976; Frazier 1976; Webb 1971; Kline
1974). These agents increase norepinephrine
at the receptor site by blocking its intracellu-
lar degradation (Appleton 1976). The correla-
tion between a decrease in MAO levels and
antidepressant effects as well as the finding
that brain MAO activity increases with age
are indicators of the efficacy these drugs
possess for certain elderly patients (Fann

and Wheless 1975; Fann et al. 1976; Nies et
al. 1973).

The changeover from a tricyclic to an MAO
inhibitor should be made only after a 10- to
14-day drug-free interval (Prange 1973; Webb
1971; Schmidt 1974). Concurrent use of the
two drug classes is not recommended, although
there is some dispute over the reliability of
evidence supporting their enhancement of each
other's toxicity. However, hyperpyretic
crises (high fevers), severe convulsions, and
death have been reported as a result of this
combination (Greenblatt and Shader 1975;
Schmidt 1974; Medical Letter on Drugs and
Therapeutics 1975). A lag time before onset
of therapeutic action also seems to occur with
these agents--although its existence is not
uniformly accepted. Patients displaying psy-
chomotor retardation particularly benefit from
these drugs. However, immediately after
treatment onset, the anxiety of a more agi-
tated patient may either be increased or go
unrelieved (Fann 1976; Markoff 1974; Kral
1976).

 

The potential side effects and the necessary
precautions involved with the administering
of MAO inhibitors are numerous. Among the
possible side effects are anxiety, agitation,
manic symptoms, worsening of psychotic epi-
sodes, constipation, edema, nausea, diarrhea,
abdominal pain, weakness, drowsiness, tachy-
cardia, blurred vision, impotence, chills, and
headaches (Fann and Wheless 1975). These
agents may block cardiovascular response,
increasing the exercise tolerance of patients
with angina pectoris and myocardial insuffi-
ciency to the point, if unwarned, of risking
myocardial infarction (Webb 1971). Hypoten-
sion is also a frequent problem, and use of
these drugs can lead to hepatocellular damage
as well (Appleton 1976; Medical Letter on
Drugs and Therapeutics 1975; Webb 1971;
Kral 1976).

 

MAO inhibitors offer further disadvantages.
They are interactively toxic with numerous
other drugs and with certain foodstuffs as
well. They potentiate the action of anesthet-
ics, barbiturates, adrenal corticosteroids,
ganglion-blocking agents, morphine, atropine,
and 4-amino-quinoline compounds. The anti-
depressant and hypotensive effects of MAO
inhibitors are, in turn, potentiated by diuret-
ics (Fann and Wheless 1975). The use of
sympathomimetic amines, which are common
ingredients of over-the-counter cold and sinus
drugs as well as analgesics, is contraindicated.
MAO inhibitors potentiate pressor amines so
that a severe to fatal hypertensive crisis can
occur. Another such pressor agent, tyramine,
which releases endogenous sympathetic amines,
is also potentiated. It is found in a wide
''range of foods whose consumption is contrain-
dicated, such as cheese, chicken liver, avoca~
do, meat extracts, beer, sherry, or Chianti
(Lifshitz 1970; Throne 1974; Fann 1973).
Older persons, besides having a greater likeli-
hood of being somewhat hypertense, are apt
to have a more difficult time remembering and
observing all the precautions and restrictions
that accompany therapy with MAO inhibitors
(Young 1972). Also it is more likely that
elderly patients will be taking one or more of
the contraindicated medications (Lifshitz and
Kline 1970). A further complication is that,
unlike the tricyclics, side effects occurring
with MAO inhibitor therapy may be long last-
ing, and harmful interactions with other drugs
or foodstuffs are still possible as long as 2
weeks after treatment termination (Medical
Letter on Drugs and Therapeutics 1975;
Appleton 1976).

Clinically derived estimates of the incidence
of mania in the aged population vary consider-
ably. One study estimates that this disorder
comprises only 0.6 percent of the functional
disorders found in this population while an-
other refers to recurrent manic or manic-
depressive episodes as a syndrome frequently
encountered in this age group (Prange 1973;
Davis et al. 1973).

Lithium carbonate has been used since 1949
in the treatment of cyclic affective disorders
and the consensus seems to be that it is pro-
phylactic in recurrent bipolar depressions
for both manic and depressive phases (Young
1972; Medical Letter on Drugs and Therapeu-
tics 1975; Davis et al. 1973; Markoff 1974;
Schmidt 1974). However, there is a diversity
of opinion regarding its effectiveness in treat-
ing acute mania attacks (Markoff 1974; Young
1972; Davis et al. 1973; Appleton 1976). Its
successful treatment of the depressed phase
may often require the concomitant administra~
tion of a tricyclic drug (Shader 1976; Hollister
1976; Frazier 1976). Here, too, there is con-
jecture about its efficacy in the actual treat-
ment of acute depressive episodes (Appleton
1976; Schmidt 1974). Some evidence points
to the usefulness of lithium as a prophylactic
for endogenous depressions (Fann 1976).

Two major contraindications to the long-term,
prophylactic use of lithium are the presence
of renal disease and cardiac insufficiency,
which occur with great. frequency in elderly
patients (Young 1972). Rapid salt depletion
during lithium treatment can cause gastroin-
testinal, central nervous system, and neuro-
muscular toxicity. Therefore, diuretic
therapy, required for several concurrent
conditions occurring in elderly patients, is
contraindicated. The half-life of lithium is
considerably longer in elderly patients, so

that smaller dosage levels are sufficient to
build up an adequate therapeutic blood level.
Lithium toxicity and an accompanying confu-
sional syndrome can occur at lower blood
levels in the elderly patient. Careful and
continuous monitoring of blood levels is par-
ticularly important when the outpatient is
elderly as the earlier signs of toxicity can
be passed off by family and neighbors as
lapses to be expected with old age (Fann 1976;
Schmidt 1974; Davis et al. 1973; Fann 1973).

Finally, the use of stimulant compounds as
antidepressants has not met with great suc-
cess, and these are especially dangerous when
administered to elderly patients. Their cardio-
vascular effects, including increased blood
pressure and tachycardia, are particularly
dangerous in cases where cardiovascular func-
tion is compromised and there is an increased
vulnerability to cerebrovascular accidents.
Generally, their mood-elevating effect is quite
often followed by a depression which is more
severe than the original one (Fann and
Wheless 1975).

TREATMENT OF PHYSIOLOGICALLY
BASED PSYCHOSES

A broad, heterogeneous group of psychotic
conditions, consisting of varying psychopath-
ologies, are known to occur in the aged popu-
lation (Friedel and Raskind 1976). Organic
brain syndrome manifestations, for example,
appear in approximately 16 percent of persons
aged 65 and over. There are two forms of
the disease. Senile psychosis, or dementia,
is causally related to organic disease of the
nerve cells. Arteriosclerotic psychosis, or
dementia, is associated with focal indications
of cerebrovascular disease.

The latter condition is present in about one-
third of the organic brain syndromes which
occur in elderly persons. It acts as a major
contributor to pathologic conditions in only
10 percent of the above (Hollister 1975; Fann
1976). Unlike senile psychosis, cerebral
arteriosclerosis often occurs before age 65.
It is only infrequently found in patients
younger than age 55. The condition produces
pathological changes in the form of small
infarcts. These can appear as glial prolifera-
tion with only patches of scarring, or a num-
ber of small pseudocysts can be produced
which give a Swiss cheese appearance to a
“brain slice" (Hollister 1975). Onset is said
to be more abrupt than senile psychosis, al-
though headaches, dizziness, and fainting
spells are often part of the patient's history
in the months preceding onset (Prien 1972).
An increase in stressful conditions may cause
a sudden appearance of symptoms. The ill-
ness fluctuates in severity, sometimes chang-
''ing in a matter of hours, and is accompanied
by emotional lability and/or epileptiform sei-
zures and also sleep disturbances. Its vari-
ability is probably due to changes in circula-
tion. Since insight usually remains intact,
the patient is often acutely depressed or anx-
ious about his mental deterioration. As the
illness worsens, the more subtle or complex
aspects of personality tend to be destroyed
and memory, intellectual function, and judg-
ment-making ability progressively decline.
About 20 percent of cases develop paranoid
syndromes. Death, usually a result of cere-
brovascular accident, myocardial infarction,
or infection, may not occur until years after
disease onset and several periods of improve-
ment and decline (Fann et al. 1974; Prien
1972; Fann 1976; Whanger 1973).

Senile dementia normally occurs in the seventh
to ninth decades and strikes women more fre-
quently than men (Fann 1976). Two types
of nerve cell lesion can occur: senile plaques,
or clusters of enlarged, abnormal nerve fibers
and synaptic endings, and the neurofibrillary
tangles of Alzheimer, made up of twisted intra-
neuronal fibers (Hollister 1975). The latter
is most often associated with presenile, i.e.,
before 60, dementia (Prien 1972). The etiol-
ogy of senile dementia is unknown (Hollister
1975). Vague feelings of anxiety and depres-
sion frequently precede its onset, which is
often insidious and marked by a progressive
loss of memory for recent events. Depression
tends to fluctuate and then disappear as the
dementing process takes hold. Memory failure
is accompanied by intellectual impairment,
disorientation, and poor judgment (Prien 1972).
The early stages may be somewhat indistin-
guishable from the normal aging process.
However, deterioration subsequently proves
to be more rapid and profound and is accom-
panied by higher mortality (Fann 1976). Un-
steady gait, muscular weakness, fatigue, and
speech disturbance may develop. Paranoid
reactions may occur in 15 to 20 percent of
cases. Prognosis is usually poor. Diffuse
pathological changes occur over a number of
years, leading to a total disorganization and
degradation of behavior which requires insti-
tutional care. Heart failure or pneumonia
are common cause of death (Prien 1972; Fann
1976).

A combination of these syndromes occurs in
over 20 percent of cases. Paranoid behavior
manifests in 35 percent of patients with dual
pathologies. It should be noted that the pa-
tient's psychological makeup determines the
nature of any secondary reaction to mental
impairment accompanying either of these con-
ditions. Depression or agitation, withdrawal,
strong persecutory and expansive reactions,
or the absence of any marked response are

10

all possible behavioral patterns (Fann et al.
1974; Whanger 1973; Prien 1972).

Schizophrenia is another form of psychosis
which occurs in elderly patients. Some pa-
tients may have been ill for several years
preceding old age and are episodic psychotics,
whereas onset in others occurs after age 65
(Davis 1974; Davis et al. 1973). The illness
can be either functional or organic so that
the later occurring type, often called late
paraphrenia, can develop either as a conse-
quence of organic brain syndrome in predis-
posed persons, or can occur independent of
such deterioration. With this illness, an
intact personality with well-organized paranoid
delusions is frequently accompanied by symp-
toms of passivity or by classic auditory hallu-
cinations, much like the clinical description
of early onset schizophrenia (Fann 1976; Fann
et al. 1974; Young 1972). Cases of schizo-
phrenia developing after age 60 and independ-
ent of dementia comprise only 5 percent of
all schizophrenic illness. Evidence suggests
a possible hereditary predisposition. Patients
are often healthy and able to ward off demen-
tia. However, if the schizophrenic condition
is left untreated, a prolonged course can be
anticipated (Whanger 1973).

The treatment of psychoses in elderly patients
involves use of the same antipsychotic agents
commonly administered to younger patients.
Numerous double blind studies offer sound
evidence of their efficacy in treating geriatric
patients (Davis et al. 1973; Davis 1974).
However, starting doses should be reduced
by one-third to one-half the amount given to
young patients and dosage buildup should be
more gradual (Prien and Caffey 1974). These
agents are helpful in relieving symptoms such
as agitation, violent and irrational behavior,
and typical perceptual disturbances. They
do not, however, alter the course of any
underlying organic disorder. Their effect is
achieved mainly through blockage of central
adrenergic and dopaminergic synapses, result-
ing in a decrease in membrane excitability
(De Groot 1974; Eisdorfer 1975).

The phenothiazine derivatives are by far the
most commonly administered antipsychotic
agents for relief of chronic brain syndrome
and schizophrenic symptoms occurring in el-
derly persons (Prien 1972; Fann 1976; Friedel
and Raskind 1976; Schmidt 1974; De Groot
1974). Although they exhibit a diversity of
pharmacologic actions, they almost all share
the ability to exert a calming effect without
severely impairing motor function or forcing
sleep on the patient. This is probably be-
cause their chief locus of action is the sub-
cortical brain (Eisdorfer 1975). Exceptions
are thioridazine and chlorpromazine which
''can produce drowsiness (Prien 1972). These
agents are classified by chemical structure
into three side chains; aliphatic derivatives,
such as chlorpromazine (Thorazine); piperi-
dine derivatives, such as_ thioridazine
(Mellaril); and piperazine derivatives such as
trifluoperazine (Stelazine) (Greenblattt and
Shader 1974b).

Numerous side effects can accompany the use
of these agents. All initially produce a de-
gree of orthostatic hypotension (drop in blood
pressure on standing up). But this effect
is particularly strong with chlorpromazine
and thioridazine. They are also more likely
to provoke seizures and thioridazine, in high
doses, can cause irreversible retinal damage
stemming from segmentary retinopathy. Other
possible dose-related side effects are jaundice,
agranulocytosis, dermatitis, and photosensitiv-
ity. Epilepsy and mental depression may be-
come potentiated, a drop in body temperature
can occur, sometimes causing hypothermia in
elderly patients, and cerebral anoxia may be
exaggerated. These agents can also suppress
thyroid function (Lamy 1974; Markoff et al.
1974; Holloway 1974; Greenblatt and Shader
1974b). Their possession of anticholinergic
properties and resultant atropine-like symp~
toms are similar to the tricyclic antidepres-
sants. Elderly organic brain syndrome
patients are particularly vulnerable to the
confusional state which can result from cen-
tral nervous system toxicity (Friedel and
Raskind 1976). Rare side effects, such as
hepatic toxicity and blood dyscrasias, occur
with greater frequency in elderly patients
(Prien 1972; Webb 1971). Like the tricyclic
antidepressants, phenothiazines are capable
of producing a cardiomyopathy that is espe-
cially dangerous to patients with heart disease.
Electrocardiographic abnormalities of a nonspe-
cific, reversible, and perhaps benign nature,
are produced by several of the phenothiazines.
These alterations are disproportionately high
with thioridazine. Cases of cardiac toxicity
have been associated most often with this
drug, and to a lesser degree with chlorproma~
zine. Excessive dosage levels of thioridazine
have been suspected of causing supraventricu-
lar arrhythmias, conduction defects, and ven-
tricular arrhythmias (Friedel and Raskind
1976; Prien 1972; Lutz 1976).

All antipsychotic agents can produce extra-
pyramidal side effects.’ Acutely or early in
treatment, parkinsonism, acute dystonias,
akinesias, and akathesias can occur. Later
in treatment (usually years after initiation of
therapy, but can also be a matter of months),
tardive dyskinesia can develop. Half of pa-
tients over age 60 experience extrapyramidal
side effects, and 90 percent occur during
the first 10 weeks of treatment (Holloway

1974). They probably stem from blockage of
dopamine receptor sites in the basal ganglia
(Greenblatt and Shader 1974b). Thioridazine
seems to cause relatively fewer of these symp-
toms. The piperazine derivatives are the
most potent and activating phenothiazines,
and also the most likely to cause extrapyra-
midal symptoms, in particular akathisia (Prien
1972). Patients with this condition feel unable
to sit or stand still. Their motor restlessness
is frequently mistaken for psychotic agitation,
and dosage levels are increased when they
should be lowered (Medical Letter on Drugs
and Therapeutics 1975). Chlorpromazine,
although particularly effective in controlling
agitation and hyperactivity, incurs a greater
risk of parkinsonian reactions such as tremors,
muscle weakness, and rigidity (Prien 1972).
This syndrome, the most commonly experi-
enced extrapyramidal side effect in elderly
patients, can occur in a mild form or else
can be clinically indistinguishable from either
postencephalitic or idiopathic parkinsonism.
Antiparkinsonian medicines have often been
administered to elderly users of antipsychotics
as a prophylactic measure. This practice is
unwise due to the combined anticholinergic
action of these agents. Not all patients will
develop this condition, and the surfacing of
symptoms can serve as a guide for dosage
mediation. When this condition emerges,
drug dosage can be lowered and/or antipar-
kinsonian agents administered. Continued
need of all medication should be reviewed
periodically.

 

Tardive dyskinesia appears in a significant
proportion of older patients, especially women,
and most often emerges after years of treat-
ment with antipsychotics. Sometimes-it ap-
pears only after drug treatment has been
withdrawn or drastically reduced. The condi-
tion consists of buccal-facial-mandibular and
buccal-lingual movements along with involun-
tary choreiform limb and occasionally trunk
movements. It can persist indefinitely or
gradually remit, but does not progressively
worsen after drug withdrawal or minimal dose
administration. The etiology of this appears
to be a denervation sensitization of dopramine
receptor sites. Elderly persons with a his-
tory of treated psychosis are especially at
risk because they may have received high
doses over long periods of time. Persons
with brain damage are also more vulnerable.
Drug holidays are strongly recommended dur-
ing long-term use of antipsychotics along with
lowered doses of these agents as a way to
minimize the build-up of these symptoms and
to check for their presence (Fann 1976;
Eisdorfer 1975; Medical Letter on Drugs and
Therapeutics 1975). Elderly patients on these
drugs over long periods of time should be
examined regularly, especially the tongue area

ll

 
''because this is usually the first sign of dys-
kinetic movement.

It should be noted that the combining of vari-
ous phenothiazines, such as the more potent
piperazine derivatives with one of the aliphat-
ics, has shown no convincing evidence of
increased efficacy or lowered side effects.
However, total dosage may be reduced in this
manner. Certain other combinations of pheno-
thiazines are contraindicated and may actually
cancel therapeutic effects. When phenobar-
bital is administered with a phenothiazine, it
acts to accelerate its metabolism, resulting in
a lowered serum level of the phenothiazine
and a lessening of its clinical effect. Pheno-
thiazines administered with tricyclic antide-
pressants tend to bring about increased blood
levels of both these agents. Although anti-
cholinergic complications are increased by
this combination, there is a possibility that
their combined antagonistic dopaminergic prop-
erties act to reduce extrapyramidal symptoms.
Phenothiazines act in the same way as tricyclic
antidepressants to block the action of certain
antihypertensive agents (Fann 1973; Salzman
et al. 1975).

Finally, it should be mentioned that long-
acting injectable forms of fluphenazine, either
the enanthate or decanoate ester, are cur-
rently available in the United States. Flu-
phenazine is one of the piperazines. Their
advantage is that they need to be administered
only once every 3 or 4 weeks so that, when
necessary, there can be greater control over
medication intake. This could be beneficial
in the management of elderly outpatients who
live alone. Their dosage level should be
about half that administered to younger pa-
tients. Drugs given in this manner are able
to exert an antipsychotic effect at lower dos-
age levels over equivalent periods of time.
Their overall efficacy, however, is still open
to debate. A high incidence of dystonic and
depressant side effects has been reported
along with a high incidence of extrapyramidal
reactions with the enanthete form (Arie 1973;
Prien and Caffey 1974).

SUMMARY

This paper reviews 1) some of the major phys-
iologic changes attendant upon the aging proc-
ess, that occur in varying degrees and affect
an elderly person's ability to metabolize psy-
choactive drugs, and 2) the efficacy of psy-
choactive drug treatment of such emotional
disturbances or mental illnesses as anxiety,
insomnia, depression, and physiologically
based psychosis found among aged persons.

12

The aging process produces physiologic alter-
ations that affect the absorption, transport,
tissue localization, metabolism, and excretion
of drugs. There appear to be wide variations
in the extent of these changes among the
elderly; they vary according to the number
and severity of chronic diseases and patho-
logical processes present in the specific indi-
vidual. The central nervous system is the
most sensitive organ in terms of age-related
response to psychoactive drugs. Changes in
the various aging body systems that alter
the central nervous system, the arterial and
venous flow, blood components, renal flow,
functional tissue, and homeostatic capability
have significant effect on the ability of the
elderly to metabolize and eliminate psychoac-
tive drugs. Accurate diagnosis and prescrib-
ing require that the patient's drug history
and biologic and chronologic age be taken
into account.

In drug treatment of anxiety in the elderly,
the benzodiazepine derivatives (minor tran-
quilizers)--although not ideal agents--are
considered the most effective of currently
available anxiety-reducing agents. Depending
on dosage level, the hypnotics are interchange-
able to a large degree with the anxiolytics.
Barbiturates are a poor choice as anxiolytics,
and antihistamines are inadvisable.

In the treatment of insomnia, the use of the
benzodiazepine derivatives (oxazepam and flur-
azepam), barbiturates, the piperidinedione
hypnotics, and the quinazalone derivatives
(methaqualone and chlorohydrate) were re-
viewed. Particular caution in relation to bar-
biturates, the piperidinedione hypnotics, and
methaqualone was indicated, due to their REM
depression characteristics, addictive potential,
and tendency to accelerate liver microsomal
metabolism.

Depression in the aged has characteristics
common to that occurring in younger persons,
and its treatment with antidepressant drugs
is similar. However, diagnosis of depression
in elderly patients requires special care, since
many symptoms of depression are also charac-
teristic of senility or the general difficulties
of old age. The efficacy, actions, and side
effects of the tricyclic antidepressants, mono-
amine oxidase (MAO inhibitors), lithium car-
bonate, and stimulants are reviewed. In
general, it is recommended that dosages begin
at lower levels and increase at a more gradual
rate for the elderly than for younger persons,
in order to prevent undesirable side effects.

Drug treatment of physiologically based psy-
chosis, such as organic brain syndrome, and
some schizophrenias, in the elderly is similar
to that of younger persons, with the
''exception of dosage levels. Recommended
beginning dosage levels of antipsychotic
agents are one-half to two-thirds that of
younger persons. The phenothiazine deriva-
tives are the most commonly used agents and
have the ability to have a calming effect, with-
out severely impairing motor function or mak-
ing patients sleepy. Nevertheless numerous
side effects accompany their use. The long-
acting piperazine, fluphenazine, has the
advantage of requiring administration only

once every 3 or 4 weeks, thus allowing
greater control over the medication. Its over-
all efficacy remains in doubt however.

The use of psychoactive drugs in the treat-
ment of emotional disturbance and mental ill-
ness in the elderly requires accurate diag-
nosis and both physician and patient aware-
ness of the necessity to titrate dosages and
the duration of administration according to
the person's biologic and chronologic needs.

13
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16
''PATTERNS OF PSYCHOACTIVE DRUG USE AMONG
THE ELDERLY

Robert Prentice

INTRODUCTION

In 1970, people 65 years of age and over rep-
resented about 10 percent of the total U.S.
population, and that figure is expected to
climb to over ll percent in the year 2000.
By way of contrast, people 65 and over con-
stituted only about 4 percent of the popula-
tion in 1900 (American Health Care Association
1975). A large share of that increase can
be attributed to improved health care in the
earlier years, enabling more people to live
into old age.

Older people as a group, however, still suf-
fer from a highly disproportionate share of
chronic illnesses (Manard 1975) and, largely
as a result, they receive more medications
than other age groups. While people 65 and
over represent 10 percent of the total popula-
tion, they receive over 25 percent of all pre-
scriptions written (U.S. Senate Special
Committee on Aging 1973).

An increasing share of all prescriptions is

accounted for by psychoactive drugs, espe-
cially since the introduction of tranquilizers
in the mid-1950s. In 1970, 214 million pre-
scriptions for major and minor tranquilizers,
antidepressants, stimulants, sedatives, and

hypnotics were filled in American drugstores,
representing 17 percent of all prescriptions
filled (Parry et al. 1973). Nearly a third of
the adult population indicated that they had
used at least one prescription or over-the-

counter psychoactive drug in a l~year period
(Parry et al. 1973).

17

As yet, there have been very few systematic
attempts to explore the extent to which older
people use psychoactive drugs. In 1967, a
DHEW Task Force on Prescription Drugs as-
sembled a Master Drug List, ranking the pre-
scription drugs used most frequently by
persons 65 years of age and over. Of the
21 most widely used drugs, 8 were psychoac~
tive drugs (DHEW 1968). That study was
conducted 10 years ago, and little work of a
comparable nature has been done since then.
Both the absence of data and the need for
additional research were cited in the report
of the Conference on Drug Use and the Elder-
ly (1975), sponsored by the National Institute
on Drug Abuse and the National Institute for
Drug Programs. Against that background,
then, it is the purpose of this paper to draw
together the currently available data on pat-
terns of psychoactive drug use among the
elderly as an initial effort in what is hoped
will be an ongoing research direction.

It is important to make clear at the outset
that the discussion of psychoactive drug use
patterns among the elderly is based solely on
data from surveys and case studies. Preva-
lence rates for particular drugs are not as~
sessed in relation to the advisability of using
those drugs for specific conditions experi-
enced by elderly patients. The presentation
and discussion of data should therefore be
taken only as an attempt to profile the extent
to which older people use psychoactive drugs.
Whether or not that drug use is appropriate,
even in cases where prevalence rates are com-
paratively high, is contingent upon more de-
tailed analyses of the relationship between
drug use, diagnoses, and the physiological
and social characteristics of aged persons.
''It is also important to specify the types of
drugs being considered in this report. Al-
though the term "psychoactive" may refer to
both licit and illicit drugs, it was determined
that illicit drugs are beyond the scope of this
paper. Accordingly, throughout the remain-
der of the discussion, the term psychoactive
drugs is taken to be synonymous with legally
prescribed or legally purchased over-the-
counter psychoactive drugs. As a general
guide to the drugs being considered, a classi-
fication system, taken from Parry et al. (1973)
is provided in table 1.

There are some difficulties in the task at hand.
Few studies have attempted to measure the
nature and extent of psychoactive drug use
among the elderly. Among the studies that
do exist, the data are often not directly com-
parable. There is variation, for example, in
the classification of psychoactive drugs. In
one study, sedatives are combined with minor
tranquilizers, in another they are grouped
with hypnotics, and in another they are
treated as a separate class. There are also
discrepancies between studies in terms of what
constitutes the "older population." Among
the studies cited in this report, the oldest
age categories represented range from "50
and over" to "65 and over."

There are also differences in terms of method-
ological strategies pursued and data sources
utilized. In the case of prescription psycho-
active drugs, for example, some studies use
prescription orders based on physicians! rec-
ords, some focus exclusively on drugs actually
administered, and others are concerned with
reported use based on direct interviews. In
an ideal situation, the different data sources
could be considered as merely separate com-
ponents in a comprehensive data base, from
which fruitful comparisons could be made.
However, the general paucity of studies frus-
trates that potential and makes comparisons
extremely difficult.

Given the variations among studies, and the
lack of information in general, it is very diffi-
cult to present the data in a synthetic and
comparative fashion; accordingly, the style
of presentation will tend to rely on serial dis-
cussions of individual studies, with integrat-
ing comments when appropriate.

The following section focuses on prescription
psychoactive drugs. Data on patterns of use
among the elderly are presented in two parts:
The first part summarizes studies on psycho-
active drug use in the general elderly popula-
tion; the second part reviews studies con-
ducted among institutionalized populations.
Following the presentation of data on patterns
of prescription psychoactive drug use, there

18

is a review of studies on noncompliance, im-
proper prescribing, and drug-related illness
and death.

The next section focuses on over-the-counter
(OTC) psychoactive drugs. Data are pre-
sented on the extent of OTC psychoactive
drug use among the elderly.

The final section summarizes the findings cited
in this report. In addition, suggestions are
made for future directions of research efforts.

PRESCRIPTION PSYCHOACTIVE DRUGS

Psychoactive drugs are prescribed for a vari-
ety of reasons, not all of which are directly
related to diagnoses for psychiatric illnesses.
Balter and Levine (1969) have indicated that
most psychoactive drugs are prescribed by
general practitioners and internists, and only
a third of all prescriptions for antidepressants
and major tranquilizers--usually prescribed
for psychiatric disorders--are written by psy-
chiatrist and neurologists. Parry et al. (1973)
found that 85 percent of the people in their
survey who reported use of a prescription
psychoactive drug had never seen a psychia-
trist. Psychoactive drugs are also prescribed
in a variety of contexts, including doctors!
offices, outpatient clinics, general hospitals,
nursing homes, and psychiatric wards.

The apparent far-reaching use of prescription
psychoactive drugs raises several issues that
need to be examined. A prerequisite for any
further discussion, of course, is a basic
knowledge of the extent to which people use
particular drugs, in what contexts, and for
what purposes. It is also important to know
whether people use those drugs properly and,
if not, why misuse occurs. "Misuse" here
refers to inappropriate use of prescription
psychoactive drugs, resulting either from
the patient's failure to comply with proper
directions for the use of a medication or from
improper prescribing on the part of a physi-
cian. If misuse does occur, it is important
to know how widespread it is, what the rea-
sons for it are, and whether it involves harm-
ful consequences.

The discussion of prescription psychoactive
drug use among the elderly that follows is
presented with those issues in mind. How-
ever, the paucity of available data makes it
very difficult to address those issues directly.
Accordingly, the purpose of this section is
to provide relevant information to the extent
possible, and to point out the limitations of
the data in relation to the issues under
''61

TABLE 1.—Classification of psychoactive drugs

Type of Class

Prescription Drugs

Major tranquilizers
Phenothiazine derivatives
Butyrophenones
Thioxanthenes

Minor tranquilizers
Substituted diols
Benzodiazepines
Miscellaneous

Antidepressants
Tricyclics
Monoamine oxidase inhibitors
Other

Stimulants
Amphetamines

Others

Sedatives
Barbiturates (long-acting and
intermediate-acting)
Others
Hypnotics
Barbiturates (short-acting)
Others

Over the Counter

Stimulants
Tranquilizers
Sleeping pills

Examples: Generic Names

 

Chlorpromazine, thioridazine
Haloperidol
Thiothixene, chlorprothixene

Meprobamate, tybamate
Chlordiazepoxide, diazepam, oxazepam
Hydroxyzine, buclizine

Imipramine, amitriptyline

Isocarboxazid, phenelzine

Methylphenidate, combination of
amitriptyline and perphenazine

Detroamphetamine (and combinations),
methamphetamine -

Deanol, pentylenetetrazol (and combi-
nations)

Phenobarbital, butabarbital
Bromisovalum

Secobarbital, pentobarbital
Glutethimide, ethchlorvynol

Caffeine
Scopolamine and/or methapyrilene
Scopolamine and/or methapyrilene

Examples: Trade Names

Thorazine, Mellaril
Haldol
Navane, Taractan

Equanil, Miltown, Tybatran
Librium, Valium, Serax
Atarax, Softran

Tofranil, Elavil
Marplan, Nardil
Ritalin, Triavil, Etrafon

Dexedrine, Dexamyl, Desoxyn

Deaner, Metrazol

Eskabarb, Butisol
Bromural

Seconal, Nembutal
Doriden, Placidyl

No-Doz, Vivarin, No-Nod
Cope, Compoz

Sleep-Eze, Mr. Sleep,

- Sominex, Nytol
''consideration. Some suggestions for further
research are offered in the final section.

PATTERNS OF PSYCHOACTIVE
DRUG USE AMONG THE ELDERLY

The studies to be discussed presently are
grouped into two general types. The first
group consists of studies that address pat-
terns of prescription psychoactive drug use
in the general elderly population. The second
group focuses specifically on the elderly resid-
ing in institutional settings.

General Population

One of the best available data sources on pre-
scription drugs is the National Disease and
Therapeutic Index (NDTI 1975a,b). Prescrip-
tion data from the NDTI are based on a sur-
vey of U.S. physicians who are asked to fill
out forms on a quarterly basis, detailing drug
orders for patients during a 48-hour period.
The NDTI, unfortunately, is a private data
source, available on a subscription basis only;
accordingly, permission must be received be-
fore data can be published.

While the NDTI is a comprehensive data source,
time and cost factors have restricted this
analysis to a presentation of data on the pro-
portion of selected prescription psychoactive
drug orders issued to the elderly. Table 2
summarizes the findings. It is important to
emphasize here that the number represents
appearances, and not prescriptions or people.
Appearances are the number of times a partic-
ular drug is recorded in the NDTI survey;

it is a broader category than prescriptions,
since it also includes hospital orders, physi-
cian samples, direct dispensing, nursing home
orders, etc. Appearances also differ from
the number of people receiving drug orders,
since some people may receive more than one
order.

If it is kept in mind that people 65 years of
age and over constitute 10 percent of the
total U.S. population, it can be seen that,
with the exception of the stimulants and Stela-
zine (a major tranquilizer) older people re-
ceive a highly disproportionate number of
orders for the prescription psychoactive drugs
sampled. In fact, again with the exception
of the stimulants and Stelazine, older people
receive at least one-fifth of all orders for
the sampled drugs; in the case of Thorazine
(a major tranquilizer), the sedatives, the non-
barbiturate hypnotics, and three out of four
of the barbiturate hypnotics, older people
receive over one-fourth of all drug orders.
While data on Mellaril (another major tranquil-
izer) are not presented, evidence (cited else-
where in this monograph) suggests that use

patterns in respect to age do not differ sub-
stantially from Thorazine, and, in fact, Mel-
laril may even be used more extensively by
older people.

Of the most widely used individual prescrip-
tion psychoactive drugs sampled, older people
receive 21.2 percent of all orders for Valium
(minor tranquilizer), 23.4 percent of all
orders for Librium (minor tranquilizer), 30.4
percent of all orders for Dalmane (nonbarbi-
turate hypnotic), 21.1 percent of all orders
for Elavil (antidepressant), and 27.1 percent
of all orders for phenobarbital (sedative).
Older people receive the most highly dispro-
portionate percentage of drug orders for Buti-
sol Sodium (sedative), for which nearly half
of all orders are issued to people 65 and over,
and Doriden, Placidyl, and Amytal (hypnotics),
for which approximately a third of all orders
are issued to people 65 and over.

It is also apparent from the data presented
that, for the drugs sampled, it is not uncom-
mon for women to receive two out of every
three drug orders issued. That general pat-
tern appears to hold true among people 65
and over as well, with a few exceptions.
The gap closes substantially when looking at
barbiturate hypnotics, and in the case of
Tuinal, older men actually receive more drug
orders than older women. In the case of Ela-
vil, an antidepressant, all women receive a
little more than three out of every four drug
orders, but older women receive a more highly
disproportionate number in comparison to older
men. The analysis takes into account the
fact that women constitute a greater propor-
tion of the population 65 years of age and
over than they do in the population as a
whole.

Approaching the issue of psychoactive drug
use patterns from another direction, Parry
et al. (1973) interviewed a national household
sample of 2,552 persons, ranging in age from
18 to 74. The interviews, conducted in late
1970 and early 1971, consisted of a series of
questions related to the respondents' drug
use during a l-year period preceding the
interview. A validity study conducted prior
to the national survey indicated that the re-
sults may tend to underestimate prevalence
rates by a few percentage points.

It is important to point out two features of
the survey that restrict its scope when con-
sidered in the present context. First, since
the sample was based on adults in households,
it does not include those who were residing
in institutions at the time of the survey; thus,
the data should be regarded as reflecting
only psychoactive drug use patterns in the
noninstitutionalized population. Second, no

20
''Te

TABLE 2.—Number and percentage of appearances of selected prescription psychoactive
drugs by age group and sex, NDTI, 1975 (Number in thousands)

 

 

 

All Ages 65 Years and Over
Male Female Total Male Female Total

Drug Class and Name Number % Number 6 Number %_ Number %_ Number %_ Number 3%
Major tranquilizers

Thorazine 1,714 38.9 2,688 61.1 4,402 100 384 3.7 777 ~=«-17.7 1,161 26.4

Stelazine 880 35.3 1,611 64.7 2,491 100 92 3.7 196 109 288 §©11.6
Minor tranquilizers

Valium 10,959 35.7 19,729 64.3 30,688 100 2,229 7.3 4,267 13.9 6,496 21.2

Librium 2,464 36.0 4,378 64.0 6,842 100 538 Te 1,060 15.5 1,598 23.4
Antidepressants

Elavil 1,514- 22.2 5,319 77.8 6,833 100 246 3.6 1,197 17.5 1,443 21.1

Tofranil 1,151 32.6 2,383 67.4 3,533 100 195 5105 498 14.1 693 19.6
Stimulants

Biphetamine 121 17.0 590 = 83.0 711 = 100 N.A. N.A. 8 Lied: N.A. N.A.

Dexedrine 225 48.2 274 =51.8 529 100 18 3.4 7 1.3 25 4.7
Sedatives

Phenobarbital 2,163 40.2 3,222 59.8 5,285 100 456 8.5 1,004 18.6 1,460 27.1

Butisol sodium 343 27.4 910 72.6 1,253 100 141 «11.3 411 32.8 552 44,1
Barbiturate hypnotics

Seconal 1,139 3585 2,072 64.5 3,211 100 318 9.9 381 =611.9 669 21.8

Nembutal 848 33.4 1,690 66.6 2,538 100 268 10.6 473, 18.6 741 29.2

Tuinal 451 40.6 661 59.4 1,112 100 153. 13.8 143) 12.9 296 = 26.7

Amytal 159 32.6 329 67.4 488 100 66 = =13.5 9218.9 158 32.4
Nonbarbiturate hypnotics

Dalmane 3,303 36.7 5,698 63.3 9,001 100 937 10.4 1,802 20.0 2,739 30.4

Placidyl 494 35.3 906 64.7 1,400 100 130 9.3 333 ©6. 23..8 463 321

Doriden 431 41.8 600 58.2 1,031 100 156 «15.1 210 20.4 366 8=635.5

Quaalude 171 48.6 181 51.4 352 100 46 13.1 50» =14.2 96 27.3

How to read the table: In 1975, Thorazine (a major tranquilizer) appeared in the NDTI a total of 4,402 times; 1,714 (38.9 per-
cent) of those drug orders were issued to males, and 2,688 (61.1 percent) were issued to females. A total of 1,161 of those
orders for Thorazine were issued to people over 65 years of age and over, constituting 26.4 percent of all appearances; 384

(8.7 percent of all appearances) were issued to older men, and 777 (17.9 percent of all appearances) were issued to older women.

 

 
'' 

persons 75 years of age or older were inter-
viewed, thereby excluding over one-quarter
of the population 60 and over.

As can be seen from table 3, roughly one-
fifth (21 percent) of older men and one-third
(32 percent) of older women indicated that
they had used at least one prescription psy-
choactive drug in the last year. For older
men, the prevalence of use was substantially
higher than that of men in the other age
groups; a similarly disproportionate percent-
age for older women would be evident if stimu-
lants were excluded from consideration.

Minor tranquilizers/sedatives and hypnotics
are the drugs of use most frequently cited
by both older men and older women. Sub-
stantially more older women (25 percent) than
older men (11 percent), however, indicated
use of minor tranquilizers/sedatives. For
both older men and older women, the use of
minor tranquilizers/sedatives and hypnotics

is more prevalent than in any other age group.

In addition to measuring prevalence rates,
the survey attempted to determine levels of
use of prescription psychoactive drugs.
Table 4 distinguishes between "use" and "high
level of use," by age group. "High level of
use" is defined as a maximum pattern which
involves regular daily use for at least 2
months.

While the reported data do not reveal level
of use by specific class of drug, it can be
seen that, for all prescription psychoactive
drugs taken together, 9 percent of all those
in the age group 60-74, or roughly one-third
(32 percent) of those who had used a drug
during the past year, indicated a high level
of use. When comparing those figures with
the 30-44 and 45-59 age groups, it appears
that, while a larger percentage of older peo-
ple may be using prescription psychoactive ,
drugs, they are less likely to be using them
at a high level.

The survey by Parry et al. (1973) also at-
tempted to relate other demographic factors--
geographic region, Index of Social Position
(ISP), and education--to prevalence rate and
level of use of prescription psychoactive
drugs; unfortunately, the reported data did
not correlate those factors with age. Among
all persons in the survey, however, those
living in the western States tended to show
a somewhat higher prevalence rate, and they
tended more often to use drugs at a high
level. ISP (based on the standard Hollings-
head scoring) and education appeared to have
little effect on prevalence rates; however,
those persons with lower ISP and education
ratings showed some tendency to use drugs

at a high level more often. It cannot be dis-
cerned from the reported data whether, or
to what extent, those tendencies hold true
for the age group 60-74.

Abelson and Atkinson (1975) provide some
additional data which give an indication of
the extent to which recent use of prescription
psychoactive drugs is also the first use (table
5). Their study was based on interviews
with a national household sample of 3,071
adults and 952 youths, conducted between
November 1974 and March 1975. It should
be pointed out that the primary focus of the
study was on illicit drug use, a phenomenon
associated predominantly with younger age
groups; accordingly, data on prescription
drug use among older people (defined broadly
as "50 and over") was a peripheral aspect of
the study.

The data suggest that those in the age group
50 and over (as compared with adults of all
ages) are more likely to have reported use
of a sedative within the past year and less
likely to have reported use of a stimulant,
while reported use of tranquilizers (major
and minor combined) is roughly the same be-
tween the two groups. Particularly interest-
ing, however, is the indication that, for both
groups, approximately two-thirds of those
who used sedatives and one-half of those who
used tranquilizers within the past year did
so for the first time.

Guttman (1977) specified some characteristics
of elderly users of prescription drugs. In a
Washington, D.C., household sample of 447
persons aged 65 and over, with an average
age of 71.9 years and a male/female ratio of
59.6 percent to 40.4 percent, he found that
13.6 percent of the respondents in the survey
used sedatives/tranquilizers daily, and 1.1
percent indicated daily use of antidepressants.
Roughly half (50.7 percent) of those who used
psychoactive drugs on a daily basis reported
that they could not perform their regular daily
activities without their medication; 28.6 per-
cent indicated that their health was the main
reason for using psychoactive drugs; and
38.6 percent reported taking several kinds
of drugs in combination. He also found that,
with a statistically significant difference,
users of prescription psychoactive drugs
tended to be younger and native born, while
nonusers tended to be older and foreign born.

In summary, it appears that the elderly re-

ceive a disproportionately high number of

orders for the tranquilizers, sedatives, hyp-
notics, and antidepressants sampled from the
NDTI, while the number of stimulants ordered
for the elderly appears to be proportionately
low. The hypnotics and sedatives appear to

22
''TABLE 3.—Use of prescription psychoactive drugs during past year
by drug class and by sex and age

Percentage Using in Past Year Among Age Groups

 

 

 

 

Drug Class and Sex 18-29 30-44 45-59 60-74 All Ages

Major tranquilizer

Men * 1 1 * 1

Women 1 2 2 2 2
Minor tranquilizer/sedative

Men 5 7 9 11 8

Women 12 21 22 25 20
Antidepressant

Men + 2 1 4 2

Women 2 2 2 2 2
Stimulant

Men 1 2 2 1 2

Women 10 ll 6 3 8
Hypnotic

Men dL 1 2 7 3

Women 3 3 4 8 4

All psychoactive drugs
Used any during past year
Men 6 12 14 21 13
Women 23 32 31 32 29

*Less than 0.5 percent
+No cases
Past year refers to 1969-1970

SOURCE: Parry et al. (1973)

TABLE 4.—Users in past year (1969-1970) and high-level users of prescription
psychoactive drugs by age group

 

Among All Among Users
Persons in Each Age Group in Each Age Group

Percent Percent Using Percent Using

Age Group Using at High Level at High Level
18-29 15 5 31
30-44 24 10 39
45-59 23 10 42
60-74 27 9 32

23
''TABLE 5.—Medical experience with

Any
50 years and over
Used in past year *
First used in past year 15
All adults 18 years and over
Used in past year ms
First used in past year 15
*Not available
SOURCE: Abelson and Atkinson (1975)
be the classes of psychoactive drugs most

disproportionately issued to the elderly.
Women in general are more likely than men to
receive orders for psychoactive drugs, and
that pattern tends to hold true for the older
population.

In terms of the percentages of the older pop-
ulation who use prescription psychoactive
drugs, approximately one-fifth of older men
and one-third of older women reported use
of at least one drug during a l-year period.
The highest prevalence of use occurred in
the combined classes minor tranquilizers/
sedatives (11 percent of older men and 25
percent of older women), followed by hynotics,
(7 percent of older men and 8 percent of older
women); comparatively lower prevalence rates
were reported for stimulants, major tranquil-
izers, and antidepressants. A greater propor-
tion of both older men and women reported
use of minor tranquilizers/sedatives and hyp-
notics than did those in other age groups.

Among the elderly who use prescription psy-
choactive drugs, one-third reported a high
level of use (regular daily use for at least 2
months). Two-thirds of those who reported
use of sedatives and one-half of those who
reported use of tranquilizers in a l-year per-
iod indicated that it was their first use of
those drugs (age group 50 and over).

Institutionalized Populations

Although the functions of psychoactive drug
use among the elderly residing in institutions
and those in the general population may differ
substantially, it is nevertheless desirable to
include use data for the institutionalized elder-
ly in order to provide a more comprehensive
profile of psychoactive drug use in various

24

prescription psychoactive drugs during 1974 (percent)

 

Sedatives Tranquilizers Stimulants
15 14 1
10 7 1
10 15 3
7 8 2
contexts. Unfortunately, it is necessary, at

the present time, to rely on data from indi-
vidual case studies. Even those studies are
sparse, and useful data were found only in
relation to nursing home residents and psychi-
atric inpatients; accordingly, the data
presented on patterns of prescription psycho-
active drug use among institutionalized elderly
populations are limited in both scope and gen-
eralizability. The data are too scanty to be
regarded as anything but preliminary indica-
tions of use patterns; they should not be
regarded as representative.

Nursing home residents. In 1970, nearly
three-quarters (72.4 percent) of the older
population living in institutions were in nurs-
ing homes and related facilities (Manard 1975)
It has been estimated that slightly more than
5 percent of the population 65 years of age
and over are in nursing homes or related fa-
cilities on any given day, and that approxi-
mately 20 percent of the older persons can
expect to spend some time in nursing homes
during their lifetime (U.S. Senate Special
Committee on Aging 1975). The nature and
extent of psychoactive drug use within nurs-
ing homes, then, can affect a potentially sig-
nificant segment of the older population.

In terms of the psychoactive drugs most fre-
quently prescribed in nursing homes, some
preliminary data are provided in a General
Accounting Office audit of Medicaid payments
for prescription drugs in nursing homes in
Illinois, New Jersey, and Ohio (U.S. Senate
Special Committee on Aging 1973). The audit,
commissioned by the Subcommittee on Long-
Term Care of the U.S. Senate Special Commit-
tee on Aging, covers the periods of January,
April, July, and October of 1970. Table 6
presents the GAO data on prescribing
''TABLE 6.—The 10 drugs most prescribed in nursing homes in three States in 1970, by number of
prescriptions paid for by Medicaid

 

Number of Percent of All

 

Rank Drug Name and Class Prescriptions Prescriptions
1 Thorazine (major tranquilizer) 23,126 3.5
2 Darvon compound (analgesic) 21,436 3.2
3 Mellaril (major tranquilizer) 7 5.977, aut
4 Phenobarbital (sedative) 9,663 1.4
5 Chloral hydrate (hypnotic) 8,264 1.2
6 Doriden (sedative) 7,802 1.1
7 Librium (minor tranquilizer) 7259 1.1
8 Aspirin and Bufferin (analgesics) 6,875 1.0
9 Nembutal (hypnotic) 6,133 0.9
10 Valium (minor tranquilizers) 5,308 0.8
NOTES: Total number of prescriptions was 657,882.

Sample covers January, April, July, and October of 1970 in the States of Illinois, New

Jersey, and Ohio.

Drug classes used here conform with categories used elsewhere in this monograph

rather than those in the original.

SOURCE:

patterns among the elderly poor in nursing
homes.

Of the 10 most frequently prescribed individ-
ual drugs in the GAO audit, 8 were psycho-
active drugs. The first and third most
frequently prescribed drugs--and the two
most frequently prescribed psychoactive
drugs--were Thorazine and Mellaril (both
major tranquilizers) which, taken together,
accounted for 7 percent of the total number
of prescriptions.'. The sedatives phenobarbi-
tal and Doriden ranked 4th and 6th, the hyp-
notics chloral hydrate and Nembutal ranked
5th and 9th, and the minor tranquilizers Lib-
rium and Valium ranked 7th and 10th.

‘ The most notable deviation from the NDTI
data in table 2 on drug orders for the older
population taken as a whole is the proportion-
ately higher number of prescriptions for major
tranquilizers in nursing homes. That obser-
vation is supported by the NDTI data supple-
ment, "Leading Drugs Used in Nursing Homes"
(NDTI 1975), which shows that, from July
1974 through July 1975, tranquilizers (both

U.S. Senate Special Committe on Aging (1973, p. 247).

major and minor) were the most frequently
ordered drug class in nursing homes, with
Mellaril and Thorazine, respectively, being
the most frequently ordered tranquilizers.
In terms of the percentage of older people
residing in nursing homes who receive pre-
scriptions for psychoactive drugs, there are
a few studies which report relevant data.
Ingman et al. (1975) conducted a study of
the patterns of prescribing and administering
of drugs among the elderly in a long-term
care institution in Connecticut. Drug orders
for 2 different dates 10 months apart were
recorded for each of 131 patients (ages not
given) residing in 3 areas of the 300-bed
facility. These included an area primarily
for severely brain-damaged persons; an area
for ambulatory and more self-sufficient resi-
dents; and an extended care unit for the
maximally disabled and patients recently dis-
charged from hospitals.

Table 7 summarizes their data on the number
and percentage of patients with prescriptions
for psychoactive drugs. Over one-third (34.4
percent) of the patients had prescriptions

ithe figure cited here differs from that discussed in the text of the subcommittee report. The
subcommittee chose to focus on percentages calculated from total drug costs, which distorts
actual prescription patterns by injecting the added factor of variable costs between different
drugs. Percentages and ranks discussed here are based on the actual numbers of prescriptions.

25
''TABLE 7.—Number and percentage of 131 nursing home patients with prescriptions
for psychoactive drugs, by drug class

Patients with Prescriptions for

 

 

Drug Class One Drug Two Drugs Three Drugs Totals

Major tranquilizers

Number 39 5 1 45

Percent 29.8 3.8 0.8 34.4
Minor tranquilizers

Number 25 1 0 26

Percent 19.1 0.8 0 19.9
Antidepressants

Number 13 1 0 14

Percent 9.9 0.8 0 10.7
Hypnotics

Number 30 2 1 33

Percent 22.9 Led 0.8 25.2

SOURCE: Ingman et al. (1975)

for major tranquilizers, one-quarter (25.2
percent) had prescriptions for hypnotics,
one-fifth (19.9 percent) had prescription for
minor tranquilizers, and one-tenth (10.7 per-
cent) had prescriptions for antidepressants.
More patients (4.6 percent) had prescriptions
for two or three major tranquilizers than for
any other class of psychoactive drug.

Beardsley et al. (1975) conducted a study of
drug use among 270 patients (ages not given)
in five nursing homes in the Greater Minne-
apolis-St. Paul area. The nursing homes
were selected to represent different geo-
graphic locations, sizes, and types of owner-
ship. Data on drug use were collected by
two pharmacists who used patients! charts,
medication records, and nursing Kardex files.
Cases of drug use were recorded only if a
drug had been ordered by a physician and
had been administered within the month prior
to the review.

Among the 1,109 cases of drug use recorded
(an average of 4.1 per patient), psychoactive
drugs comprised 20.1 percent of the total.
As can be seen from table 8, the psychoactive
drug classes represented were sedative/hyp-
notics (9.1 percent), major tranquilizers (5.4
percent), minor tranquilizers (3.6 percent),
and antidepressants (2.0 percent). Roughly
a third of the patients were receiving seda-
tive/hypnotics and tranquilizers, while about
8 percent were receiving antidepressants.

Beardsley et al. (1975) also reported data on
the most frequently used individual drugs
within each drug class. As can be seen from
table 9, chloral hydrate was the most frequent-
ly prescribed hypnotic, issued to 12.2 percent
of the patient population. Mellaril was the
most frequently prescribed major tranquilizer,
issued to 11.1 percent of the patient popula-
tion. Valium was the most frequently pre-
scribed minor tranquilizer, issued to 9.3
percent of the population. Tofranil was the
most frequently prescribed antidepressant,
issued to 2.2 percent of the patient popula-
tion.

Published data on polypharmacy in nursing
homes are scarce. Ingman et al. (1975) found
that 4.6 percent of the nursing home residents
in their study were simultaneously receiving
more than one major tranquilizer, 2.3 percent
were receiving more than one hypnotic, and
fewer than 1 percent were receiving more
than one minor tranquilizer or antidepressant.
Beardsley et al. (1975) did not report poly-
pharmacy data specific to psychoactive drugs,
but for all drugs there was an average of
4.1 per patient, with a range from 0 to 15
per patient. They found the average number
of drugs per patient to vary in relation to
payment mechanism, with Medicare recipients
receiving 3.5 drugs, Medicaid recipients re-
ceiving 4.2, and patients with private third
party payments receiving 5.5. They also
found some variation between nursing homes, ©
ranging from a low average of 2.8 per patient
to a high average of 4.5. It is not clear,

26
''TABLE 8.—Number and percentage of psychoactive drugs prescribed in nursing
homes, by class of drug

Number of Cases

Percent of Those

Percent of Receiving Psycho-

 

Drug Class of Drug Use Total Cases active Drugs
Major tranquilizers 60 5.4 22.2
Minor tranquilizers 40 3.6 14.8
Antidepressants 22 2.0 8.1
Hy pnotics 101 9.1 37.4

TOTAL 223 20.1

NOTES:

Number of cases of drug use during the month prior to review was 1,109.

Because of polypharmacy, i.e., some patients receive more than one drug in a class,

the figures in this column are approximations.

However, these are good approximations

because the number of patients who use more than one drug in a class is very small.

SOURCE:

Adapted from Beardsley et al. (1975).

TABLE 9.—tIndividual psychoactive drugs most frequently prescribed in five nursing homes, by
class of drug

Percent of

Number of Cases Patients Who

 

Drug Class Drug Name of Drug Use Receive Drug
Major tranquilizer Mellaril 30 11.1
Minor tranquilizer Valium 25 9.3
Antidepressant Tofranil 6 2.2
Hypnotic Chloral hydrate 33 125.2

NOTES: The number of drug cases recorded is not the number of patients, as some patients

received more than one drug.

SOURCE: Beardsley et al. (1975)

however, to what extent those patterns may
hold true for psychoactive drugs.

It is difficult to make direct comparisons be-
tween the data of Ingman et al. (1975) and
Beardsley et al. (1975). It is not clear, for
example, to what extent their classification
systems overlap. Beardsley et al. combined
sedatives and hypnotics into one class, while
Ingman et al. did not specify which class in-
cludes sedatives. Another difference sur-
rounds the question of what constitutes a
"drug case." Beardsley et al. recorded only
those cases where drugs were actually adminis-
tered, while Ingman et al. recorded drugs

27

prescribed. As Ingman et al. pointed out,
53 percent of all "neuroactive" drugs in their
study (psychoactive drugs plus analgesics,
skeletal muscle relaxants, antiparkinson drugs,
and autonomic agents) were issued p.r.n.
(pro re nata, or according to need) so there
was substantial nurse discretion in administra-
tion; of the average 2.1 neuroactive drugs
per patient prescribed, an average of 1.3
drugs was actually administered.

Those differences notwithstanding, it appears
that major tranquilizers and hypnotics are
the classes of psychoactive drugs most fre-
quently prescribed in the nursing homes
''sampled. (Those findings are generally com-
patible with the GAO study cited earlier).
The data of Beardsley et al. on drugs actu-
ally administered indicated that over one-
third of the nursing home residents in their
sample received hypnotics (and sedatives),
and over one-fifth received major tranquil-
izers. The data of Ingman et al. on drugs
prescribed, which may overestimate actual
use because of p.r.n. orders, indicate that
over one-third of nursing home residents in
their sample were issued prescriptions for
major tranquilizers, while one-quarter received
prescriptions for hypnotics.

Psychiatric inpatients. Perhaps the most com-
prehensive reporting of data on elderly psy-

chiatric patients is that derived from a survey
of psychoactive drugs used in 12 Veterans
Administration hospitals, conducted in Febru-
ary 1974 by Robert Prien and colleagues
(Prien et al. 1976; Prien et al. 1975; Prien
1975). The survey was based on a sample
of 2,682 patients 60 years of age and over,
with 1,276 (48 percent) having a primary diag-
nosis of mental disorder, 197 (7 percent) hav-
ing an associated diagnosis of mental disorder,
and 1,209 (45 percent) having no diagnosis
of mental disorder. The sample was predomi-
nantly male, with no more than 6 percent
female in any diagnostic category. Diagnostic
categories were obtained from patients' medi-
cal records. Drug information was derived
from patients! medication orders, and included
all drugs administered on the day of the sur-
vey.

Of all patients 37 percent received at least
one major tranquilizer, minor tranquilizer, or
antidepressant. The proportion of psychia-
tric patients who received at least one drug
(56 percent) was substantially higher than
that of the nonpsychiatric patients (16 per-
cent). The patterns of use also differed be-
tween the two groups. Among the psychiatric
patients, major tranquilizers accounted for 69
percent of all psychoactive drug orders, with
antidepressants accounting for 17 percent
and minor tranquilizers accounting for 14 per-
cent. Among the nonpsychiatric patients,
minor tranquilizers accounted for 52 percent
of all psychoactive drug orders, followed by
major tranquilizers (33 percent) and antide-
pressants (15 percent). Five drugs--thiorida-
zine (Mellaril), chlorpromazine (Thorazine),
diazepam (Valium), chlordiazepoxide (Librium),
and amitriptyline (Elavil)--accounted for 63
percent of all psychoactive drug orders across
diagnostic groups (Prien 1975).

Prien et al. (1975) reported data on the prev-
alence of psychoactive drug use, by diagnos-
tic category, in the patient population with
primary diagnoses of mental disorder. Of

those 1,276 patients, 718 were diagnosed as
having organic brain syndrome, 362 were diag-
nosed as schizophrenic, and 196 had other
mental disorders. Of schizophrenic patients,
70 percent received psychoactive drugs (the
highest percentage), followed by those with
other mental disorders (66 percent) and those
with organic brain syndrome (55 percent).
Table 10 summarizes the data on the propor-
tion of psychiatric patients who received
specific psychoactive drugs, by diagnostic
category. Of the three drug classes repre-
sented, major tranquilizers were used most
frequently, with 44 percent of the psychiat-
ric patient population receiving at least one
drug in that class. Antidepressants (11 per-
cent) and minor tranquilizers (10 percent)
were used less extensively. The highest rate
of use of major tranquilizers was among schizo-
phrenic patients (62 percent), while the high-
est rates of use of antidepressants and minor
tranquilizers were among those with other
mental disorders (30 percent and 15 percent,
respectively). The most widely used major
tranquilizers across diagnostic groups were
thioridazine and chlorpromazine, which ac-
counted for 61 percent of all orders for major
tranquilizers; diazepam accounted for 53 per-
cent of all orders for minor tranquilizers;
and amitriptyline accounted for 37 percent of
all orders for antidepressants (data not
shown).

Laska et al. (1973), in their study of psycho-
active drug use among schizophrenic patients
in a State hospital, found patterns of use
that were generally consistent with those in
the survey by Prien et al. (1975). All drug
information was taken from the hospital's Drug
Monitoring System. Of the 587 schizophrenic
patients 65 years of age and over, 70.5 per-
cent were using major tranquilizers, 13.8 per-
cent were using antidepressants, and 8.2
percent were using minor tranquilizers (table
11). The percentage of women who used psy-
choactive drugs was substantially higher than
that of men in all three drug classes.

Prien et al. (1975) also reported data on the
proportion and dosage of psychoactive drug
use within different age categories of the psy-
chiatric patient population. Table 12 summar-
izes their findings. Contrary to findings for
the general population, it appears that both
the percentage of psychiatric inpatients re-
ceiving a drug and the mean daily dose of
the drug declined as age increased in all three
drug classes examined.

Laska et al. (1973) found a similar pattern
extended to a wider age range in their study
of schizophrenic patients. Among patients
over 20 years of age, there was a general
tendency for both the percentage of patients

28
''62

TABLE 10.—Percentage of psychiatric inpatients receiving psychoactive drugs, by diagnosis

Percentage of Those Diagnosed Who Receive Drug

 

 

Organic Brain Syndrome Schizophrenia Other Mental Disorders Total
Psychoactive Drugs* (N=718) (N=362) (N=196) (N=1, 276)

Major tranquilizers

Thioridazine 15 20 15 i?

Chlorpromazine 9 22 id 13

Trifluoperazine 2 8 4 4

Haloperidol 4 3 a 3

Others 9 L?, 13 12

Total receiving at least one

major tranquilizer 36 62 41 44
Minor tranquilizers

Diazepam 6 4 8 5

Chlordiazepoxide 3 2 5 3

Others 2 1 2 2

Total receiving at least one

minor tranquilizer 10 7 15 10
Antidepressants

Amitriptyline 3 2 15 4

Doxepin 1 2 6 2

Nortriptyline 2 2 4 2

Others 2 4 1 3

Total receiving at least

one antidepressant 8 9 30 1l

*Patients receiving more than one drug are listed under each drug.

SOURCE: Prien et al. (1975)
''TABLE 11.—Percent of

SOURCE:

drugs, by drug class

Tranquilizers

N Major Minor Antidepressants
Men 214 57.5 5.1 4.2
Women 373 78.0 9.9 19.3
Total 587 70:5: 8.2 13.8

Laska et al. (1973)

TABLE 12.—Use of psychoactive drugs by psychiatric inpatients, by age

Age of Patient

schizophrenic inpatients 65 years and over who received psychoactive

 

60-65 66-75 Over 75 All Ages
Psychoactive Drug Class and Dose (N=336) (N=328) (N=612) (N=1,276)

 

 

Major tranquilizers
Percent of patients who
receive drug 54 46 38 44
Mean daily dose (milligrams)! 310 255 152 229

Minor tranquilizers
Percent of patients who

receive drug 14 9 8 10
Mean daily dose (milligrams) 45 44 33 40
Antidepressants
Percent of patients who
receive drug 18 13 7 il
Mean daily dose (milligrams)? 93 86 74 85

1
Converted to equivalent doses of chlorpromazine.

2 Converted to equivalent doses of chlordiazepoxide.

3

All doses equivalent.

SOURCE:

Prien (1975)

30
''receiving a drug and the average daily dose
per drug to decrease as age increased (table
13).

Prien et al. (1976) reported data on polyphar-
macy patterns in their sample of elderly psy-
chiatric patients in Veterans Administration
hospitals. Of the sample of 1,276, 18 percent
received two or more psychoactive drugs; 21
percent of those with diagnoses of schizo-
phrenia and other mental disorders and 15
percent of those with diagnoses of organic
brain syndrome received multiple drug regi-
mens. The most frequently prescribed com-
binations were: 1) a major tranquilizer and
an antidepressant (23 percent of all polyphar-
macy prescriptions); 2) two major tranquil-
izers (21 percent); and 3) a major tranquilizer
and a minor tranquilizer or sedative-hypnotic
(21 percent). The proportion of patients
receiving two or more psychoactive drugs
decreased with age: 26 percent of the pa-
tients 60-65 years of age received two or
more drugs; 20 percent of the patients 66-75
years of age received two or more drugs;
and 12 percent of the patients over 75 re-
ceived two or more drugs. Substantially more
females (42 percent) received two or more
psychoactive drugs than did males (17 per-
cent), but the sample of females was so small
(N=50) as to restrict the validity of generali-
zation.

Fracchia et al. (1971) also reported polyphar-
macy data for a sample of 569 (137 male, 432
female) psychiatric patients 55 years of age
and older in a State hospital. The most fre-
quently prescribed combinations were: 1) a
major tranquilizer and an antidepressant-
stimulant (35 percent of all polypharmacy pre-
scriptions); 2) a minor tranquilizer and an
antidepressant-stimulant (17 percent); 3) a
major tranquilizer with a major tranquilizer
(16 percent); and 4) a major tranquilizer with
a minor tranquilizer (10 percent). There
was evidence to indicate that the use of major
tranquilizers in combination tended to decrease
with advancing age: 60 percent of the pa-
tients under the age of 65 received a major
tranquilizer as part of a combination, as com-
pared with fewer than 30 percent of those
over the age of 75. The use of minor tran-
quilizers as part of a combination, on the
other hand, increased with advancing age.

In summary, among the elderly psychiatric
inpatient populations sampled, major tranquil-
izers were found to be used much more exten-
sively than any other class of psychoactive
drugs. Prien found that major tranquilizers
accounted for 69 percent of all psychoactive
drugs used by psychiatric patients and that
44 percent of the psychiatric patients were
using at least one major tranquilizer (Prien

31

1975; Prien et al. 1975). Patients diagnosed
as schizophrenic were most likely to receive
major tranquilizers, with roughly two-thirds
of schizophrenic patients in two separate stud-
ies using at least one drug in that class.
Major tranquilizers were also most likely to
be used in combination with other psychoac-
tive drugs, most frequently with an antide-
pressant or another major tranquilizer.

Contrary to patterns found in the general
population, use of prescription psychoactive
drugs among the psychiatric inpatient popula-
tions sampled tended to decline with age.
That trend tended to hold true for both the
percentage of people using drugs and the
average dose per drug, as well as polyphar-
macy rates.

NONCOMPLIANCE, IMPROPER
PRESCRIBING, AND DRUG-
RELATED ILLNESS AND DEATH

The data presented thus far have focused
exclusively on patterns of prescription psycho-
active drug use among the elderly. It is also
important, on the other hand, to examine pat-
terns of misuse. Data on two types of misuse--
noncompliance and improper prescribing-~are
presented here, followed by a review of data
on drug-related illness and death.

Noncompliance

We were unable to locate any studies that
specifically addressed the extent of older peo-
ple's noncompliance with prescriptions for
psychoactive drugs. Other studies of noncom-
pliance shed little light on this issue. What
is presented here, then, is a brief review of
studies that outline only the broadest param-
eters of noncompliance.

In a review of noncompliance studies, Hussar
(1975) indicates that there has been a wide
variation between studies in terms of the de-
gree of noncompliance reported, with most

ranging from one-third to one-half of the pa-
tients sampled. Steward and Cluff (1972)

place the range at 25 percent to 59 percent.

For the most part, efforts to correlate demo-
graphic variables with noncompliance have
failed to discover any significant relationships
(Hussar et al. 1974). In a study of 154 gen-
eral medical clinic patients, Davis (1968) found
that demographic variables had no influence
on either attitudinal or behavioral compliance.
Boyd et al. (1974) found no significant rela-
tionship between noncompliance and sex, race,
or education in a sample of 134 outpatients.

A few studies, on the other hand, have found
that age has some effect on noncompliance,

 
''TABLE 13.—Percent of schizophrenic inpatients receiving psychoactive drugs and average total
daily dose, by age and by sex

 

 

Under 65 and All
Drug Class and Sex 16 16-20 21-40 41-64 Over Ages
PERCENT OF PATIENTS
RECEIVING DRUGS
Major tranquilizers
Male 89.3 96.9 94.7 76.1 67.15 80.5
Female 94.4 91.7 96.9 95.2 78.0 91.4
Male and female 90.6 95.0 95.6 86.0 70.5 85.8
Minor tranquilizers
Male 5.8 12.3 12.9 8.5 9.02 9.62
Female 8.3 22.2 17.6 11.3 1233 12.3
Male and female 6.5 15.8 14.8 9.9 8.2 10.7
Antidepressants
Male 24.3 21.5 14.6 ol 11.4 11.4
Female 47.2 30.6 21,8 18.1 20.0 20.0
Male and female 30.2 24.8 Lt.5 13.8 13.8 15.6
AVERAGE TOTAL DAILY
DOSE (Milligrams)
Major tranquilizers
(chlorpromazine standard)
Male 257.8 506.0 544.4 346.5 125.4 388.0
Female 154.9 481.1 725.0 478.3 181.4 459.1
Male and female 230.0 497.8 619.2 422.2 164.8 425.9
Minor tranquilizers
(chlordiazepoxide standard)
Male 21.7 36.3 44.3 30.9 42.6 40.8
Female 25.0 43.4 50.9 37.3 2169 38.1
Male and female 22.8 39.8 47.6 38.4 26.7 39.2
Antidepressants
(all doses equivalent)
Male 63.6 70.8 104.5 87.1 62.3 87.2
Female 60.3 90.4 102.7 88.0 65.5 84.5
Male and female 62.3 79.4 103.6 87.7 65.2 85.5

SOURCE: Adapted from Laska et al. (1973).

32
'' 

although the results are not consistent.
Latiolais and Berry (1969) conducted a study
of 180 indigent outpatients at a university
hospital; within the sample, 82 patients (45.5
percent) were 50 years of age and over, and
38 patients (21.1 percent) were 60 years of
age and over. Of the 77 patients who were
misusing their medications, Latiolais and
Berry found that 59.8 percent were over 50
years of age and 28.6 percent were over 60
years of age; conversely, of 103 patients who
correctly used their medications, 34.9 percent
were over 50 years of age and 15.5 percent
were over 60 years of age. In Chi-square
tests used to determine whether the relation-
ship between age and misuse was statistically
significant, they found that, when the sample
was divided into "over 50 years of age" and
"under 50 years of age," the significance
level was 0.1 percent; when the sample was
similarly divided at 60 years of age, the sig-
nificance level was 5 percent. Latiolais and
Berry (1969) concluded that older people are
more likely to misuse their medications.

Clinite and Kabat (1969), in a study of 30
men recently returned home after hospitaliza-
tion at a Veterans Administration hospital,
found contradictory results. Patients aged
71-80 had a lower rate of medication error
(9.6 percent) than any other group; however,
patients aged 81-90 had the highest rate
(42.9 percent). Those in the age groups
41-50 (42.5 percent) and 51-60 (36.5 percent)
had higher error rates than patients in the
61-70 age group (27.6 percent). The rela-
tionship between age and noncompliance, then,
revealed no clear pattern.

In a study of 178 chronically ill, ambulatory
clinic patients over the age of 60, Schwartz
et al. (1962) found that 68 percent of those
over 75 years of age made medication errors,
as opposed to 57 percent of those in the age
group 60-74; however, when finer age break-
downs were examined, the relationship between
medication errors and increasing age was con-
siderably less straightforward. In general,
the studies cited are too inconsistent to make
any conclusive statements about the relation-
ship between age and noncompliance.

Hussar (1975) has suggested that, while rela-
tionships between noncompliance and demo-
graphic variables have not been consistently
demonstrated, there are some patient-related
factors that contribute to noncompliance.
Specifically, he cites as being more likely to
be noncompliers, patients with chronic ill-
nesses requiring long-term therapy, patients
who live alone, patients with psychiatric ill-
nesses, and patients who receive several
drugs requiring frequent administration.
The elderly as a group have the highest

incidence of chronic illnesses, often live alone
(especially women) after the death of a spouse,
and receive a disproportionate share of pre-
scription drugs. When it is also considered
that patients with psychiatric illnesses may
tend to have higher rates of medication errors
(Willcox et al. 1965), there is at least a super-
ficial basis for speculating that noncompliance
rates among the elderly who receive prescrip-
tions for psychoactive drugs may be compara-
tively high. As yet, however, there are no
studies which verify that speculation.

In a related issue, Doyle and Hamm (1976)
have reported data which suggest that tend-
encies toward self-medication may have some
effect on the manner in which older people
use prescription drugs. Their study, based
on a sample of 405 persons 60 years of age
and older residing in three Florida counties,
indicated that older people sometimes decide
for themselves how they will use their medica-
tions, especially in terms of discontinuing
medications they do not like and generally
determining the duration of medication use.
Roughly 40 percent of the respondents indi-
cated that they do not continue to take medi-
cations that they dislike; only 43.3 percent
of the respondents reported that they took
medications until their doctor told them to
stop. While 18.8 percent stopped when their
prescriptions ran out, 18.3 percent stopped
when they felt better, and 3.8 percent stop-
ped when they thought they should. When
asked why they kept old prescriptions, a
large majority (82.2 percent) did not answer
the question; however, 12.8 percent re-
sponded that they might need them, and 2.4
percent said they had not thought about
throwing them out. A comparatively small,
though still significant, percentage of respond-
ents said they did not believe that sharing
of prescriptions is harmful (13.3 percent),
while 12.6 percent indicated that they had
shared, or would consider sharing, their pre-
scriptions.

Improper Prescribing

The issue of improper prescribing of psycho-
active drugs is one that deserves careful
study--especially in the case of the elderly,
who receive a disproportionate share of those
drugs. That issue is underscored by an ap-
parent lack of special vigilance on the part
of the elderly, as indicated in the study by
Doyle and Hamm (1976), who found that 71.6
percent of their sample did not discuss the
prescription of one doctor with another doctor,
74.8 percent asked no questions (about con-
tent, side effects, or cost) when filling their
prescriptions, and only 13.0 percent went to
see their doctor to have their medications
prescribed, while 30.3 percent simply called

33
'' 

TABLE 14.—pPercentage of nonconformance to criteria for psychoactive drug prescriptions in five
nursing homes

Nursing Home

 

Drug and Class A B Cc D E

Thioridazine

(major tranquilizer) 24.7 18.2 11.2 18.8 16.2
Chlor diazepoxide

(minor tranquilizer) 5.0 13.3 5.0 16.0 2.5
Amitriptyline

(antidepressant) 4.8 12.5 6.0 6.3 5.4
Chloral hydrate

(hypnotic) 1.8 0.4 0.8 0.5 25

SOURCE: Adapted from Stewart et al. (1976).

their doctor and 30.5 percent had the phar-
macist call the doctor.

Unfortunately, we were able to find only a
few studies that dealt with improper prescrib-
ing of psychoactive drugs among the elderly,
and their emphasis was primarily on psychia-
tric inpatients and nursing home residents.
While they do not necessarily constitute a
representative body of data, they do high-
light the need for additional research.

A 1971 DHEW study of 75 nursing homes,
cited in the report on drugs in nursing homes
of the Subcommittee on Long-Term Care of
the U.S. Senate Special Committee on Aging
(U.S. Senate 1973) provides some background
on the context of questionable prescribing
and administering of drugs. While much of
the information was reported in anecdotal
form, some interesting findings were pre-
sented: two-thirds of the patients sampled
had not been given physical exminations at
admission, and of those who did receive phys-
icals, less than one-third covered more than
3 of the 10 body systems; 40 percent of the
patients had not been seen by a physician
for over 3 months; only 18 percent of the
patients had received revised treatment of
medication orders within the past 30 days;
and 35 percent of the patients receiving tran-
quilizers had not had their blood pressure
recorded in over a year.

Beardsley et al. (1975), in a study of drug
use patterns in five nursing homes, at-
tempted to determine whether p.r.n. medica-
tions were justified. They analyzed patient
charts in order to correlate recorded symp-
toms with prescribed drugs. They found

34

that 37 percent of tranquilizer p.r.n. orders
and 35 percent of hypnotic p.r.n. orders
were not justified by the patient charts.
While it was not clear to what extent those
nonjustifications could be attributed to impro-
per prescribing or to improper recordkeeping,
the results at least raise questions as to the
appropriateness of the medication orders.

Stewart et al. (1976) attempted to measure
the degree of nonconformance to drug use
criteria of drugs prescribed in five nursing
homes. A single drug was selected to repre-
sent a drug class, and standards for proper
prescribing were based on a combination of
professional expertise and professional litera-
ture. Their results for psychoactive drugs,
expressed as percent nonconformance, are
summarized in table 14. The authors sug-
gested that the low percentage of nonconform-
ance for chloral hydrate most likely reflects
the small number of patients who received
the drugs more than three times a week.
The wide ranges of nonconformance rates for
amitriptyline and chlordiazepoxide are ascribed
to the small number of patients receiving
those drugs in the five nursing homes. The
most notable finding was the comparatively
high rates of nonconformance for thioridazine
(a major tranquilizer), the most frequently
ordered psychoactive drug in nursing homes
(NDTI 1975a,b).

In a study of 131 elderly nursing home pa-
tients, Ingman et al. (1975) found that pa-
tients with superior mental and physical

abilities actually received more neuroactive
substances (psychoactive drugs plus analge-
sics, skeletal muscle relaxants, antiparkinson
drugs, and autonomic agents) than did
''TABLE 15.—Percentage distribution oft drug abuse mentions, by age and facility type

 

 

Age :
50 and

Facility 6-9 10-19 20-29 30-39 40-49 Over, Total

Drug Abuse Warning Network
Emergency rooms ¥ 20 43 20 ll 6 100
Crisis centers * 40 50 7 2 1 100
Medical examiners * 8 43 20 13 16 100
Inpatient units 1 17 49 18 8 6 100
Total DAWN System * 27 44 16 8 5 100
1970 U.S. Census 18 17 15 12 12 26 100

*Less than 0.5 percent.

SOURCE:

patients with diminished mental and physical
capacities. The differences were significant
at the .05 level for both dimensions.

In a study of 53 female psychiatric inpatients
aged 62-89, Barton and Hurst (1966) con-
ducted a double-blind experiment in which
an inert syrup was substituted for chlorproma-
zine. Patients were rated along seven dimen-
sions by ward nurses, who did not know
whether the patients were receiving chlorprom-
azine or the placebo. When the last week of
chlorpromazine therapy was compared with
the third week of placebo administration, five
dimensions showed slight deterioration as meas-
ured by mean scores, while two dimensions
showed no significant change. Ward nurses
were unable to distinguish between patients
receiving chlorpromazine and those receiving
placebos. The results led the authors to con-
clude that 80 percent of the patients were
receiving tranquilizers unnecessarily.

While the studies cited above cannot provide
the basis for making generalizations about
the magnitude or pattern of improper prescrib-
ing of psychoactive drugs to the elderly, they
do provide at least some preliminary indica-
tions that the appropriateness of prescribing
practices needs to be examined in greater
depth and scope.

Drug-Related IlIness and Death

Another issue that needs to be explored in
relation to psychoactive drug use and the
elderly is the extent to which that use may
lead to drug-related illnesses or death. While
we found no studies that estimate the propor-

Drug Abuse Warning Network (1974-1975)

tion of the elderly population so affected,
there are some studies that provide informa~
tion on hospital admissions and deaths result-
ing from abuse of drugs.

One source of information is the Drug Abuse
Warning Network (DAWN 1974-1975), a nation-
wide system which continuously monitors drug
abuse contact reports from selected hospital
emergency rooms, hospital inpatient units,,
crisis centers, and medical examiners (coro-
ners). Although the DAWN data do not show
the percentages of older people who contact
the monitored facilities as a result of abuse
of psychoactive drugs, they do indicate gener-
al patterns related to age and types. of drugs
abused.

Based upon data on selected leading drugs
for the period April 1974 to April 1975, it
appears that nearly half of all drug mentions
are related to abuse of prescription psychoac~
tive drugs. Minor tranquilizers account for
19 percent of all drug abuse contact mentions,
followed by barbiturate sedatives (10 percent),
nonbarbiturate sedatives (7 percent), stimu-
lants (6 percent), and psychostimulants (2
percent). The most frequently mentioned ~
individual drug was diazepam, which ac~
counted for 10 percent of all mentions.

People aged 50 and over (the oldest age cate-
gory represented), who constitute 26 percent
of the U.S. population, accounted for 5 per-
cent of all mentions in the total DAWN system
(see table 15). That was the lowest propor-
tionate representation among all adult age

groups. The relatively low frequency of con-
tact may be partially explained by the fact

35
''that people aged 50 and over are much less
likely to abuse illicit drugs, thereby reducing
the overall likelihood that they would contact
the monitored facilities. (Petersen and
Thomas [1975], for example, found that dur-
ing 1972 no persons aged 50 and over who
contacted a Florida hospital for acute drug
reactions had done so as a result of abuse of
illicit drugs.)

The comparatively low frequency of contact,
however, also appears to carry over into the
prescription psychoactive drugs. While DAWN
data do not provide correlations between age
and all prescription psychoactive drugs, in-
formation on selected individual drugs may
be used as a rough indicator. Diazepam--the
most frequently mentioned drug of abuse in
the DAWN system--may serve as a case in
point: People aged 50 and over accounted
for only 7 percent of all diazepam mentions.
Figures for other individual drugs are similar:
chlordiazepoxide (8 percent); oxazepam (7
percent); phenobarbital (8 percent); butabar-
bital (8 percent); flurazepam (14 percent);
secobarbital (8 percent); and pentobarbital
(16 percent). Thus, it appears that the fre-
quency of contacts due to abuse of prescrip-
tion psychoactive drugs, as well as for all
drugs, is comparatively low among people aged
50 and over.

The largest proportion of mentions (16 per-
cent) accounted for by people aged 50 and
over come from medical examiners (see table
15). Nearly two-third (62 percent) of the
medical examiner mentions for people aged 50
and over were attributed to suicide gestures
or attempts, a figure that is nearly twice as
high as that for any other age group. A
majority of emergency room mentions (50 per-
cent) and inpatient unit mentions (53 percent)
for people aged 50 and over were attributed
to suicide gestures or attempts, figures which
were also higher than those for other age
groups.

Thus, it appears that people aged 50 and
over are less likely to contact any of the moni-
tored facilities (including medical examiners)
as a result of drug abuse than are other
adults, but when they do make contact, the
pattern reflects a disproportionately high rate
of deaths and suicide gestures or attempts.
The DAWN data do not indicate to what extent
those deaths or suicide attempts can be direct-
ly attributed to prescription psychoactive
drugs. (Benson and Brodie [1975] have sug-
gested that the high rate of chronic physical
and mental illness--especially depression
caused by social factors--among the elderly
contributes significantly to suicide attempts,
and that prescription psychoactive drugs are
often used as a means.)

Petersen and Thomas (1975), in a study of
acute drug reaction admissions to a Florida
hospital, provide some supplementary data to
the DAWN system, although the data are not
necessarily representative. Consistent with
the DAWN data, they found that, while people
aged 50 and over constituted 39.0 percent of
the county population served by the hospital,
they represented only 5.4 percent of all admis-
sions for acute drug reactions. Among those
people aged 50 and over who were admitted
to the hospital for acute drug reaction, nearly
two-thirds (61.7 percent) were white females.
Admissions for older females exceeded their
distribution in the county population, as did
admissions for older blacks (male and female).
Nearly half (49.0 percent) of all aged admis-
sions were for abuse of sedatives (as opposed
to 35.9 percent for all ages) and nearly a
third (31.9 percent) were for abuse of tran-
quilizers (as opposed to 24.4 percent for all
ages). Roughly a third (35.0 percent) of
aged admissions were associated with suicide
attempts, a figure that was generally consist-
ent with that for all ages (33.7 percent).
In comparable settings, the DAWN data indi-
cate that suicide attempts or gestures ac-
counted for 53 percent of inpatient unit
mentions for people aged 50 and over, as op-
posed to 28 percent for all ages. Thus, the
Petersen and Thomas data on suicide attempts
deviate from the patterns reported in the
DAWN system.

In summary, we found no data that indicate
the proportion of the elderly population for
which illness or death can be attributed to
abuse of prescription psychoactive drugs.
There is evidence, however, which suggests
that older people are less likely than other
adults to be admitted to hospitals or to die
as a consequence of abusing drugs. The
comparatively low percentages of older people
who contact DAWN-monitored facilities as a
result of abuse of selected prescription psycho-
active drugs, especially when considered in
conjunction with the NDTI data cited earlier,
suggest the possibility that older people may
be particularly responsible in their use of
those drugs.

OVER-THE-COUNTER PSYCHOACTIVE
DRUGS

The manner in which over-the-counter (OTC)
drugs are acquired and used makes it more
difficult to obtain data on the nature and ex-
tent of their use than for prescription drugs.
There are, for example, no equivalents to
physicians' records or patients' charts to
serve as useful data sources. Even

36
''TABLE 16.—Self-reported use of OTC psychoactive drugs during the past year, by age and by

 

 

 

 

by sex
Percent by Age Groups
Drug Class and Sex 18-29 30-44 45-59 60-74
Stimulants
Men 17 2 2 2
Women 8 1 * *
Sleeping pills
Men 8 4 3 7
Women 7 7 4 5
Tranquilizers
Men 4 1. 1 2
Women ll 6 3 2
All psychoactive OTC drugs
Men
Any use in past year 25 7 5 9
No use in past year 75 _93 95 91
Total 100 100 100 100
Women
Any use in past year 21 12 7 7
No use in past year _79 88 _93 393
Total 100 100 100 100

*Less than 0.5 percent.

SOURCE: Parry et al. (1973)

pharmaceutical industry data, which can pro-~
vide information on production and sales vol-
ume, cannot easily be correlated with user
characteristics. Unlike prescription drugs,
which are dispensed through a system involv-
ing the physician, pharmacist, and patient,
consumers purchase and use OTC drugs in
relative anonymity. The most likely source
of information, then, appears to be the con-
sumers themselves. .

In the survey of national psychoactive drug

use patterns by Parry et al. (1973), the inter-

views included questions related to use of

OTC psychoactive drugs. Table 16 summar-
izes the findings on the percentages of men
and women, by age group, who indicated use
of OTC psychoactive drugs during a l-year
period preceding the interview. The classes
of drugs represented are somewhat arbitrary
since, as the authors pointed out, many of
the tranquilizers used are advertised as hav~
ing tranquilizing effects, but actually have
the same ingredients as OTC sleeping pills.

In the 60-74 age group only 9 percent of men
and 7 percent of women reported use of any
OTC psychoactive drugs within the past year.
OTC sleeping pills were the most commonly
used drugs for both older men and women,
although the percentages were relatively low
(7 percent and 5 percent, respectively).

Unlike the patterns of prescription psycho-
active drug use, the extent of use of OTC
psychoactive drugs among older people is not
disproportionately high. The highest preva-
lence rates for OTC drugs are in the age
group 18-29,

The authors also reported data on OTC psy-
choactive drug use by geographic region,
education, and Index of Social Position. They
found use to be substantially higher in the
West than in other regions of the country,
and somewhat higher among those with more
education and higher social position. Since
those factors were not broken down by age
group, however, it is not clear to what
''extent those patterns, hold true for the age
group 60-74,

Only 3 to 4 percent of people in all age
groups indicated that they used both prescrip-
tion and OTC _ psychoactive drugs.

SUMMARY AND CONCLUSIONS

Roughly a third (32 percent) of the elderly
population (60-74 years of age) reported use
of a prescription or over~the-counter psycho-
_active drug within a l-year period. One-fifth
(21 percent) of older men and one-third (32
percent) of older women reported use of a
prescription psychoactive drug, while 9 per-
cent of older men and 7 percent of older
women reported use of an OTC psychoactive
drug.

The most widely used classes of prescription
psychoactive drugs among older men and
women were minor tranquilizers/sedatives (11
percent of older men, 25 percent of older
women) and hypnotics (7 percent of older
men, 8 percent of older women), both of
which were used by greater proportions of
older men and women than other age groups.
The most widely used class of OTC psychoac-
tive drugs among older men and women was
sleeping pills (7 percent of older men, 5 per-
cent of older women) although, as was the
case for all OTC classes, smaller percentages
of older men and women used them than did
those in the age group 18-20.

Older people (65 years of age and over) re-
ceived disproportionately high percentages of
orders for most prescription psychoactive
drugs sampled from the NDTI, especially
among the sedatives and hypnotics. As is
the general case in relation to prescribing
patterns by sex, older women received sub-
stantially more orders for psychoactive drugs
than did older men.

The data cited on prescription psychoactive
drug use among institutionalized elderly popu-
lations were inadequate for making general
statements about national patterns of use.
Among the studies reported, however, major
tranquilizers and hypnotics were found to be
the psychoactive drugs most widely used in
nursing homes. Major tranquilizers were the
psychoactive drugs most widely used among
elderly psychiatric inpatients, especially among
those diagnosed as schizophrenic; however,
contrary to use patterns in the general popu-
lation, both the percentage of people using
psychoactive drugs and the dosage per drug,

38

as well as the prevalence of polypharmacy,
tended to decline with increasing age.

Reported studies of noncompliance failed to
establish any significant relationship between
noncompliance and demographic variables.
In general, however, the magnitude of noncom-
pliance reported in various studies ranged
from 25 percent to 59 percent of patients sam-
pled. Data presented on the extent of im-
proper prescribing practices were insufficient
for generalization. Data on the percentages
of older people who contact hospitals, crisis
centers, and medical examiners (coroners) as
a result of abuse of drugs indicate that older
people are less likely to do so than are other
adults, although when they do make contact,
it is likely to be related to suicide attempts.

In general, the limited nature of most of the
published studies cited in this report has
made it impossible to present a comprehensive
profile of psychoactive drug use among the
elderly. To suggest that data are not avail-
able, however, is not to imply that data
sources do not exist; on the contrary, the
potential for research in the area of psycho-
active drug use and the elderly is promising.
The National Disease and Therapeutic Index,
for example, is rich in unmined information.
NDTI data could be broken down by age,
sex, type of drug, diagnosis, and location of
patient, constituting a comprehensive national
sample of prescription psychoactive drug
orders. A major drawback of the NDTI, un-
fortunately, is that it is a privately published
data source, thereby restricting access and
publication potential; it is also based on volun-
tary reporting, which may affect its represent-
ativeness. Physicians' records, pharmacists!
records, and patient interviews are other
sources of data that could be utilized for
national or regional samples.

In terms of directions for further research,
more information is needed on the nature and
extent of psychoactive drug use among the
elderly. The survey by Parry et al., for
example, provided very useful data on na-
tional patterns of psychoactive drug use; how-
ever, it dealt with only the broadest classes
of psychoactive drugs (combining minor tran-
quilizers and sedatives), and it did not sur-
vey the elderly living in institutional settings.
Ideally, future research could provide more
information on prescribing and use of individ-
ual drugs as well as drug classes, and corre-
late the data with diagnoses and location of
the patient (nursing home, hospital, etc.).
Such a profile could provide better insights
into the reasons why older people use (or
are issued) psychoactive drugs, in addition
to providing more detailed information on pat-
terns of use.
'' 

More information is also needed on the extent
of, and reasons for, misuse of psychoactive
drugs. The studies of noncompliance, for
example, have not generally been comprehen-
sive enough to develop an accurate picture
of the extent to which older people make med-
ication errors for prescription drugs in gen-
eral, or for psychoactive drugs in particular.
Another issue that deserves particular atten-
tion is the improper prescribing and adminis-
tering of psychoactive drugs. Older people
would appear to be especially vulnerable to
improper prescribing since the physiological
changes associated with aging can have a sig-
nificant effect on the way in which drugs
are metabolized (Piland 1977). In addition,
there has been some suggestion that the pre-
scribing and administering of drugs in nurs-

ing homes are often accomplished without
adequate safeguards, and are sometimes
carried out with the regimen of the home as

a primary consideration (U.S. Senate 1973;
Learoyd 1972). As a general principle, the
disproportionate use of psychoactive drugs
by the elderly should warrant a close examina-
tion of the appropriateness of that use.

As a final comment, it has been apparent
throughout this report that the reliance on
individual case studies has often led to situa-
tions where data were not comparable due to
differences in methodology or categories em-
ployed. The development of a data base on
psychoactive drug use and the elderly would
seem to require some future efforts to insure
greater consistency between studies.

39
''REFERENCES

Abelson, H.I., and Atkinson, R.B. Public Experience with Psychoactive Substances. Response
Analysis Corporation, 1975.

 

American Health Care Association. Long Term Care Facts. 1975,

Balter, M.B., and Levine, J. The nature and extent of psychotropic drugs usage in the United
States. Psychopharmacological Bulletin, 5:3-14, 1969.

Barton, R., and Hurst, L. Unnecessary use of tranquilizers in elderly patients. British

Journal of Psychiatry, 112:989-990, 1966.

Beardsley, R.; Heaton, A.; Kabat, H.; and Martilla, J. Patterns of Drug Use in Nursing Home
Patients. Minneapolis, Minn.: University of Minnesota, College of Pharmacy, 1975.

Benson, R.A., and Brodie, D.C. Suicide by overdoses of medicines among the aged. Journal
of the American Geriatrics Society, 23:304-308, 1975,

 

Boyd, J.R.; Covington, T.R.; Stanaszek, W.F.; and Coussons, R.T. Drug defaulting: Analy-
sis of noncompliance patterns. American Journal of Hospital Pharmacy, 31:485-491, 1974.

 

Clinite, J.C., and Kabat, H.F. Errors during self-administration. Journal of American Pharma-

cological Association, NS9:450-452, 1969.

Conference on Drug Use and the Elderly. Sponsored by the National Institute on Drug Abuse
and the National Institute for Drug Programs, June 12-13, 1975.

 

Davis, M. Physiologic, psychological, and demographic factors in patient compliance with doctors!
orders. Medical Care, 6:115-122, 1968.

Department of Health, Education, and Welfare, Task Force on Prescription Drugs. The Drug
Users. Washington, D.C.: U.S. Government Printing Office, 1968.

Doyle, J.P., and Hamm, B.M. Medication Use and Misuse Study Among Older Persons. Jackson-
ville, Fla.: The Cathedral Foundation of Jacksonville, Inc., 1976.

 

Drug Abuse Warning Network. Project DAWN III. Rockville, Md.: National Institute on Drug
Abuse, 1974-1975.

Fracchia, J.; Sheppard, C.; and Merlis, S. Combination medications in psychiatric treatment:
Patterns in a group of elderly hospital patients. Journal of American Geriatrics Society,
19:301-307, 1971.

 

Guttman, D. A Survey of Drug-Taking Behavior of the Elderly. Rockville, Md.: National Insti-
tute on Drug Abuse, 1977.

 

Hussar, D.A. Patient noncompliance. Journal of American Pharmacological Association, 15:183-
190, 1975.

 

Hussar, D.A.; Boyd, J.R.; Covington, T.R.; Stanaszek, W.F.; and Cousson, R.T. Drug de-
faulting: Determinants of compliance. Part I. American Journal of Hospital Pharmacy, 31:
362-367, 1974,

 

Ingman, S.R.; Lawson, I.R.; Pierpadi, P.G.; and Blake, P. A survey of the prescribing and
administration of drugs in a long-term care institution for the elderly. Journal of American

Geriatrics Society, 23:309-316, 1975.

Laska, E.; Varga, E.; Wanderling, J.; Simpson, G.; Logeman, G.W.; and Shah, B.V. Patterns
of psychotropic drug use for schizophrenia. Diseases of the Nervous System, 1973.

 

40
'' 

Latiolais, C.J., and Berry, C.C. Misusé of prescription medication by outpatients. Drug Intel-
ligence and Clinical Pharmacology, 3:270-277, 1969.

 

Learoyd, B.M. Psychotropic drugs and the elderly patient. Medical Journal of Australia, 1:
1131-1133, 1972.

 

Manard, B.B. Old Age Institutions. Lexington, Mass.: Lexington Books, 1975.

National Disease and Therapeutic Index. Ambler, Pa.: IMS, 1975a.

 

National Disease and Therapeutic Index. S.v., Leading drugs in nursing homes. Ambler, Pa.:
IMS, 1975b.

 

Parry, H.J.; Balter, M.B.; Mellinger, G.D.; Cisin, I.H.; and Manheimber, D.I. National pat-
terns of psychotherapeutic drug use. Archives of General Psychiatry, 28:769-783, 1973.

 

Petersen, D.M., and Thomas, C.W. Acute drug reactions among the elderly. Journal of Geron-
tology, 30:552-556, 1975.

Piland, N.F. The aging process and psychoactive drug use. SRI International, 1977.

Prien, R.F. A survey of psychoactive drug use in the aged at Veterans Administration hospitals.
Aging, 2:143-154, 1975.

Prien, R.F.; Haber, P.A.; and Caffey, E.M. The use of psychoactive drug in elderly patients
with psychiatric disorders: Survey conducted in 12 Veterans Administration hospitals.
Journal of American Geriatrics Society, 23:104-112, 1975.

 

Prien, R.F.; Klett, C.J.; and Caffey, E.M. Polypharmacy in the psychiatric treatment of elder-
ly hospitalized patients: A survey of 12 Veterans Administration hospitals. Diseases of the

Nervous System, 37:333-336, 1976.

Schwartz, D.; Wang, M.; Zeitz, L.; and Goss, M.E.W. Medication errors made by elderly,
chronically ill patients. American Journal of Public Health, 52:2018-2029, 1962.

 

Steward, R.B., and Cluff, L.E. A review of medication errors and compliance in ambulant pa-
tients. Clinical Pharmacology and Therapy, 13:463-468, 1972.

 

Stewart, J.E.; Kabat, H.; and Wertheimer, A.I. Drug usage review sample studies in long-term
care facilities. American Journal of Hospital Pharmacy, 33:138-144, 1976.

 

U.S. Senate Special Committee on Aging, Subcommittee on Long-Term Care. Drugs in Nursin
Homes: Misuse, High Costs, and Kickbacks. (Supporting Paper #2). Washington, D.C.:

U.S. Government Printing Office, 1973.

 

U.S. Senate Special Committee on Aging, Subcommitte on Long-Term Care. Nursing Home Care
in the United States: Failure in Public Policy. (Introductory Report). Washington, D.C.:
U.S. Government Printing Office, 1975.

 

Willcox, D.R.C.; Gillan, R.; and Hare, E.H. Do psychiatric outpatients take their drugs?
British Medical Journal, 2:790-792, 1965.

4)
''''PSYCHOACTIVE DRUG MISUSE AMONG THE
ELDERLY: A REVIEW OF PREVENTION AND
TREATMENT PROGRAMS

James Gollub

INTRODUCTION

The elderly consume over 25 percent of all
prescription drugs. An increasing proportion
of these prescriptions is accounted for by
psychoactive drugs, defined in this paper as
major and minor tranquilizers, antidepressants,
stimulants, sedatives, and hypnotics.

There is growing, though limited, evidence
of intentional and nonintentional misuse of
psychoactive drugs by the aged, often result-
ing in physical and social harm (Eisdorfer
and Stotsky 1977). Sometimes faulty diagno-
sis and application by the physician is the
causal factor, while in other cases the individ-
ual may make a deliberate choice to misuse a
drug, or may simply make a mistake.

Recognition of this problem has led to the
development of intervention programs both
for more accurate diagnoses of symptoms aris-
ing from complex medical and psychosocial
problems and as environmental supports that
afford the older individual an alternative to
the misuse of psychoactive drugs. Only a
few programs have been identified which are
directly concerned with drug misuse by the
elderly; however, other existing service pro-
grams could provide the basis for expansion
or modification of service components to deal
with drug abuse among aged persons. This
report provides overviews of 1) programs
that monitor the diagnosis, prescription, and
administration of psychoactive drugs, and 2)
programs designed to intervene in psychoac-
tive drug misuse among the elderly.

43

A survey of the literature on drug misuse
among the elderly reveals that misuse occurs
at any point in the continuum of health care.
Ten factors conducive to the misapplication
or misuse of psychoactive drugs among the
elderly have been identified in this report
and fall into two categories: those attribut-
able to health professionals and those attribut-
able to the elderly. Actions for which health
professionals may be responsible include:

e Inaccurate diagnosis

Inaccuracies in drug treatment

e Polypharmacy, including failure to consider
drug interactions

e Deliberate overmedication of arbitrary medi-
cation (institutional patterns).

Misuse by elderly persons includes:

e Drug overdoses, due either to emotional
disturbance or to error

e Misuse, due to behavior resulting from
organic brain disease

e Use of multiple prescriptions without the
physician's knowledge

e Overuse of prescriptions without the physi-
cian's knowledge, including improper use
of automatic refills and telephone prescrip-
tions

e Exchange of drugs between individuals

e Use of expired drugs

The conditions that contribute to the misuse
of psychoactive drugs among the elderly have
been the subject of intervention programs in
medicine, pharmacy, psychiatry, nursing,
social work, and other related areas.
''METHOD

The information for this report was derived
from an extensive survey of the literature in
the field of health and social services, supple-
mented by interviews with, and materials from,
researchers and service providers in the fields
of gerontology, psychiatry, psychopharmacol-
ogy, pharmacy, nursing, drug-abuse interven-
tion, and social work.

The search for programs dealing with the
misuse of psychoactive drugs among the elder-
ly revealed that very few such programs exist.
Most programs are not concerned specifically
with the elderly as the sole or major client.
Although there are social service programs
which serve the elderly consumer--such as
hospitals, nursing homes, pharmacies, clinics,
and community mental health programs--these
programs are not reviewed in this report.
This report reviews programs directly rele-
vant to the problem of psychoactive drug use
among the elderly.

Intervention programs that address the prob-
lem of psychoactive drug misuses by the el-
derly fall into two categories which reflect
_ the current policies of health care and social
service providers. The first category of inter-
vention programs, initiated by health care
providers, deals with errors of diagnosis,
prescription, and drug administration by the
health professional. This category includes
programs of medical and psychiatric diagnosis
that ensure appropriate treatment of the aged
as well as retroactive and continuous drug-
consumption monitoring in inpatient and outpa-
tient settings (including mental health centers,
nursing facilities, and housing environments).

The second category consists of those pro-
grams specifically designed to permit interven-
tion in, and treatment of, the problems of
psychoactive and other drug misuse among
the elderly. Programs addressing this prob-
lem include chemical dependency outreach,
referral, treatment, and followup programs;
acute- and chronic-care programs for alco-
holics and drug users; drug education pro-
grams; peer counseling; and _ behavioral
therapy. These programs are initiated by
health care professionals, by social service
agencies, and sometimes by concerned individ-
uals,

PROGRAMS THAT MONITOR THE DIAGNOSIS,
PRESCRIPTION, AND ADMINISTRATION OF
PSYCHOACTIVE DRUGS

INTRODUCTION

The increased sensitivity to drugs among
older persons, and the potential for altered
effects when drugs are used in combination,
are important reasons why drug users and
drug regimens should be carefully scrutinized
by medical personnel. Pharmaceutical re-
searchers and physicians in recent years have
focused on the related issues of diagnosis of
disorders, accurate prescribing for the elder-
ly, general control of monitoring of the pre-
scription process, and patterns of use by
specific client groups. Much of this focus
has been aimed at developing improved moni-
toring tools for institutions and community
pharmacies, and on increasing the knowledge
of medical practitioners in the area of drugs
and their applications to and use by the elder-
ly. Efforts to develop programs of interven-
tion and alternatives to psychoactive drug
use by the aged include the following:

e Improved diagnostic procedures

e Improved physician knowledge of age-
oriented prescribing of medications

e Alternative methods of administering drugs

e Computerized and manual evaluations of
drug use and impact in institutions, in
the community, and in training programs

e Increased involvement of pharmacists in
drug monitoring

The following sections of this report provide
overviews of programs in“ each category.

THE ROLE OF DIAGNOSTIC
PROCEDURES AND PROGRAMS IN
REDUCING PSYCHOACTIVE DRUG MISUSE

Accurate diagnosis in the treatment of the
elderly is crucial to the reduction of drug
misuse, either intentional or nonintentional.
Changes that occur in the social life, physio-
logic structure, and psychosocial environment
of the older person often produce symptoms
deceptively similar to those of more serious
disorders, such as organic brain syndrome
(Fann et al. 1976). In some instances, the
solution is as simple as recognizing that the
presenting problem is nonpsychiatric and
therefore does not require a prescription for
psychoactive drugs. The physician who under-
stands the symptomatology of disease and
aging will be better able to determine when
it is more appropriate to suggest a social

44
''worker than to prescribe a psychoactive drug
(Hall 1973).

Conversely, failure to diagnose psychiatric
disturbance can lead to faulty treatment and
create new medical problems for the older
person. Burville (1971) points out that men-
tal problems are overlooked in up to 50 per-
cent of any group of medical or surgical
patients. The probability of nondiagnosis of
mental disorder in the elderly patient, where
an underlying mental disorder may be masked
by a somatic complaint, is even higher
(Mechanic 1972). Schuckit et al. (1975) also
stress the need for accurate diagnostic cri-
teria applicable to older populations. Using
personal interviews and chart reviews,
Schuckit et al. (1975) established the preva-
lence of unrecognized psychiatric disorders
in elderly medical and surgical patients at a
Veterans Administration hospital. They at-
tempted to integrate present criteria for these
disorders into their diagnostic procedure
(Alexander 1972; Foley 1971) and identified
major mental undiagnosed disorders in 24 per-
cent of their study population. This identi-
fication of undiagnosed disorders suggests
that there is great potential for improvement
of medical treatment of the aging patient,
with particular reference to the prescription
of psychoactive medications.

The two programs discussed below provide
examples of diagnostic services geared specif-
ically toward the geriatric patients, which
help reduce the likelihood of improper diag-
noses. Services include clinical assessment
from a multidisciplinary approach, education,
and consultation with physicians, patients,
and families.

The Philadelphia Geriatric Center

Psychological assessment of the elderly has
been considered at length by members of the
Philadelphia Geriatric Center, who have devel-
oped a program specifically oriented toward
the clinical assessment of the older person
for the purpose of determining appropriate
treatment (Whelihan 1976).. The Philadelphia
Geriatric Center's Baer Consultation and Diag-
nostic Center uses a multidisciplinary approach
and assesses function from biomedical, psycho-
logical, and social points of view. The diag-
nostic process includes a complete medical
history and physical examination, medical
laboratory and pulmonary function tests,
X-ray and electrocardiograph studies, oph-
thalmological and audiometric examinations,
neurological and EEG studies, social work
and evaluation of activities of daily living,
nutritional assessment, and psychological and
psychiatric examinations. Computerized

tomography studies and brain scans are fre-
quently performed.

The diagnostic procedures are followed by a
team conference, where the findings of the
various disciplines are analyzed and inte-
grated to provide a picture of overall
strengths and weaknesses. At a second con-
ference, the client and his or her family re-
ceive a detailed verbal report. Reports from
each discipline are then sent to the primary
care physician; a shorter report in layman's
language is forwarded to the client. A 6-
month followup monitors progress.

The psychologists systematically evaluate cog-
nitive, behavioral, and emotional functioning
in the elderly client. Functional analysis of
the person vis-a-vis the environment (Lawton
1970) and the administration of psychological
tests designed specifically for the elderly

client assure that all areas of functioning are
considered. Incorporation of both neuropsy-
chological and psychological assessment tests
in a single diagnostic package increases cor-
roboration of observations concerning behav-
ioral symptoms and physiological damage, and
it also enhances the probability of correct

treatment, thus reducing the likelihood of

inappropriate use of psychoactive drugs.

Southeast/Bayview Mental Health
Center, Geriatric Services Program

The Southeast/Bayview Mental Health Center,
Geriatric Services Program, in San Francisco,
California, also shows that evaluation and
health service delivery media can play a cri-
tical role in ascertaining the specific mental
and physical health needs of older adults be-
fore they are prematurely or inappropriately
assigned to _ institutional settings.

The Geriatric Services Program uses a multi-
disciplinary service team of psychiatric social
workers, psychiatrists, and a senior aide.
A physician is available for consultation and
medical assessment, when indicated. The
program emphasizes prompt evaluation, treat-
ment, and followup in the care of the elderly.
Precrisis intervention is aimed at maintaining
the elderly person at optimum functioning in
his or her own home. Home services are a
major mode of treatment, supplemented by
day-hospitalization for those who require it.

Primary prevention, including education, con-
sultation, and community organization services,
focuses on the causative factors of mental
illness in the elderly. Secondary prevention
uses geriatric evaluation techniques to distin-
guish between irreversible chronic brain dis-
ease and acute reversible brain syndrome due
to drug toxicity, electrolyte imbalance,

45
''infection, vitamin deficiency, endogenous de-
pression, or malnutrition (all of which can
cause an individual to manifest overt symp-
toms simjlar to those of chronic organic brain
syndrome). The diagnosis of disorders other
than chronic brain syndrome often enables
older persons to be treated in their homes,
thereby preventing  institutionalization.

The immediate priorities of the program in-
clude:

e Distribution of Resources Handbook for
Seniors

 

e Identification of residents in need of serv-
ice and treatment by Geriatric Services
staff; aggressive case finding, development
of followup-care and after-care programs
for the elderly in their own homes and
care facilities; liaison with Napa State Hos-
pital for evaluation of patients and their
return to the community, where appropriate;
and implementation of State-mandated con-
tinuing care services to track, link, moni-
tor, and refer certain patients who have
been discharged from crisis outpatient serv-
ices.

THE ROLE OF PRESCRIPTION AND
ADMINISTRATION CONTROLS IN
REDUCING PSYCHOACTIVE DRUG MISUSE

After a specific mental disorder has been
appropriately diagnosed, there still remains
ample opportunity for misapplication of thera-
peutic treatment. The source of error in
these cases is not related to selection of treat-
ment, for there are fairly standard guidelines
for the application of psychoactive drugs to
the treatment of psychiatric disorders. The
problem is related to the effect of the physio-
logical changes that occur with age on the
older person's sensitivity to and tolerance of
specific drugs. The hazards that may be
related to physiologic change are also com-
pounded when a multiple drug regimen is used.

In response to the problems of drug/person
compatibility, pharmacists and doctors have
evolved guidelines for use in prescribing for
the elderly. Among the examples of guide-
lines discussed below are the review of factors
related to patient history, current mental and
physical status, and actual amounts of drugs
required for therapeutic results.

Lamy Approach

Lamy has developed procedures for reducing
drug misuse in his own clinical practice.
Lamy (1976) points out the hazard that drugs
may pose to the aged, particularly certain
psychoactive drugs such as the phenothiazines

and barbiturates, and suggests that many
drug-induced illnesses are not detected be-
cause of their similarity to stereotypical
aspects of old age such as forgetfulness, weak-
ness, confusion, tremor, anorexia, and anxiety.

Lamy urges caution in geriatric prescribing

based on physiological and pharmacological

difference in treating the aged, and suggests
a careful drug history and periodic review of
drug consumption. He also states that the

wise physician will not take for granted that
the patient a) has the prescription filled, b)
understands how to take the medicine, c) is
taking no medication other than that which

the physician has prescribed, d) continues

to take the prescribed drug, and e) accu-

rately reports intake and adverse reactions.
Lamy proposes a systematic approach to pre-
scribing for the geriatric patient, a system

that would include careful diagnosis, record-
keeping, and reevaluation of the treatment.

He also believes that pharmacy records and
drug labeling are important tools to insure

proper use of prescribed drugs.

Hall Approach

Hall (1973) also recognized the need for extra
caution when treating the elderly with phar-
macologically active drugs and drew up a list
of simple rules pertaining to drug use by
the elderly. These rules constitute an
informal program that, within the context of
Lamy's more comprehensive process, might
promote more careful prescription and use of
psychoactive drugs among the aged (De Groot
1974). The program consists of six points:

e Knowledge of the pharmacological action of
the drug, and how it is metabolized;

e Use of the lowest effective dose in the
individual patient; in practice, this means
that the dosage should always be titrated
with patient response;

e Use of the minimum number of drugs neces-
sary; since memory tends to deteriorate
with age, patients may neglect to take their
medications if drug regimens are too com-
plex;

e Avoidance of the use of drugs to treat
symptoms, seeking rather to treat the
cause; mental disturbance in the elderly
patient is often diagnosed as senile psycho-
sis without adequate consideration of alter-
native diagnoses;

e Neither withholding medication because
the patient is "too old" nor continuing to
use a drug when its side effects are worse
than the patient's original symptoms; and

46
''e Use of a drug for no longer a period than
is necessary.

Drug Spotlight Program

The Drug Spotlight Program is another infor-
mational program designed to improve pharma-
cists' and physicians' knowledge of drug
qualities and interactions. Through the joint
efforts of several national hospitals and med-
ical, nursing, and pharmacy groups, a
program of continuing education has been
initiated that is aimed at helping pharmacy
and therapeutic committees of local hospitals
review and, when necessary, improve drug
therapy. The Drug Spotlight Program was
initiated by the American Society for Clinical
Pharmacology and Therapeutics; participants
include the American Academy of Family Phy-
sicians, the American College of Pharmacists,
the American College of Surgeons, and many
other professional organizations. The specific
goals of the Drug Spotlight Program (Reilly
1972) are:

e To achieve maximally effective drug thera-
Py;

e To reduce the incidence of serious adverse
drug reactions; and

e To achieve the lowest cost for drug thera-
py compatible with maximum effectiveness
and safety.

A national advisory committee selects four
drug groups to be "spotlighted" during the
coming year, and suggests that these drugs
be the focus of study by local hospitals, phar-
macies, and therapeutic committees. The
activities of the Drug Spotlight Program also
include publication of scientific papers and
editorials on the subject of the target drugs.

ALTERNATIVE METHODS
OF DRUG ADMINISTRATION

Researchers in pharmacy and medicine have

also initiated experimental programs that offer
alternative approaches to the traditional pat-
terns of drug administration, programs that

may help avert specific types of drug misuse.
In the two approaches described below, one

emphasizes the value of teaching inpatients

how to self-medicate in preparation for their

release, while the other focuses on minimizing
medication error by reducing drug dosages

to once per day.

Libow and Mehl Approach
Libow and Mehl (1970) piloted a program using

patient self-administration of therapeutic drugs
to circumvent the problems a person encoun-

ters when he or she must adjust to self-
administration of medications following release
from a hospital or nursing home. In this
program, 20 elderly, frail, chronically ill pa-
tients were given medications for self-admini-
stration while in the hospital. They were
judged by nurses and staff to be in a "good"
mental state, resembling that of the physically
ill elderly who reside in the community. The
subjects in this program had significant medi-
cal diseases. In some cases the disease was
in the subacute phase; in others, it was qui-
escent. The test "medications" were placebos
(sugar), which patients were told would in-
crease "appetite and strength." The medicine
was issued in the usual pharmacy vial with
the usual label, accompanied by verbal instruc-
tions from the physician. The subjects were
instructed when and how much to take of the
medication. Every few days, the physician
counted the remaining medications in each
vial and questioned the patients about their
general well-being, appetite, and strength.

Of the 20 patients self-administering their
medicines, five made errors. In 588 oppor-
tunities, there were 14 errors (2.3 percent);
6 errors were made by one patient. The
results show impressive abilities for self-
administration of medication, although this
was probably enhanced by the structure of
the study. The study period was brief, and
participation was stimulating for the patients.
The approach permits the patient to "learn"
the medication schedule while under the "teach-
ing" direction of the hospital staff. The in-
abilities raise questions about realistic post-
hospital medication planning, e.g., should
diuretics be given parenterally or orally;
should prescribed drugs be variously shaped
rather than several white tablets; and what
would be the most convenient schedule? The
ultimate goals of this program are to free
nursing time for other tasks, to reduce post-
hospital morbidity caused by patients! medica-
tion errors, and reduce hospital costs.

Ayd Approach

Drug administration within the psychiatric
institution has been explored by Frank Ayd,
Jr. (1975), who suggests a program of once-
a-day drug dosage as a means of reducing
noncompliance, the hazards of polypharmacy,
and the unnecessary use of psychoactive
drugs by the aging patient. Ayd argues that
the aging brain is particularly sensitive to
psychopharmaceuticals and that it is likely
that at least 20 percent of psychogeriatric
admissions are precipitated by the adverse
effects of psychoactive drugs (Learoyd 1972).
Polypharmacy and the consequent complexity
of drug schedules complicate administration
and are a burden on nurses. Error is

47
'' 

inevitable, increasing in frequency with the
complexity of drug regimens.

Ayd suggests that the total daily dose of many
drugs now prescribed in divided doses could
be administered once or twice daily, in the
morning and/or evening. This pattern of
administration has several advantages: 1) a
single dose is more convenient for both pa-
tient and staff than divided daily doses; 2)
outpatients who self-medicate, and families
who have to medicate patients, find a single
daily dose convenient, easy to remember, and
economical.

Ayd refutes the objection that single-dose
administration may increase side effects.
DiMascio and Shader (1969) address claims
that a single dose may be less effective than
divided doses: "While few studies have shown
a clinical superiority of the daily or twice
daily schedule over the multiple dose schedule,
none have reported the reverse." While such
a program has yet to be tested extensively,
it represents another attempt to minimize the
problems encountered by the elderly in their
use of drugs.

MONITORING THE PRESCRIP-
TION AND USE OF DRUGS

Formalized methods for monitoring drug use
have existed for a long time, particularly in
institutional settings; however, the processes
of prescribing, dispensing, administering,

and taking drugs (Brodie 1971) have often

been studied for their role in fiscal manage-
ment of medical supplies, rather than as a

mode for ensuring appropriate therapy for

patients.

Pharmacists have long had the opportunity to
informally monitor drug prescription--both
by reviewing amounts and dosages in the dis-
pensing area and by checking the appropriate-
ness of drugs selected in the ward (Knoben
1976). In the case of the community pharma-
cist, a review of a patient's history of drug
use when comprehensive drug profiles are
available can be accomplished, although some
studies indicate that profiles have not been
adequately used in determining actual or po-
tential drug interaction hazards (Nelson et
al. 1976). If a drug is given in the hospital
or nursing home, the nurse provides another
review of drug and dosage prior to administra-
tion.

Utilization studies of specific drugs or classes
of drugs have been conducted by pharmacy
and therapeutics committees, either routinely
or in response to a potential problem. The
ongoing medical audit of care, normally carried

48

out by hospital review committees, generally
includes a review of the treatment regimen.

Methods for carrying out drug monitoring
and utilization studies have become highly
technical in recent years. Computers, and
the use of remote terminals at pharmacies and
clinics, have enabled programs to maintain
updated medical and pharmacy records of many
patients and customers, as well as to compare
drugs in use for interactive potential and for
indicators of overuse and expiration of pre-
scriptions.

Innovative programs for monitoring drug pre-
scription and use are discussed below and
include computer monitoring programs, com-
munity monitoring programs, institutional
monitoring programs, programs in training
monitoring skills, and drug use evaluation
programs. While these programs do not
directly address the problem of drug misuse
by the elderly, the problem is subsumed in
their broad applicability.

Computer Monitoring and
Utilization Programs

Computer drug utilization review (DUR) pro-
grams are a new dimension in monitoring insti-
tutional patterns of drug prescription and
consumption. Computer systems are used
most frequently in institutional studies because
of the greater accessibility of both patient
medication data and data-processing equipment.
However, computer drug utilization systems
have also been used in the community to iden-
tify patterns of drug prescription and use
by community pharmacy clients and by out-
patients in health maintenance organizations
and medical clinics. Prospective review sys-
tems are located at the Los Angeles County-
University of Southern California (LAC-USC);
the Medical University of South Carolina,
Family Practice Clinic MIIS System; the Drug
Intake and Management System (DIMES) in
Massachusetts; and Monitoring and Evaluation
of Drug Interactions by a Pharmacy Oriented
Reporting System (MEDIPHOR) at Stanford,
California. Retrospective drug use systems
(including the LAC-USC and MEDIPHOR sys-
tems) include the PAID program in North
Carolina, the Columbia Medical Clinic in Mary-
land, and the New Haven Health Care Plan
in Connecticut.

The purpose of the drug review and control
processes mentioned above is "rational pre-
scribing," which is described by the Task
Force on Prescription Drugs as "...the right
drug for the right patient at the right time"
(Task Force on Prescription Drugs 1969).
'' 

The LAC-USC System

In 1967, medical professionals at the Los
Angeles County-University of Southern Cali-
fornia (LAC-USC) Medical Center published a
description of the first computer system that
combined on-line prescription processing and
review procedures. The aims of this kind of
system are to 1) prevent excessive dispensing
of drugs with known abuse potential; 2) pre-
vent harmful drug interactions by surveying
the patient's drug record before a new pre-
scription is processed; 3) insure and monitor
the proper drug and dosage for intended clin-
ical purpose; 4) study the drug usage pat-
terns and correct inefficient expenditures of
funds through redirecting purchases of spe-
cific drugs; and 5) implement inventory con-
trol. The use of this system to perform
prospective and retrospective drug use review
has been highly successful. Prospective utili-
zation to prevent potentially harmful drug
interactions revealed that 7 percent of outpa-
tient prescriptions were potentially dangerous.
The process has been used to improve pre-
scription patterns for antibiotics and hyperten-
sive medications. With the advent of the
Professional Standards Review Organizations
and Health Maintenance Organizations, it is
probably that greater emphasis will be placed
on the role of systems for prospective and
retrospective monitoring of drug use.

Medical University of South Carolina,
Family Practice Clinic Program

 

At the Medical University of South Carolina's

Family Practice Clinic, a computer-based sys-

tem to monitor outpatient drug use is part of

a comprehensive medical record system

(Braunstein and James 1976). The pharmacy

subsystem has been under development and

revision for approximately 3 years (Karig et
al. 1974) and has been fully operational in
the Family Practice Center for approximately

l year. The system stores records of 6,000

patients using the Family Center facilities.

The monitoring system assumes that 1) prac-

tice of medicine in the outpatient situation is

based largely on pharmaceutical intervention
in disease processes (i.e., drugs, not sur-
gery) and 2) the physician in an outpatient
setting cannot supervise the patient's drug
therapy as closely as the physician in an in-
patient setting.

The pharmacy system has four parts:

e The pharmacist at the computer terminal
enters the new drug into the patient's pro-
file. The profile displays patient status
information (e.g., Medicaid), information
on the interaction potential of the pre-
scribed drug (Martin 1971), and educa-

tional information for the patient. The
label for the medicine is printed at a ter-
minal in clear English.

e The patient's history is displayed, includ-
ing dates of drug renewals.

e A short sequence on the characteristics
and use of drugs other than the new pre-
scription appears.

e A warning of potential drug-drug interac-
tion of the new prescription and any drugs
the patient is currently taking is displayed.

The computer also produces a weekly report
listing all patients who returned at an inappro-
priate interval for a renewal or who did not
return at all. The computer completes drug
searches, listing all patients with a history
of using a particular drug and indicating
those individuals currently using the drug in
question, which is useful for large-scale drug
utilization studies.

Members of the center may use any pharmacy
in the area, because the pharmacists record
prescription data on postcards and send it to
the center for entry on the computer profile.
The system increases communication between
physician and pharmacist, and reduces misuse
of drugs in cases where the physician and
pharmacist can interact with the patient.

The DIMES System

A computerized drug-management system that
is in the implementation phase in Massachusetts
is the Drug Intake Management and Evaluation
System, or DIMES (La Brie Associates 1976).
This computer-based diagnostic, information-
storage and retrieval system monitors the use
of psychoactive drugs in both hospital and
outpatient clinic settings.

The DIMES system is currently capable of
monitoring 125 drugs (both psychoactive and
medical) commonly prescribed to psychiatric
patients. As the system is further refined,
more drugs will be added. Using the system's
stored information, the computer evaluates
the following questions and prints out the
answers.

e Do the symptoms match the diagnosis?

e is the drug prescribed consistent with
the symptoms and diagnosis?

e is the drug within effective dose range
and below maximum dose?

49
''e Does the patient have any medical condi-
tions for which the drug is contraindi-
cated?

e Is the patient taking any other medical or
psychoactive drugs that have potentially
negative interactions with this drug?

Is the drug available in a more cost-
effective form?

e Are new symptoms that occur after medica-
tion side effects of the current medication?

e Does a review of the patient's symptom
history indicate the changes should be
made in the drug administration schedule?

e Does a review of the patient's drug intake
record suggest that changes should be
made in the drug schedule?

Patients' current information files are avail-
able at any time, and periodic reviews of their
symptom histories and drug intake records
are generated automatically (with the introduc-
tion of each set of current symptoms) when
new entries are made. The system also ac-
cepts previously generated patient medication
profiles, which enables the DIMES system to
begin functioning with an active database.

The MEDIPHOR System

The MEDIPHOR system (Tatro et al. 1975) is
a computer-based monitoring and reporting
system developed at Stanford University to
study drug interactions in hospitalized pa-
tients. It has recently been adapted to moni-
tor in community settings as well. The
system uses information entered at a central
inpatient pharmacy to monitor drug use,
creates patient medication profiles, and gener-
ates drug interaction reports. It also prints
or displays patient medication profiles.

The community pharmacy component of the

MEDIPHOR system is particularly relevant to
the elderly psychoactive drug user. The

community pharmacy involved in the develop-
ment of the prototype of the MEDIPHOR sys-
tem (MEDIPHOR-C) is located near Stanford
University, and has a prescription volume of
approximately 175 per day. The process is
as follows:

e The patient enters the pharmacy with one
or more prescriptions;

e Responding to a series of prompts on a
CRT, the prescription information is
entered by the pharmacist and relayed to
the central computer;

50

The central computer formats a prescrip-
tion label from the information received
and sends this information back to the
pharmacy; and

e An interaction search is performed by the
central computer, matching the newly pre-
scribed drug(s) against the previously
stored patient profile information. If poten-
tial drug interactions are found, a short
message ("mini-alert") is relayed to the
label printer in the pharmacy with the pa-
tient's name, the interacting drugs, and a
short description of the anticipated inter-
action.

These "mini-alerts" are divided into two
groups. Group A includes those interactions
for which telephone notification of the prescrib-
ing physician is desirable before the medica-
tion is dispensed to the patient. Group B
interactions, because of lesser immediacy and/
or severity, do not require such notification.
For both groups, a full interaction report is
printed by computer and is sent to the pre-
scribing physician the next day.

Community Monitoring Programs

 

The computer drug-monitoring systems dis-
cussed above are highly technical methods of
managing large amounts of data and drug-
related questions in a short period of time.
At the present time, there are few pharmacies
and community clinics that have access to,
or can afford to purchase, the services of
this type of monitoring system. The most
common and the most economically feasible
alternatives are manual monitoring systems.
Critical factors in these systems include
awareness of all facets of drug-drug interac-
tion and drug/body chemistry/food interaction,
as well as the behavioral correlates of drug
abuse. As a response to the need for moni-
toring of drugs in the community, pharmacists
have initiated new roles and technical assist-
ance approaches to improve their capacity to
perform their job well.

The DIAL System

A noncomputerized system for detecting poten-
tial drug interactions, the DIAL system (Drug
Interaction Alert System) is a compact proce-
dure that uses a flow chart and a cross~
indexed list of drug interactions to enable
the pharmacist to evaluate a given patient's
potential for experiencing drug interaction
effects from a new prescription (Fish and
Cooper 1975).

The DIAL system requires the pharmacist,
upon receiving a new prescription order, to
obtain the patient medication profile, the Drug
'' 

Interaction Alert List, and the Drug Interac-
tion Flow Chart. Following the steps of the
flow chart, the pharmacist answers a series
of questions. The first question asks if any
of the ingredients on the new prescription
appear on DIAL. The pharmacist checks the
profile for any existing prescription for which
there are possible interactive drugs. He then
identifies the potential interactions between
the old prescription and the new. If likely
drug interactions are identified, the pharma-
cist checks to see if the physician has antici-
pated the interactions and has prescribed
compensatory drugs. If not, the pharmacist
contacts the physician. An alternate medica-
tion may be prescribed by the physician, or
the original prescription may be issued with
appropriate warnings to the patient. All
drugs with known interaction potential being
taken by the patient are noted in the patient
profile.

DIAL has been used successfully in hospital,
nursing home, and community settings. The
system could easily be computerized for moni-
toring large volumes of patient drug use data.
However, it lacks a patient profile system
specifically oriented to the monitoring task.
The DIAL system has several attractive fea-
tures, particularly its economy. It also per-
mits a recordkeeping process that can be
adapted to aspects of drug consumption other
than drug interactions.

Tennessee Medication Maintenance Program

 

A program in Tennessee demonstrates that
the pharmacist can perform a significant role
in the treatment and maintenance of mentally
ill patients in the community (Evans 1976).
The program's objective was to éstablish and
operate a model medication maintenance service
in a community pharmacy, using support from
the Northeast Community Mental Health Center,
and subsequently, to conduct a limited evalua-
tion of the model program in 1) patient accept-
ance of location and pharmacist's role and 2)
quality of care.

Problems such as medication noncompliance,
drug side effects, drug interactions, and
minor alterations in the patient's mental sta-
tus were handled by the pharmacist. How-
ever, telephone consultations with the psychia-
trist were also used, particularly in the case
of an uncontrolled patient. These actions
were followed by dispensation of medications,
review of the patient's need for education
regarding aspects of the drug therapy, entry
of information into the patient's progress
notes, necessary referrals to the Center, and
scheduling of the patient's next appointment.

51

The program was well accepted by mental
health professionals and some patients. The
data showed an overall improvement in partici-
pating patients, and suggested that selected
patients could be safely maintained by the
community pharmacy as part of an outreach
program.

A program of this kind, though not aimed at
the elderly per se, has a high degree of rele-
vance to psychoactive drug use problems
among this group. It is apparent that any
formerly institutionalized older person who
desires to return to the community might re-
spond positively to the maintenance services
this kind of program offers.

Institutional Monitoring Programs

High levels of drug use occur in institutions
as might be expected in an environment where
people are experiencing health problems.
Medications are often prescribed to alleviate
pain and anxiety, or to control undesired
behaviors, in amounts that may be very
strong, or for lengths of time that go beyond
the boundaries of therapeutic benefit. As a
means of averting misuse of drugs under
these circumstances, drug utilization reviews
were mandated by law. However, the DUR
process does not call for continual monitoring
and review of medications for each patient,
or even for frequent reviews of each patient's
regimen. New monitoring processes have been
devised to address this need. Community
and institutional pharmacists have also found
new roles in working in institutional settings
and working with nurses and doctors to in-
sure appropriate use of drugs.

Appalachian Regional Hospitals Program

 

In 1971, a study outlined by the Appalachian
Regional Hospitals pharmacy staff was con-
ducted at the Wise, Virginia, Regional Hos-
pital (Solomon et al. 1974). The major goal
of the study was to determine the pharmacist's
ability to detect potential therapeutic problems
by using a patient medication profile. It was
assumed that 1) far more therapeutic problems
will be detected by the pharmacist with, than
without the use of a patient medication profile;
2) the incidence of therapeutic problems will
be higher for new prescriptions than for refill
prescriptions; 3) the overuse of medications
will be the most common therapeutic problem;
4) prescriptions financed by a third-party
payor will more commonly be overused than
underused; 5) medications payed for directly
by the patient will more commonly be under-
used than overused; 6) psychotherapeutic
drugs will be overused more often than drugs
in other classifications; and 7) the potential
misuse of medications (either overutilization
''or underutilization) will be more prevalent
among patients 65 years of age and over than
among patients in other age groups.

The results of the study indicate that the
use of medical profiles by the pharmacist en-
ables him to detect potential therapeutic prob-
lems that otherwise would go undetected for
extended periods of time. Since it is believed
that self-medication errors in nonmonitored
cases occur in between 25 percent and 59
percent of all users (Stewart and Cluff 1972),
pharmacist intervention would appear to be a
valuable monitoring service. Because of this
high level of self-medication error and poten-
tial for intervention, there is serious reason
to further consider the validity and need for
legally mandated monitoring services in both
ambulatory and long-term care facilities where
they do not already exist.

California Regional
Medical Programs Area V

 

In 1972, the California Regional Medical Pro-
grams Area V funded a study to document
potential contributions of pharmaceutical serv-
ice providers to nursing facilities and ex-
tended care facilities. The objectives of the
study were to demonstrate that 1) the applica
tion of clinical pharmacy practice in an ex-
tended care facility can improve the quality
and cost-effectiveness of patient care through
promotion of safe and rational use of drugs,
and 2) expanded use of the community's exist-
ing pharmacy manpower can be integrated
into quality health care _ services.

The study was implemented in four extended-
care facilities. A clinical pharmacist was ap-
pointed by the University of Southern
California School of Pharmacy to work in the
experimental extended care facilities, spending
a month at each facility. The responsibilities
of the clinical pharmacist in the experimental
extended-care facilities included the following:

e To obtain a drug history of each patient
on admission and to maintain each patient's
drug profile;

e To evaluate each patient's clinical response
or lack of response to drug therapy, in-
cluding adverse drug reactions, and to
verify these reactions with the patient's
physicians;

e To provide drug information to the staff
of the extended care facility and the pa-
tient's physicians;

e To instruct discharged patients and their
families in the proper use of medications;

e To participate in the extended-care facil-
ity's drug utilization review committee;
and

e To consult with the staff on their systems
of procurement, preparation, and distribu-
tion of drugs.

Results of the study indicated that the inci-
dence of medication error and inappropriate
drug use was reduced as was the incidence
of adverse drug reactions and drug interac-
tions.

The study improved the cost-effectiveness of
patient care because of the fewer drug-
induced complications and fewer inappropriate
drugs. The overall savings was $80,000,
excluding the cost of the pharmacist's services.
The authors suggested that a reimbursement
system would persuade the community pharma-
cist to provide clinical pharmacy services to
patients in extended-care facilities. In July
1975, the California Department of Health be-
gan to reimburse pharmacists for the drug-
monitoring services that the pharmacists are
required to perform. This offers the phar-
macist a significant incentive to provide com-
prehensive patient-oriented pharmacy services
and thereby control and reduce the inappro-
priate use of psychoactive drugs.

Isabella Geriatric Center Programs

 

The Isabella Geriatric Center is an example
of drug monitoring at different levels of insti-
tutional and parainstitutional care through
one central organization. The ongoing serv-
ices at Isabella also attest to the significance
of the nurse and pharmacist in promoting pro-
per use of drugs by the elderly. The Isabella
Center has three levels of housing and service
for the aged: congregate housing apartments
(250 persons), intermediate nursing care
(Home Health Related Facility), and a nursing
home.

Pharmacy services to apartment residents are
similar to community pharmacy dispensing,

including patient profiles. When a "House"
resident presents a new prescription or a

refill request to the pharmacist, the profile
is automatically examined. (As in community
pharmacies, full supervision of drugs used

in the apartment house area is impossible

since residents are not required to use Isa-
bella home medical staff.) Charge slips for
medications provide the pharmacist with a

daily accounting system used to review pa-
tients! charts and adjust profiles.

Services to the Health Related Facility are
adapted to meet the needs of residents who
require institutional care to maintain a certain
''level of independence. The nursing depart-
ment may administer medications to this group.

However, since the State code allows self-
administration of medication with the attending
physician's written permission, the Isabella
Center initiated a program of self-administra-
tion of medication 10 years ago. This program
is considered by the staff to preserve individ-
ual dignity and a degree of independence that
should be acknowledged and nurtured.

The pharmacy receives a social history of
each new admission. This preintroduction
serves as a guideline for future observations.
The members of the pharmacy staff attempt
to establish a personal relationship with each
of the residents. Only 4 out of the Health
Related Facility's 207 residents do not qualify
for self-administering medications; these pa-
tients are served in a private consultation
room and their prescriptions are filled while
they wait. The self-administering residents
have medication boxes with clearly marked
use and location information. Each resident
has a profile card indicating: 1) if any dupli-
cate prescriptions have been noted; 2) if any
drug interactions have been observed or antic-
ipated due to the medication; 3) the label
and date; 4) type of sleeping medication in
use, if any; 5) synopsis of diagnosis, and
how it is reflected in the medication selected;
and 6) a notation to retrieve containers.

The Isabella Home Skilled Nursing Facility is
for aged persons in need of continuing nurs-
ing supervision and medical care, primarily
residents who can no longer manage in the
intermediate facility. The system used to
administer and monitor medications in the
Skilled Nursing Facility is a modification of
the traditional bulk-drug floor stock system.
This modified system uses a specially designed
cart with space for drugs, recordkeeping,
and storage of order sheets and profiles.
The profiles for each patient are reviewed
every 30 days, although there is an automatic
"stop order" time for prescriptions. The
carts are replenished by the pharmacy with
precounted medications. The doctor reviews
the patient's chart on his rounds; the pharma-
cist checks the medication order sheet and
records the information on the patient profile
record.

The John Rawlings and
Associates Service Approach

John Rawlings and Associates is a pharmacy
service firm that serves nursing homes.
Rawlings and Frisk (1975) report on the model
program they have applied in three nursing
homes, using a centralized unit-dose delivery
system based on the model developed by Beste

at Providence Hospital in Seattle. The sys-
tem is characterized by pharmacy review of
the physician's original order, a medication
profile sheet, a 24-hour cabinet exchange
system featuring individual patient drawers,
and a nurse's medication record. The serv-
ices program revolves around the pharmacy
services committee, which was generated as a
result of Federal regulations governing skilled
nursing facilities. The basic activities are:

e Taking in orders from the attending phy-
sician and compiling a medication history
and profile for a new patient;

e Dispensing drugs;
e Monitoring and evaluation of drug storage;

e Monitoring of drug regimens every 30 days,
with notes on irregularities continuously
entered into the patient profile;

e Interprofessional relationships (the nurse
practitioner working under the supervision
of a physician is allowed to alter the drug
therapy of certain medication classes) ;

e Establishing an adverse drug reaction re-
porting procedure, including the use of
phone calls and adverse reaction report
forms, that keep the physician notified of
conditions; and

e@ Provision of written quarterly reports of
pharmacy services provided, as mandated
by Federal regulations.

The pharmacist providing these services be-
lieves that the cost for the pharmacy service,
the average number of medications taken by
each patient, and the medication cost per pa-
tient have all been substantially reduced
through the implementation of this model.

The Nursing Home
Demonstration Project (NHDP)

 

Responding to recent Federal regulations for
nursing homes (which stipulate basic patient
care and services, including expanded clinical
pharmacy functions), Devenport and Kane
(1976) developed a program of integrated pa-
tient care and education. The program uses

a primary care team composed of a nurse prac-
titioner, a social worker, a physician, and a
clinical pharmacist.

The Department of Family and Community Medi-
cine at the University of Utah College of
Medicine established the Nursing Home Demon-
stration Project (NHDP), described by Kane
et al. (1974).

53
''Although all 13 homes involved in the project
continued to obtain drug orders from their
local pharmacies and the State hospital (for
those patients followed by the community
mental health centers), the NHDP clinical phar-
macist was involved in five major areas of
drug use: 1) initial drug review for each
patient; 2) monitoring drug therapy; 3) pro-
viding drug information; 4) inservice educa-
tion; and 5) patient counseling.

Each home was visited by the nurse practi-
tioner and social worker at least once a week.
The physician and pharmacist were consulted
on problems of patient management. Thera-
peutic problems were discussed with the recom-
mendations approved by the physician in the
areas of 1) drugs of choice; 2) therapeutic
efficacy; 3) bioavailability; 4) dosage; 5) con-
traindications; 6) potential drug interactions;
and 7) adverse effects.

The Nursing Home Demonstration Project sug-
gests that the Federal requirements for a phar-
macist in nursing care facilities can be met,
and that measurable improvements in the area
of rational pharmacy and skill of nursing home
staff can also be achieved.

Monitoring Training Programs and Materials

In the majority of cases, innovative monitor-
ing schemes have been designed by research-
ers in pharmacy and public health. Concern
for the monitoring of drug use as an integral
component of health care has lead to the devel-
opment of training workshops and explanatory
manuals by pharmaceutical associations. These
not only describe an appropriate protocol for
monitoring the use of drugs, they also attempt
to inculcate in pharmacists a sense of aware-
ness concerning sources of drug abuse, the
symptoms that may be produced by the partic—
ular problem, and the appropriate strategy
to take regarding medication.

California Pharmaceutical
Association Monitoring Course

 

In the syllabus for a course on drug monitor-
ing in long-term care facilities, the California
Pharmaceutical Association (CPhA) identifies

strategies for alleviating drug misuse. Steps
to be taken include the following:

® View all patients as potential drug misusers,
Compliance is unpredictable. The level of
knowledge concerning drugs possessed by
the patient should not be overestimated.

e Look for risk factors that may contribute
to drug misuse: a) patient characteristics--
physical, psychological, and social factors
that affect the patient's ability to comply;

and b) patient perceptions and expecta-
tions--failure to comprehend the serious-
ness of the illness, the importance of
therapy, consequences of noncompliance,
and misuse of over-the-counter drugs.

e Disease characteristics: lack of symptoms
makes proper treatment difficult.

e Characteristics of the drug regimen: inade-
quate instructions of drug labeling; com-
plexity of multiple drug therapy; cost of
the medications; and untoward effects (i.e.,
unpleasant taste or adverse effects). Also,
there is a greater risk of noncompliance
in treatments of long duration.

e Patient education can improve compliance.
e Maintain comprehensive patient records.

Recent legal precedents have established that
both the physician and the pharmacist are
responsible for informing the patient of the
risks of the drug. Written instructions may
be more effective than verbal warnings, since
they accompany the medication and the patient.
A patient should know: a) the name of the
medication; b) the appearance of the medica-
tion; c) the general purpose of the medication;
d) the method of administering it; e) the tim-
ing and frequency of administration; f) the
maximum daily dose of the drug; g) how long
to use the medication; h) pertinent side ef-
fects and cautions; i) early symptoms of seri-
ous adverse effects (without causing the
patient undue concern and potential noncom-
pliance); j) other drugs, food, or activities
(such as driving) that should be avoided;
and k) the proper storage and handling of
the drug.

California Pharmaceutical Association
Long-Term Care Monitoring Workshops

 

Since January 1974, when the.final regula-
tions for Skilled Nursing Facilities (SNFs)
were published in the Federal Register, there
has been a significant effort by the California
Pharmaceutical Association and the trade jour-
nal California Pharmacist to acquaint the phar-
macist-provider with his/her expanding role.
Their activities have included a series of work-
shops and a workbook on monitoring drug
therapy in the long-term care patient with
psychogenetic disorders.

The syllabus was written for the Department
of Health, Education, and Welfare under a
contract between the California Pharmaceutical
Association and the Office of Long-Term Care,
U.S. Public Health Service, Region IX. The
workbook focuses on drug therapy for pa-
tients with psychogenetic disorders and

54
''discusses the tools and methods of effective
drug regimen monitoring. The workbook rein-
forces the pharmacist's knowledge of the char-
acteristics of major psychogenetic problems
found in the long-term care patient (e.g.,
anxiety, endogenous depression, chronic brain
syndrome, exogenous depression, and acute
brain syndrome). The workbook also tests
the pharmacist's knowledge of recommended
dosages of particular psychoactive drugs,
such as diazepam, chlordiazepoxide, haloperi-
dol, flurazepam, amitriptyline, and phenobar-
bital. The learning objectives of the workbook
also include improving the ability of pharma-
cists to recognize the normal limits and poten-
tial significance of abnormal findings, as
relates to drug therapy, for a series of labor-
atory tests. There is information in several
other areas, including recognizing commonly
occurring and potentially injurious adverse
effects of psychoactive drugs in aged long-
term care patients, recognizing the mechan-
isms associated with acute brain syndrome in
the elderly, the merits and disadvantages of
the use of certain drugs as hypnotics, and
the means of improving the quality (safety,
efficacy, and compliance) of drug therapy in
aging patients.

The workbook and the associated workshops
attempt to increase the skill of pharmacists,
thereby reducing the misuse of psychoactive
drugs in the older patient. The issue of

implementation remains, however, since moni-
toring processes are not common and have

yet to be mandated.

Health Resources Administration

 

The Health Resources Administration of HEW
has also funded research and training in mon-
itoring drug therapy of the long-term care
patient. A major contract with the American
Pharmaceutical Association involved extensive
pharmacy training for nurses (HSM 110-73-421
1975). The purpose of this project was to
expand the quality and scope of training
offered by State and local pharmaceutical
associations and schools of pharmacy to per-
sonnel involved with pharmacy services in
nursing homes, and to offer a curriculum to
schools of pharmacy to provide similar train-
ing to student pharmacists. Sixty programs
were carried out under the contract. Of the
2,127 participants, 95 percent were pharma-
cists. The project included the development
of a drug monitoring approach and protocol.
In addition, a workbook for pharmacists was
written, "Monitoring Drug Therapy of the
Long-Term Patient" (American Pharmaceutical
Association 1975).

55

DRUG UTILIZATION
EVALUATION PROGRAMS

Drug utilization studies are another way to
observe and review drug prescriptions of pa-
tients in long-term care facilities. Where
monitoring of drug use is an ongoing in-house
activity performed by resident or consulting
pharmacists, such studies are either mandated
by the State or are part of an extended pro-
ject to collect data on patterns of drug use.
Examples of protocols for review of drug use
and the gathering of data on patterns of drug
use are described below.

Kabat, Martilla, and Stewart Protocol

Kabat et al. (1975) designed and evaluated
drug utilization review protocols (format) to
be used by review committees in conducting
the medical care evaluation studies (commonly
referred to as sample studies) required by
Federal regulations. The protocols are de-
signed to contain all the information neces-
sary to help the long-term care facility
perform drug utilization review sample studies
and to explain, in detail, the criteria found
on the abstract sheet.

The drug utilization review process, however,
provides only a general view of drug use pat-
terns in institutions and often fails to remedy
inappropriate drug administration practices.
The reasons for this are: a) a patient requir-
ing individual scrutiny may be treated as part
of the larger group of patients, whose medica-
tion requirements for the same drug may vary;
and 2) the committee's norms, criteria, and
standards may not be stringent enough to
insure remedial action on the part of resident
physicians and consultant pharmacists.

Review of drug use, which is mandatory in
all skilled nursing facilities certified for par-
ticipation in the Medicare and Medicaid pro-
grams, includes medical care evaluation
studies to promote the most effective and ef-
ficient use of available health facilities and
services.

A DUR Committee in a skilled nursing facility,
studying the current use of a psychoactive
drug to determine if medication errors of inter-
actions with other drugs are being ignored,
would first determine what constitutes proper
use of the drug. The committee then would
compare patient medication records with the
criteria for proper use and examine any dis-
crepancies. Problem areas might be identified,
such as physicians' carelessness in prescrib-
ing, a pharmacist's oversight during the
monthly regimen review, or failure to perform
necessary laboratory tests. The committee
could suggest corrective measures, such as
''educational programs for physicians and phar-
macists. A followup study is performed to
determine how effectively the problem has
been dealt with and whether further investiga-
tion is required.

Bureau of Quality Assurance
Drug Evaluation Protocol

The Bureau of Quality Assurance of HEW's
Public Health Service has published drug eval-
uation protocols, several of which concern
the evaluation of psychoactive drug use.
Medical appraisal norms (statistical measures
of observed drug performance) are generated
and medical care criteria are established.

Boston Collaborative
Drug Surveillance Program

The Boston Collaborative Drug Surveillance
Program in operation in 23 hospitals, uses
trained nurses and pharmacists to perform
daily monitoring, recording, and compilation
of data on drug use among hospitalized pa-
tients (Allen and Greenblatt 1975). Monitors
conduct structured interviews with newly ad-
mitted patients, collecting vital statistics and
a medication history. A medication sheet is
used to record all prescribed medication, ther-
apeutic indications for each drug, the date
the drug is started, and its dose, route, and
frequency of administration. Medication
changes are recorded, as well as the total
amount of the drug consumed and the ob-
served effectiveness of the treatment. When
a medication is discontinued because of drug
interactions, a special form is completed.

The Boston Collaborative Drug Study Program
processes information from each hospital once
a month. The data have been the basis for
80 publications over the past 10 years on
such subjects as patterns and factors influenc-
ing the toxicity of drugs, drug-attributed
adverse reactions, and clinical factors affect-
ing adverse drug reactions and interactions.

At some of the hospitals involved in the Col-
laborative Drug Surveillance Program, the
information generated is used to effect
changes in individual drug regimens. This
is the case in the program at the Arizona
Medical Center (Trinca et al. 1975). At this
hospital, the pharmacist involved in drug mon-
itoring provides a link between the prescrib-
ing physician and the Department of Phar-
macology by presenting difficult management
problems at pharmacology rounds attended
by physicians and students. By this means,
drug surveillance is an educational tool for
both students and physicians.

The PAID Program

The PAID Program is an example of retrospec-
tive intervention through utilization review.
Patients covered by the Title XIX Medicaid
Program in North Carolina have had their
drug consumption monitored through a pro-
gram operated by the PAID Prescriptions Com-
pany (specialists in prescription drug claim-
processing) under contract to the North
Carolina Department of Social Services and
modeled on a program in California
(Yarborough and Laventuries 1974; Hull et
al, 1975).

Six pharmacists and a physician from each of
four geographical regions meet once a month
to review computer printouts of drug pur-
chases. Local physicians and pharmacists
are informed of unnecessary and inefficient
drug use by a letter of inquiry, and they
receive copies of recipients' drug profiles.
This system has brought about a reduction
in costs to the State and Federal Governments.
Although many factors are not reflected in
the prescription claims data, potential thera-
peutic problems can be identified; for example,
a computer printout of medications purchased
by outpatients in the California program in-
dicated that 7.5 percent of drugs taken by
42,000 patients could have caused adverse
reactions resulting in medical problems.

In their article on the PAID Program, Hull et
al. (1975) cite four types of drug problems
that can be revealed by patient profiles:
prescription and therapeutic duplication; over-
utilization; drug interactions; and noncom-
pliance. DUR committees have been able to
identify problems in the first three of these
areas, but noncompliance is apparently detect-
able only in hospital environments. The DUR
committee has focused on drug reactions with
anticoagulants because they are widely pre-
scribed to Medicaid patients and interact with
many other drugs, particularly barbiturates
(Starr and Petrie 1972). The program has
immense practical application for the evalua-
tion of psychoactive drug use among older
persons, and can effectively address some of
the drug use problems that do not require
an in-depth knowledge of the individual pa-
tient's physiologic characteristics.

SUMMARY

The five types of programs described in this
section--improved diagnostic procedures, im-
proved prescription controls, improved drug
administration procedures, drug prescription
monitoring, and drug utilization review--

indicate a trend toward the development of

more rational use of drugs, both psychoactive

56
''and nonpsychoactive. There still remains,
however, a significant potential for abuse by
the individual who does not comply with the
drug regimen, even when it is correctly pre-
scribed. This source of variance lies with
the individual and must be addressed through
other means, such as education or therapy,
depending on the motivation for the particular
pattern of use. The following section pro-
vides examples of how the processes of diag-
nosis, prescription, administration, and
monitoring of drug use can be supplemented
through interventive programs within the com-
munity and institutions.

PROGRAMS DESIGNED TO INTERVENE
IN PSYCHOACTIVE DRUG MISUSE
AMONG THE ELDERLY

Psychoactive drug misuse by the elderly has
only recently been recognized as a significant
public health problem. Because the incidence
and prevalence of psychoactive drug misuse
by the elderly are not yet well known, there
have been relatively few policies designed to
offer intervention or treatment for those af-
fected. The previous section described a
predominantly preventative approach, although
monitoring procedures also are capable of de-
tecting misuse situations. Careful control of
psychoactive drug applications, through clini-
cal and community health services, will con-
tinue to be of significance in reducing the
future incidence of certain categories of psy-
choactive drug misuse. However, there
remain unidentified numbers of older persons
who are suffering from one or more physical
and emotional complications that center on,
or are related to, psychoactive drug use and
who have not received the attention they may
require.

This section focuses upon the efforts made
by various social and public health organiza-
tions to design interventions that specifically
address psychoactive drug misuse problems
found among the elderly. There are very
few of these programs at this time although
the number seems to be growing concurrently
with the growth in awareness of the problem.
Many of the established programs are exten-
sions of preexisting programs for the treat-
ment of alcoholism and the elderly alcoholic.
In such programs, the intervention generally
focuses on what is thought to be the motivat-
ing variable in the abuse phenomenon--social
isolation, limited economic resources, and pos-
sible lifelong pathology that is associated with
addiction to alcohol. Other interventions,
however, do not operate with the same assump-
tions, and often treat misuse of psychoactive

drugs by the elderly as an inadvertent re-
sponse produced by lack of information, or
some aspect of social pathology that may be
experienced in later life. Many of the pro-
grams recently initiated do not propose any
hypotheses concerning the misuse of psycho-
active drugs by the elderly; rather, they
are investigating the misuse problem while at
the same time offering clinical corrective treat-
ment and guidance, thus collecting data while
rendering services.

This section presents brief descriptions of
the objectives, therapeutic approaches, and
activities of a number of established or recent-
ly developed programs. The programs dis-
cussed include outpatient facilities emphasizing
outreach, referral followup and education;
inpatient drug abuse treatment in hospital
and nursing home settings; drug abuse com-
ponents of mental health centers; education
and counseling programs; peer counseling;
and rational self-help therapy.

The first programs to be described are those
operated in Minnesota. Minnesota was the
first State to recognize that there were psy-
choactive drug misuse problems among the
elderly. As part of the 1973 Governor's Bill
for the Chemically Dependent chemical depend-
ency intervention programs are offered to
underserved populations, including blacks,
Chicanos, women, adolescents, and the elder-

ly.

Three programs have been initiated in Minne-
sota that offer a service component to the
elderly with psychoactive drug misuse prob-
lems: the Hennepin County Alcohol and Drug
Access and Intervention Unit (A.I.D.); the
Ramsey County Senior Chemical Dependency;
and the Ebenezer Society Intervention Plus
programs. These programs, established inde-
pendently from one another, follow similar
models of service provision, centered upon
processes of misuse identification, referral to
(if needed) a detoxification center, participa-
tion in a mutual-assistance Alcoholics Anony-
mous model, and efforts to change lifestyle
and drug consumption patterns.

The programs also include examples of refer-
red treatment programs for those elderly re-
quiring higher levels of intervention and/or
medical supervision. Programs of this type
include: the Northwestern Hospital Treat-
ment Program for the Chemically Dependent;
the Queen Nursing Home Alcohol Treatment
Program, which treats psychoactive drug
abusers; the Camellia House Nursing Home
Treatment Program, which offers similar serv-
ices; and the Bridgeway Center.

57
''Other programs described vary in their inter-
ventive mode and organizational foundation.
In Tennessee, a coordinated program investi-
gating the drug phenomena, while offering
treatment to the elderly, has been initiated
by the Department of Mental Health and Men-
tal Retardation and associated mental health
centers. In Chicago, the Augustana Hospital
offers health education, counseling, and a
research program centering on drug use prob-
lems among the elderly. In New York State,
the Broome County Drug Awareness Center
has been the source of an extensive drug
education program for the elderly, including
a traveling "minicourse" for the aged designed
to improve knowledge about drugs. The Col-
lege of Pharmacy at the University of Minne-
sota has also designed a series of programs
to be presented to the elderly in order to
increase their knowledge of psychoactive
drugs. In Florida, the THEE DOOR service
organization offers a variety of centers and
counseling programs for prevention of, and
intervention in, psychoactive drug abuse situ-
ations among the elderly. The Institute for
the Study of Aging in Florida has funded a
program focusing on peer counseling in their
Management of Drug Abuse Among the Elderly
program. The University of Kentucky has
initiated a research program to study drug
use patterns in the elderly and the utility of
rational behavior training in reducing chemical
dependency. The National Institute on Drug
Abuse is currently supporting the Center for
Human Services, in their efforts to develop
and disseminate educational material for the
elderly.

PROGRAMS!

Hennepin County A.I.D. (Minnesota)

The Hennepin County Alcohol and Drug Access
and Intervention Unit (A.I.D.) established a
special outreach project in March 1973 to pro-
vide assessment, intervention, referral, and
followup care for the chemically dependent
elderly in Hennepin County, Minnesota. The
A.I.D. organization initially became involved
with the chemically dependent elderly following
requests by social workers, who had been
receiving complaints from the residents of
public housing projects concerning the dis-
turbing behavior of intoxicated older resi-
dents. Intervening A.I.D. staff would often
find the individual half-dressed, with bottles
of pills on the cupboard or dresser, cans of
opened food spoiling, and wastebaskets full
of liquor bottles.

The A.I.D. program hired a _ chemical-
dependency counselor whose main responsibil-
ity was to assist the A.I.D. director in devel-
oping an outreach program to train volunteers
in assisting the intervention and followup
processes of the special project.

The general program structure consists of

six activities related to the objectives of ac-
cess, intervention, referral, and followup for
the chemically dependent elderly:

e The immediate call for help, either directly
from the older person or through a refer-
ral, is handled by the A.I.D. Special Pro-
gram Counselor.

e Intervention is handled by the counselor
and a volunteer; the team approach is fa-
vored.

e Evaluation of the client is performed by
the project counselor, with the assistance
of A.I.D. staff members.

e Diagnosis of chemical dependency or other
disorders requiring treatment is followed
by a referral to an appropriate service
agency--a hospital or nursing home detoxi-
fication center, drug treatment center, or
other special program. Two outreach vol-
unteers are available to assist the client
to the appropriate treatment facility.

e Followup contact is maintained by the spe-
cial program counselor, with the assistance
of the volunteers. The followup program
involves the chemically dependent person
in growth groups modeled after those used
in the treatment of alcoholics and drug
addicts.

e Improved social functioning is measured by
comparison of current and former behav-
iors.

Eleven satellite offices have been developed
in the Minneapolis area. Transportation is
provided for the handicapped or physically
disabled, especially during the winter months.
A.I.D. also operates a 24-hour answering
service and conducts home interviews. Pro-
gram services are provided on a continual
basis, progress notes are kept on all client
contacts, and group attendance records are
maintained.

Between March 1, 1973, and November 1975,
the A.I.D. program served 620 clients; 251

1s ddresses and contacts are listed in appendix B.

58
''men and 97 women are actively involved in
the therapeutic groups, several of them vol-
unteering their services. Other clients listed
as inactive still receive followup contacts;
half of this group shows improved social func-
tioning, while others are active in AA-type
groups and aftercare programs.

Since November 1975, the program has pro-
vided a series of informational seminars empha-
sizing the prevention of drug dependency.

It also provides information on alcoholism and
drug problems in high-rise residential settings,
as well as information on health centers, home-
maker programs, and other services for the
aged.

Ramsey County Senior Chemical
Dependency Program (Minnesota)

Services provided by the Ramsey County

Senior Chemical Dependency Program include
prevention, intervention, counseling (both
individual and group), transportation, client
advocacy, aftercare, followup consultation,

and education.

The program also acts as an advocate for
clients who have been denied detoxification
and medical treatment, possibly resulting in
prolonged hospitalization and/or premature
entrance into nursing homes or board-and-
care units.

Ebenezer Society (Minnesota)

The Ebenezer Society serving older men and
women, has recently initiated a chemical-
dependency program called Intervention Plus.
This program is designed to reduce drug mis-
use among the elderly of Hennepin County.
The focus of the program is on outreach,
evaluation, early intervention, nonresidential
treatment, referral, followup, aftercare, coor-
dination with other agencies, prevention, con-
sultation, and education.

Northwestern Hospital (Minnesota)

Northwestern Hospital in Minneapolis operates
a treatment program for chemically dependent
patients referred to the hospital from detoxi-
fication centers, other hospitals, doctors,
families, and the Hennepin County A.I.D.
program.

Most arriving patients have been detoxified,
but some require detoxification treatment.
The program provides hospitalization and treat-
ment for as long as 28 days, with possible
extension of up to 2 weeks longer based on
the evaluation of patient response at the end
of the first 28 days. The program takes place
in an age-integrated ward of the hospital,

which the program director believes facilitates
social interaction and leads to more improve-

ment among the older patients. Each patient

is given a comprehensive physical and psychi-
atric examination on arrival and again at the

time of discharge.

Program activities include three lectures daily
on educational and therapy-oriented topics.
Among the topics discussed are: adverse
drug reactions, drug interactions, individual
differences in physiology, and the problems
of noncompliance, deliberate overuse, the
potential misuse of over-the-counter drugs,
and the Alcoholics Anonymous approach.

The program also offers individual consulta-
tion with trained chemical-dependency para-
professionals to ease the clients' emotional
problems and to determine their service needs.
At the end of the 28-day period, a client is
evaluated and judged ready to leave, and he
or she is referred to Alcoholics Anonymous
groups and/or to other service agencies for
aftercare. A patient who requires still fur-
ther treatment may remain for an additional 2
weeks. If s/he continues to require care
and treatment after that time, s/he is referred
to a local nursing home with a chemical-
dependency program, or to the Hennepin
County A.I.D., which will assist him/her in
finding appropriate services and placement.

Queen Alcohol Treatment
Program (Minnesota)

The Queen Alcohol Treatment Center is repre-
sentative of the small number of existing pro-
grams in nursing homes for the chemically
dependent and physically or mentally impaired
elderly. It was designed to treat the chronic
alcoholic and chemically dependent older per-
son. It maintains a 24-hour nursing staff
and an 8-hour-a-day counseling staff for older
persons who could not benefit from other pro-
grams because of significant physical and/or
mental disorders related to past chemical
abuse, and who have a medical disorder that
is complicated by chronic alcoholism.

The initial effort of the program is toward
physical improvement and an increased aware-
ness of one's feelings. The focus is then
broadened to include recognition and accept-
ance of living problems, and the importance
of setting and achieving goals. Counseling
and involvement in industrial and recreational
therapies are also emphasized. Although the
program emphasis appears to be on treatment
of alcoholism, the staff are of the opinion
that their treatment approach is also suitable
for the elderly psychoactive drug abuser.
''Upon admission to the program, clients are
withdrawn under medical supervision from all
mood-altering chemicals, with the exception
of major tranquilizers prescribed for certain
psychiatric disorders. In these cases, how-
ever, the patient is still evaluated for poss-
ible discontinuation, in order to assess the
chemical dependence and treatment plan.

Prior to discharge, the client is required to
join an AA chapter and complete the AA ori-
entation program. If the patient needs voca-
tional training, he is enrolled in an outside
training program to acquire the desired skills.
Housing arrangements are also made at this
time. Followup contact, monthly or more
often, assures the patient that he is welcome
at the clinic at any time.

Camellia House (Minnesota)

One-third of the facilities at Camellia House
nursing home are devoted to treating the chem-
ically dependent patient. This is the second
such home in Minnesota, and, like the Queen
Alcohol Treatment Program, the goal is to
establish and maintain patterns of living free
from chemical dependency. The low-profile
program at Camellia House is designed to over-
come the feeling that treatment is associated
with punishment.

The chemical-dependency program is geared
to slower paced elderly patients and patients
with temporary or permanent physical or men-
tal disabilities. The program incorporates
Alcoholics Anonymous program steps, group
therapy, individual counseling, and educa-
tional lectures. Group therapy involves
supportive confrontations directed toward en-
countering defense systems modifying behavior,
and replacing the delusionary system with
realistic awareness. Gestalt therapy is used
as the basis for identifying and accepting
the illness so that the patient can "come to
grips with the conflict between values and
behavior" with the discovery or rediscovery
of himself as a thinking and feeling person.
Weekly attendance in the AA group is re-
quired as part of group therapy.

Bridgeway Center (Minnesota)

The Bridgeway Center is a multidisciplinary
chemical~dependency unit, operating in a facil-
ity under the ownership of King Care Centers,
Inc., a private health care corporation. The
program provides intervention services for
the chemically dependent elderly and for other
age groups. The program offers 30-day pri-
mary and extended care treatment programs
that are oriented toward treatment of the
physical, mental, and emotional illnesses of
the chemically dependent person and that

provide one-to-one counseling and participa-
tion in group therapy.

At the end of the first 30 days, the client is
evaluated and is either discharged or assigned
to the continued care or the extended care
program. The latter program lasts another
30 days. The program is designed to permit
physical as well as mental recuperation. While
the Northwestern program refers the patient
to another program at the end of 6 weeks,
the Bridgeway program attempts to carry out
necessary treatment and rehabilitation within
2 months. If the client has not recuperated
within that time, the patient is referred to a
nursing home, such as the Camellia House.

State of Tennessee

In October 1976, representatives from four
Tennessee mental health centers and three
sections of the Department of Mental Health
and Mental Retardation of the State of Ten-
nessee met to plan a statewide program that
addresses the problems of drug and alcohol
abuse among the elderly. The mental health
centers represented were Joe Johnson Mental
Health Center in Chattanooga, Overlook Men-
tal Health Center in Knoxville, Dede Wallace
Mental Health Center in Memphis, and the
University of Tennessee Mental Health Center.
Together with representatives from the Geria-
tric Services Section, the Alcohol and Drug
Abuse Section, and the Public Affairs Section
of the State of Tennessee Department of Men-
tal Health and Mental Retardation, they set
the following objectives:

e To increase public awareness of alcohol
and drug problems among the elderly, and
to familiarize the public with resources
and services available.

e To develop strategies and begin efforts to
coordinate existing services.

e To develop specific plans and investigate
the need for new programs and services.

Program planning is a cooperative venture,
involving each of the participating agencies
and mental health centers. In addition, the
University of Tennessee Mental Health Center
is conducting group sessions to deal with
drug-related problems of the elderly; Over-
look Mental Health Center is developing a
screening process to detect alcohol and drug
abuse problems; and Joe Johnson Mental
Health Center is collecting data on the drug
and alcohol problems of the over-60 population
in their catchment area.

60
''Augustana Hospital (Illinois)

Augustana Hospital in Chicago operates a pro-
gram of health education, instructing elderly
hospital patients in the effects and proper
use of medications. It was soon noted, how-
ever, that the use of drugs within the hos-
pital fostered dependency and made it difficult
for the patients to benefit from the education
program, which stressed independence. This
realization resulted in a broadening of the
program, which now addresses problems re-
lated to the independent functioning of senior
citizens. Eleven health education topics have
been developed: medication safety, the heart,
high blood pressure, stress, laxatives and
bowel preparations, analgesics and antibiotics,
diabetes, consumer awareness, eye care,
arthritis, and nutrition. Public attention has
also been brought to the problems of the elder-
ly through local television coverage and arti-
cles in a senior citizens' newspaper.

Medical counseling has been effective in build-
ing confidence in the health care system and
encouraging greater use of these services,

A research program has been established to
assess the health care needs of the elderly,
to examine patterns of medication use, to eval-
uate the level and quality of services offered
to the public by pharmacies, and to determine
the factors contributing to noncompliance in
medication use by the elderly.

Broome County Drug
Awareness Center (New York)

The program model designed at the Broome

County Drug Awareness Center attempts to

provide the elderly with health care informa-
tion, particularly with regard to the safe and
effective use of drugs, and also to aid them
in developing a behavioral program for them-
selves and significant others.

THEE DOOR (Florida)

THEE DOOR is a service organization in
Osceola County, Florida, addressing drug
abuse problems in all age groups. Their facil-
ities and programs include the Alpha Center
for education and prevention of drug misuse,
a center for individual and family counseling;
a Youth Development Center with an alterna-
tive school and a residential program; a metha-
done center; and a Substance Abuse Program.
THEE DOOR recently initiated an outpatient
counseling center specifically oriented toward
misuse of prescription medication by the elder-
ly (overdosage, duplication of prescriptions,
swapping of medications, and use of outdated
drugs).

In addition to its direct counseling services,
the counseling center provides educational

services designed to be as accessible as pos-
sible to the elderly, through the use of an
outreach program conducted at community

centers in residential areas.

In March 1977, THEE DOOR began a training
program for service providers to the elderly.
Direct service workers (visiting nurses,
county welfare workers, social and economic
services workers, nursing home personnel,
and others) participated in the training ses-
sions. Training modules, with workbooks
and cassette tapes have been developed for
dissemination to other programs. In addition,
the program has developed guidelines for the
creation of a task force of elderly persons,
to advise social service agencies and increase
the effectiveness of referrals.

A Peer Counselor Approach (Florida)

"Management of Drug Abuse Among the Elder-
ly: A Peer Counselor Approach" is a program
organized by the Institute for the Study of
Aging at the University of Miami, on behalf
of 30 agencies in Dade County, Florida. It
provides services to elderly persons identi-
fied as heavy users of drugs.

Drug use problems are attributed both to lack
of information and to sociopsychological prob-
lems arising from isolation, physical disability,
and economic difficulties. Intervention con-
sists of the training of elderly persons as
peer counselors, a method that has been effec-
tive among younger persons in both the pre-
vention and the treatment of drug abuse.

Older Life Drug Experience Research
Project (OLDER) (Kentucky)

OLDER is a demonstration research program
operating out of the Department of Psychiatry,
University of Kentucky Medical Center, de-
signed to study effectiveness of rational behav-
ior therapy in the treatment of drug misuse
problems among the elderly. The program
operates under the hypothesis that learning
an emotional self-help technique can enable
the older person to cope with stresses of
aging without the use of tranquilizers and
nonprescription drugs. It is also hypothe-
sized that these self-help techniques are best
taught by laypersons rather than by mental
health professionals, a belief that is supported
by the success of such groups as Alcoholics
Anonymous, etc.

This program also provides a systematic, fac~
tual, drug counseling effort designed to influ~
ence patterns of drug use. A 3-year research

61
''project will evaluate the effectiveness of this
approach.

SUMMARY

The variety of programs now in existence to
meet the problem of psychoactive drug abuse
among the elderly suggest that the nature of
and solution to the problem are not yet known.
Evaluations of these existing programs are
not yet available, and there are few guidelines
against which the programs can be measured.

CONCLUSIONS

Programs addressing the problem of psychoac-
tive drug misuse among the elderly fall into
two broad categories: monitoring of drug
use and intervention programs.

PROGRAMS THAT MONITOR THE
DIAGNOSIS, PRESCRIPTION,
AND ADMINISTRATION OF DRUGS

Considerable attention has been focused on
the issue of more accurate diagnosis of psychi-
atric disorders in the elderly. This concern
is centered on pairing a correctly diagnosed
disorder with the most effective treatment,
resulting in a decreased likelihood of incorrect
or needless medication.

Increased physician awareness of the signif-
icance of accurate diagnostic procedures and
appropriate therapeutic interventions for the
aged has led them to recognize the role that
individual physiological and psychological dif-
ferences play in drug response. Consequent-
ly, physicians have developed formal and
informal protocols to identify the correct drug
for a given patient. They also have devel-
oped strategies adaptable for insuring correct
drug administration and compliance. These
include guidelines for selecting psychoactive
drugs for the elderly and for determining
the optimal quantities, duration, and struc-
ture of the drug regimen.

The increased volume of drug prescription
and use, and the consequent increase in ad-
verse reactions--due to drug/drug and drug/
individual interactions--have provided an in-
centive for pharmacists and physicians to
develop programs to monitor and evaluate drug
consumption.

Interest on the part of Professional Standards
Review Organizations has also promoted devel-
opment of systematic methods of medication
profile review and troubleshooting. With the
growth of an extended pharmacy role in

community health maintenance, and the in-
creased availability of computer-operated mon-
itoring systems, opportunity for encouraging
appropriate or reduced use of psychoactive
drugs in the elderly is enhanced.

PROGRAMS DESIGNED TO INTER-
VENE IN PSYCHOACTIVE DRUG
MISUSE AMONG THE ELDERLY

The increase in public awareness of psycho-
active drug use problems among the elderly
has led to the creation of new intervention
programs, designed strictly to serve the
elderly drug user. These programs fall into
five categories:

e Outreach and referral

e Hospital and nursing home treatment pro-
grams

e Educational programs in combination with
another intervention such as health care,
therapy, or a social activity

e Peer counseling
e "Rational" behavior training

There are at present, few active programs in
the area of specific interventions and treat-
ments for the elderly psychoactive drug user,
other than the examples reviewed in this docu-
ment, several of which originate in one State--
Minnesota.

TRENDS

Several observations can be made concerning
trends in the provision of services to prevent
or intervene in psychoactive drug misuse
among the elderly. ,

A Rational Approach to
Prescription and Administration

There is an apparent trend to develop a more
"rational" approach to the application and
dispensation of psychoactive drugs that affect
the elderly. This is manifested primarily in
the development of enhanced information sys-
tems for use by physicians in prescribing
medications; in the development of prospective
monitoring and retrospective use studies; and
in the increased role of health professionals
in guiding and reviewing the prescription
and use of drugs.

Improved prescription and monitoring systems
will have a greater impact on the elderly
drug users when three conditions are met:
a) when the protocols for drug monitoring
are used more universally and consistently;

62
''b) when monitoring programs develop pre-
scription criteria that take into consideration
both the physiology and socioemotional status
of the elderly consumer; and c) when drug/
drug and drug/person interactions are con-
sidered in prescription. At the present time,
very few pharmacies are capable of monitoring
drug consumption in the community. This
problem is complicated by the fact that drug
consumers can move from pharmacy to phar-
macy, and can obtain multiple prescriptions
from different physicians. The need for cen-
tralized information in monitoring drugs must
be seriously considered and evaluated in
terms of the potential savings in lives and
health care costs, as well as in terms of the
issue of medication profile confidentiality.
Should comprehensive drug monitoring sys-
tems be implemented, with guidelines for cor-
rect use and safeguards for privacy, the
aged person will share the same benefits as
other drug consumers.

Direct Intervention Programs

There is a growing interest in developing
programs for direct intervention in psychoac-
tive drug misuse by the elderly.

At the present time there are two major pro-
gram thrusts: the first is toward identifying
the drug misuser and placing him/her in con-
tact with treatment resources and followup
care; and the second is in the area of drug-
use education. Many program developers are
of the opinion that drug misuse in the elderly
is attributable to lack of information as well
as to emotional difficulties. The outreach
programs recognize these factors, but the

63

more immediate concern is with the existing
cases of misuse that require immediate treat-
ment. Patterns of future drug intervention
for the aged may attempt to synthesize the
identification component of the outreach pro-
grams with innovative therapeutic interven-
tions and service referrals, followed by
continuing education programs. Peer coun-
seling and education will doubtless play an
important role in all programs.

The most disconcerting aspect of the trend
in development of drug interventions for elder-
ly psychoactive drug misusers is the lack of
central information clearinghouses where health
care professionals can make contact and share
their design concepts and service problems,
as well as gather information on the aged.

A second point of interest is the lack of con-
tact between service providers in the field of
direct intervention and pharmacists interested
in promoting drug monitoring activities. Fur-
ther interaction between those prescribing
and dispensing drugs will facilitate more effec-
tive program interventions and alternatives
for elderly psychoactive drug misusers. The
U.S. Department of Health, Education, and
Welfare Task Force on Prescription Drugs
(1969) reported that at that time, over $3
billion a year was being spent to correct ad-
verse response to therapeutically adminstered
drugs. It is probable that the aged repre-
sent a significant portion of the population
requiring corrective therapy for drug prob-
lems. Therefore, the personal and public
savings to be derived from an integrated
approach to monitoring and intervening in
psychoactive drug use are apparent.
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Holloway, D.A. Drug problems in geriatric patients. Drug Intelligence and Clinical Pharmacy,
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69
''''ANNOTATED BIBLIOGRAPHY

Aagaard, G.N. The Drug Spotlight Program. Annals of Internal Medicine, 78:603-605, 1973.

e The Drug Spotlight Program was established by the American Society for Clinical Pharmacol-
ogy and Therapeutics in order to help hospitals develop policies and set standards appro-
priate to drug therapy that comply with the recommendations of the Joint Commission on
Accreditation of Hospitals. This hospital-based continuing education program has both a
national and a local hospital phase. The program's National Advisory Committee, comprised
of its member organizations, is responsible for the national phase. This entails selecting
the drugs that will be spotlighted, providing scientific papers that center on them, and
publishing questions about their use that merit consideration at the local hospital level.

For a 3-month period a drug or class of drugs will receive Spotlight attention. Relevant
current information will be presented in scientific papers appearing in the following partici-
pating member group journals: American Family Physician, American Journal of Hospital
Pharmacy, American Journal of Nursing, Annals of Internal Medicine, Journal of American
Medical Association, and Patient Care. A videotape program will be offered by the Network
for Continuing Medical Education consisting of a variety of viewpoints presented by numer-
ous experts. The above publications as well as others of the participating organizations
will, during the first month of each presentation, announce the upcoming drug subject for
spotlighting, along with the questions to be considered. The local phase is planned to be
carried out by each hospital's committee on pharmacology and therapeutics. A question
relating to the spotlighted drug is chosen for study and its answer sought by gathering
and analyzing data from hospital records. This important phase ends with its participants
drawing conclusions and presenting them to the hospital staff.

Amin, M.H. Drug treatment of insomnia in old age. Psychopharmacological Bulletin, 12:52-54,
1976.

e It is estimated that 55 percent of persons over age 60 suffer from some degree of insomnia.
The intensity of sleep processes is known to diminish with advancing age, and stage IV
sleep in a 60-year-old is less than half that experienced at age 20. REM time begins to
decline, while awake time in bed increases. Brain deterioration accompanying aging, regard-
less of its cause, is associated with greater disturbances in sleep. Treatment of insomnia
with anxiolytic sedatives is made difficult and dangerous in part because of the likelihood
of physical dependency on the barbiturates and also because of the longer half-life and
period of percepto-motor as well as cognitive deficits associated with benzodiazepine use.
These agents, during the first few weeks of administration, successfully increase stage II
sleep and REM latency; but chronic use causes increased latency to sleep, increased number
of awakenings, frequent stage shifts, continued suppression of REM sleep, and a dminished
stage IV sleep. Withdrawal from these drugs produces unpleasant symptoms such as jitteri-
ness, nervousness, difficulty in falling asleep, and fragmented sleep. An increased state
I REM, i.e., REM rebound, and intensified REMs also occur during withdrawal, the rebound
being dangerous because vegetative tone increases during REM sleep. Cardiac arrhythmias,
anginal attacks as well as substantially increased acid secretion in duodenal ulcer patients
occur with greater frequency during a REM period. Drugs such as the benzodiazepines,
that particularly decrease slow wave sleep, only complicate the hyperthyroidism and uremia-
associated insomnia that itself reults from decreased slow wave sleep. Meprobamate in doses
not exceeding 800 mg, chloralhydrate at 500 mg and flurazepam at 15 mg, if administered
for no longer than 2 to 6 weeks, are the best choices in instances where hypnotic use is
absolutely unavoidable for elderly patients. Flurazepam, a benzodiazepine, does cause a
reduction in slow wave sleep without REM rebound upon withdrawal. The hypnotic chloral-
hydrate decreases sleep latency and awake time while increasing total sleep time. Meproba-
mate possesses certain hypnotic properties. Small dosage levels of chlorpromazine (25 mg)
or levomepromazine (10 mg) may have to be administered during the recommended gradual
withdrawal period.

Bender, A.D. Pharmacodynamic principles of drug therapy in the aged. Journal of the American
Geriatrics Society, 7:296-303, 1975,
71
''e This paper presents a review of research concerning the functional, physiological, and
pathological changes associated with increasing age and the pharmacologic aspects of aging.
The discussion is oriented both to the effect of age on systems and events that influence
the drug's concentration at its site of action and the age-related changes that affect systems
and tissues directly or indirectly influenced by the drug's mechanism of action. Such fac-
tors as drug absorption, drug distribution, drug excretion and metabolism, and the effect
of age on the activity of drugs are discussed. Among the findings reported are:

Absorption of some substances is reduced or delayed in the elderly.

Changes in drug activity with age are the result of impaired circulation and mem-
brane permeability.

The rate at which drugs are metabolized and eliminated is decreased.

Changes in the number of receptors and concentration of substrate occur, thereby
reducing the action of stimulants and enhancing the action of depressants.

This paper is directed toward the prescribing physician and emphasizes that fact that there
may be an altered response in elderly and debilitated patients that requires adjustment in
the patient's therapeutic regimen. (There are 72 references.)

Benson, R.A., and Brodie, D.C. Suicide by overdoses of medicines among the aged. Journal
of the American Geriatrics Society, 23:304-308, 1975,

 

e The authors indicate that drugs rank third, after firearms and hanging, in suicide. Pre-
scription drugs are used in one of three suicides in the United States. The elderly are
prone to suicide because of failing health and diminished life satisfaction. The older white
male, in particular, is called upon to adjust to income and status loss at a time when he is
least able to adapt. The rate for suicides in this group exceeds that for all other combina-
tions of age, sex, and race. Depression is often the only early clue or warning sign in a
group whose attempts are almost always serious.

Prescriptions for hypnotics and psychotherapeutic drugs are readily available to the elderly.
Barbiturate hypnotics accounted for over 20 million prescriptions filled in America during
1973; half of these were ordered for hypnotic purposes. The barbiturates an elderly insom-
niac consumes can actually produce or intensify any existing tendencies toward depression
or suicide, particularly if combined with alcohol consumption.

Although there is evidence that the prescribing of barbiturates is slowly decreasing, the
death rate per million prescriptions is on the rise. The prescribing physician is caught in
the bind of deciding whether to make psychotropic drugs available to elderly patients,
thus providing an easy means of suicide, or to withhold these drugs, leaving the patient
alone in his struggle with depression and an often accompanying wish for death. Further
complicating this dilemma is the difficulty surrounding the estimation of what constitutes a
lethal dose of these drugs. It is suggested that elderly patients must be assessed on an
individual basis by the prescribing physician so that treatment can be varied according to
the patient's overall status.

Birkett, D.P., and Boltuch, B. Psychotropic drugs in old age. The Journal of the Medical
Society of New Jersey, 70:647-648, 1973.

e Birkett and Boltuch conducted a study on the effects of psychotropic drugs on aged per-
sons. Thirty psychogeriatric unit patients over age 65 participated in an open crossover
study of the side effects of three antipsychotic drugs: thioridazine, chlorpromazine, and
haloperidol. These subjects were not already stabilized on a psychotropic drug, their
mental symptoms were more extensive than memory loss or confusion, they had no history
of adverse reactions to phenothiazines, and they were free of any liver disease indications.
Patients were not given phenothiazine-, butyrophenone-, or thioxanthine-type drugs during
the week prior to the study. Ten patients each were then randomly assigned to three treat-
ment groups where they followed study drug regimens for nine consecutive evenings. Each

 

72
''drug was administered separately for three consecutive evenings in the following amounts:
haloperidol, 0.5 mg, 1 mg, 2 mg; thioridazine, 25 mg, 50 mg, 100 mg; and chlorpromazine,
25 mg, 50 mg, 100 mg. The above schedule was assigned to one of the groups while the
other two followed schedules of either taking thioridazine first and then haloperidol and
chlorpromazine, or of being administered chlorpromazine followed by thiroidazine and halo-
peridol. There were no significant differences between drugs in the severity of side effects
they produced and none was particularly free of these problems. Both systolic and dia-
stolic blood pressure fell most on thioridazine and least on chlorpromazine. Rigidity and
unsteadiness on the feet were greatest on haloperidol, drowsiness was the most prominent
on chlorpromazine, and tremor on thioridazine. No falls or accidents occured over the 9-
day study period.

Boyd, J.R., et al. Drug defaulting. Part II: Analysis of noncompliance patterns. American
Journal of Hospital Pharmacists, 31:485-491, 1974.

 

e Forty-two outpatients age 65 and over were included in a study of noncompliance with pre-
scription instructions at an Oklahoma City teaching hospital. Pertinent information was
gathered during patient home interviews within 7 to 10 days following a clinic visit where
prescriptions were administered. A total of 380 prescriptions were written for the 134 par-
ticipating patients, ranging in age from under 24 to 65 and over, of whom more than three-
fourths were over 45 years old. Patients 65 and over received 107 prescriptions compared
to the 63 patients age 45 to 64 who received 184. In all cases the association between com-
prehension and compliance was statistically significant (p=0.05). The 45 to 64 age group
had the highest level of comprehension, significantly higher (p=0.05) than the lowest, age
65 and older, group. The 45 to 64 age group also had the smallest number of errors per
prescription (p=0.001). The greater number of errors in the elderly population was attrib-
uted to a combination of more complex health problems and decreasing capacity for self-
care.

Clinite, J.C., and Kabat, H.F. Prescribed drugs ... Errors during self-administration. Jour-
nal of the American Pharmaceutical Association, NS9:450-452, 1969.

 

e Thirty male outpatients ranging from 21 to 90 years old were interviewed about their pre-
scription medication administering habits approximately 1 week after leaving a Veterans
Administration hospital. Increasing age was not a factor in medication errors since patients
over 70 had the lowest error rate. It was possible that they had more time than younger
patients to carry out their therapeutic regimens correctly, and this may have accounted
for their greater accuracy.

Covington, J.S. Alleviating agitation, apprehension, and related symptoms in geriatric patients:
A double-blind comparison of a phenothiazine and a benzodiazepine. Southern Medical
Journal, 68:719-724, 1975,

e In order to compare the efficacy of a phenothiazine (thioridazine or Mellaril) with a benzo-
diazepine tranquilizer (diazepam or Valium) in relieving geriatric apprehension and agitation,
40 senile, but nonpsychotic, nursing home patients were used as subjects in a 4-week,
double-blind study. Patients were randomly assigned to treatment groups where 20 were
administered diazepam and 20 received thioridazine in daily doses adjusted to each patient's
need, These ranged from 10 to 80 mg of thioridazine, with a mean of 32.9 mg, and from 4
to 18 mg of diazepam, with a mean of 7.2 mg. Patients were evaluated before the study
and at weekly intervals with a modified Hamilton Anxiety Rating Scale and a Modified Nurses!
Observation Scale for Inpatient Evaluation (NOSIE). Global ratings were also made before
and during the study of the degree of both illness and overall change.

A pretrial versus week-4 comparison based on the Hamilton Scale showed that thioridazine
reduced the severity of all eight items more than diazepam, with significant reductions for
the anxious mood and depressed mood items (p=0.10 or more). Thioridazine significantly
reduced the severity (p=0.05 or better) of four of the eight items, but the diazepam group
showed no significant reductions. A greater percentage of the thioridazine group (23 to
45 percent) than the diazepam group (15 to 30 percent) showed at least some improvement
on each item. Time response trends differed, and significantly so (p=0.05 or better) for

a3
''four items, with the thioridazine group generally showing a pattern of steady symptom im-
provement compared to a more erratic and less positive pattern in the diazepam group.

NOSIE results showed that after 4 weeks only thioridazine had significantly reduced the
frequency of retardation (p=0.10) and this group had experienced more improvement on
every factor, significantly more so (p=0.05 or better) on five of nine factors. Their time
responses were significantly different (p=0.10 or better), favoring thioridazine for depres-~
sive manifestations and total positive factors. Separate global ratings by a physician and
by nurses at the end of 4 weeks each showed a significant reduction (p=0.5 or better) in
the degree of mental illness along with significant improvement (p=0.05 or better) in the
degree of change in thioridazine patients, with a comparative significantly greater improve-
ment (p=0.05) in these patients for both ratings. Worsening in these two ratings had oc-
curred in the diazepam patients. No serious side effects of clinically significant changes
in either vital signs or laboratory test results were found in either set of patients.

Davison, J.R.T., et al. Psychotropic drugs on general medical and surgical wards of a teaching
hospital. Archives of General Psychiatry, 32:507-511, 1975.

 

e A 6-week study of psychotropic drug use on the wards of a 480-bed university teaching
hospital was conducted to examine the prescribing patterns of gynecologists, surgeons, and
internists. One hundred twenty-eight patients, or 9.4 percent of all 1,361 admissions, were
administered psychotropic medicine. Preoperative and postoperative hypnotics were not in-
cluded. They were administered the most frequently by the department of medicine, to
14.4 percent of their patients, followed by surgery (8.9 percent) and obstetrics-gynecology
(4.7 percent). A ratio of 1:1.09 men to women received psychotropic drugs compared to
the total admissions population ratio of 1:1.37. The ratios of black patients to white were
1:1.93 and 1:1.75, respectively. Generally, patient's age was not a determinant of choice
of drug. The mean age of men patients was 45.9 and 47.7 for women. The 30- to 65-year-
old admissions, comprising 45 percent of total admissions, were overrepresented in the psy-
chotropic group (67 percent), whereas the over-65 patients were 14 percent of the total 15
percent of the psychotropic groups. Minor tranquilizers were the most widely used agents
(72 percent); major tranquilizers comprised 16 percent of the prescriptions; barbiturates,
used only for seizure disorders, represented another 6.7 percent and antidepressants, 5.3
percent.

Davison, W.T.D. Pitfalls to avoid in prescribing drugs in the elderly. Geriatrics, 1975. pp.
157-158.

e The author's editorial was directed toward geriatricians and emphasized both the importance
of reviewing the patient's complete drug schedule and the need for constant questioning of
every drug on the patient's prescription list, when prescribing medication. One special
problem discussed is polypharmacy that results in a bigger drug burden, an increased risk
of adverse drug reactions, and decreased patient compliance. Guidelines suggested to in-
sure maximal response with minimal risk include: full knowledge of the diseases present,
an understanding of drug actions, selectivity in drugs, the simplest drug schedule, and
adequate supervision.

De Groot, M.H.L. The clinical use of psychotherapeutic drugs in the elderly. Drugs, 8:132-138,
1974,

e De Groot's article indicates that general principles of drug administration for the elderly
patient apply as much to psychotherapeutic as to other drug classifications. The ability of
the aging system to absorb, and particularly to detoxify and excrete, drugs is reduced;
therefore, it is wise for the physician to be knowledgeable about the pharmacological action,
metabolic and excretive characteristics of proposed drug therapy. The lowest effective dos-
age level should be established for each elderly patient, and complicated, multiple-drug reg-
imens are best avoided.

Depression in the elderly patient is most effectively treated by the tricyclic antidepressants.
A more pronounced sedative effect occurs with the use of amitriptyline, imipramine, trimipra-
mine, and doxepin than results from using nortriptyline, protriptyline, and desipramine.

74
''Initial lw doses are recommended as hypotension can develop in elderly patients with unsta-
ble blood pressure. However, the action of adrenergic neuron blocking antihypertensive
drugs can be antagonized by the presence of amitriptyline, imipramine, and derivatives.

The tricyclic doxepin surmounts this problem if administered at the usual optimum dosage

of 75 to 150 mg daily.

Atropine-like side effects can occur when these drugs are used along with other drugs pos-
sessing anticholinergic activity. Monoamine oxidase inhibitors are effective as antidepres-
sants, but involve the dietary avoidance of foodstuffs rich in tyramine or dopamine and
also the ingestion of preparations containing sympathomimetic amines. Only those elderly
persons who are capable of remembering and carefully following instructions should be
treated with these drugs. Elderly mania patients receiving lithium carbonate treatment re-
quire a lowered dosage due to their diminished ability to excrete the lithium ion. Use of
barbiturates in these patients should be avoided as dependency is likely. The phenothia-
zines, although the most commonly used treatment in elderly schizophrenic patients, can
produce extrapyramidal reactions that, particularly in older patients, are unresponsive to
antiparkinsonian medication. Elderly endentulous female patients are particularly vulnerable
to developing dyskinetic complications. Hypotension may occur in normotensive patients,
and blood pressure control in hypertensives may be interfered with. The use of benzo-
diazepines or barbiturates in the treatment of anxiety in elderly patients can increase con-
fusional states, thereby often increasing anxiety, creating dependency and even hostility.

Eisdorfer, C. Observations on the psychopharmacology of the aged. Journal of the American

Geriatrics Society, 23:53-57, 1975,

e According to Eisdorfer, phenothiazines are currently the most widely used antipsychotic
drugs. Side effects such as extrapyramidal motor signs, tardive dyskinesia, and akathisia
are common. Difficulties are encountered in establishing a medical program for elderly psy-
chotic patients. The acute stage of psychosis is best handled by commencing drug dosage
at a low level, followed by a rapid increase up to an effective amount.

 

A chronic psychosis should be treated by using the lowest dosage level possible. A regime
consisting of a single dose at bedtime along with no utilization over the weekend appears

to maintain therapeutic effectiveness while diminishing unwanted side effects. The use of
antiparkinson drugs to combat extrapyramidal side effects should be discouraged along with
the administration of various psychotropic drugs from the same or even from different cate-
gories.

Psychotropic drug use in the elderly and in middle-aged, potentially chronic users should
begin with a dosage level one-quarter to one-third less than the normal adult dosage and

should gradually be raised according to individual tolerance. Side effects such as cardio-
vascular disorders, premonitory signs of glaucoma, or loss of libido should be watched for
in elderly as well as in younger patients. Drug influence on cerebral circulation can make
hypotension a particular danger for the elderly patient.

The aged are a population vulnerable not only to disease but to iatrogenic illness caused
by both direct and indirect drug action. Although the elderly are more prone to drug in-
duced side effects, clinical drug trials are usually conducted and dosage levels are devel-
oped based on results obtained from younger and healthier subjects. Older people have
greater tissue storage of drugs due to a higher ratio of fat to muscle tissue, along with
lower levels of metabolic function and a greater risk of metabolism related respiratory and
renal systems diseases. The benefits of psychotropic drugs can best be realized in a pro-
gram that includes a proper medical diagnosis formulated upon the patient's mental, emo-
tional, and physical condition.

Fann, W.E. Interactions of psychotropic drugs in the elderly. Postgraduate Medicine, 53:182-
186, 1973.

e Fann's article indicates that altered metabolism, blocked transport, altered excretion, altered

mediator activity, and impaired gastrointestinal absorption may result from the multiple use
of major psychotropic agents, particularly in the more vulnerable systems of older patients.

15
''Liver microsomal metabolism of the anticonvulsant diphenylhydantoin, of tricyclic antidepres-
sants, phenothiazines, and certain anticoagulants is retarded by the presence of methyl-
phenidate, a mild central nervous system stimulant. When given to counter the sedative
effect of a drug, it often increases sedation by blocking liver metabolism, thereby raising
blood level of the sedative. Conversely, because the sedative phenobarbital accelerates
liver microsomal metabolism in certain phenothiazines, warfarin, coumarin, and diphenylhy-
dantoin, its use with a phenothiazine can lower that drug's serum level and reduce its clin-
ical, including sedative, effect. The hypotensive effect of the antihypertensive drug
guanethidine can be antagonized by the concurrent use of tricyclic antidepressants or cer-
tain phenothiazines. These drugs can prevent guanethidine from accumulating in the adren-
ergic neuron by blocking the activity of the adrenergic membrane transport system that
would normally deliver it there. Since both depression and hypertension occur frequently
in elderly persons, this interaction is a likely and dangerous one that physicians should be
on the alert for, particularly in psychiatric outpatients.

Lithium therapy is useful in the treatment of cyclic affective disorders, but selective renal
lithium reabsorption and toxicity can occur if the patient does not maintain a physiologically
normal serum sodium level. Even though many elderly, cyclic affective disorder patients
also have concurrent conditions demanding diuretic therapy, such treatment is contraindi-
cated while lithium therapy is being administered.

Monoamine oxidase inhibiting compounds such as the antidepressant tranylcypromine and
the anthypertensive drug pargyline, reduce intraneuronal breakdown of norepinephrine.
These compounds potentiate the pharmacologic action of pressor amines, such as tyramine
and amphetamine and its congeners, which in turn act to release the available norepineph-
rine.

Patients undergoing either of these treatments should be warned against eating certain
tyramine-rich foods or ingesting sympathomimetic amines such as amphetamines, often avail-
able in over-the-counter cold remedies. The physician also must be careful not to prescribe
such combinations as they can produce a hypertensive crisis. Desired absorption of the
major tranquilizer chlorpromazine from the gastrointestinal tract can be threatened by gel
antacids containing magnesium or aluminum. Further research is needed pertaining to cho-
lestyramine, a hypercholesterolemia treatment agent, and its ability to interfere with absorp-
tion of psychotropic agents.

Fann, W.D. Pharmacotherapy in older depressed patients. Journal of Gerontology, 31:304-310,

1976.

According to Fann, treatment for depressive conditions is generically the same for various
age groups although dosage levels should be initially low and more gradually increased in
elderly patients. Tricyclic antidepressants are a better treatment choice than the Monoamine
Oxidase (MAO) inhibitors because they are safer; although in severe geriatric depression
tricyclics may be more effective. Both have a 1 to several weeks lag time before therapeu-
tic efficacy is noticeable.

Tricyclics are particularly effective in treating endogenous-type depressions. Nonsedating
tricyclics such as protriptyline and imipramine are well suited to treatment of retarded or
withdrawn depressives whereas the sedating amitriptyline or doxepin are more appropriate
cases of agitated or hyperactive depression. Certain tricyclic side effects such as twitch-
ing, tremor, ataxia, hypotension, dry mouth, and atropine-like effects are especially trou-
blesome in elderly patients. Reduced liver metabolism makes them more vulnerable to glau-
coma, urinary retention, orthostatic hypotension during early treatment, constipation, and
a central atropine-like delirium often mistaken for an increase in psychiatric symptoms.
MAO inhibitors are dangerous because of their hepatoxicity and potentiating effect upon
pressor amines, the latter resulting in hypertensive crises. All sympathomimetic agents
are contraindicated during their use. A lowered initial starting dose should range from 10
to 25 mg a day and increase by 20 mg in 2 to 3 days if no side effects are evident.

The antianxiety agent diazepam has a slight advantage over the others in its antidepres-
sant action but side effects such as habituation, sedation, aggravation of glaucoma, diplo-
pia, blurred vision, and withdrawal phenomena can occur. Of the neuroleptics, thioridazine
possesses helpful antidepressant properties. Certain piperazine derivatives, such as per-

76
''phenazine and trifluoperazine, can be useful in agitated depression when administered with
tricyclics. They must be used with care in the treatment of any underlying psychoses
accompanying depression. Elderly patients are particularly vulnerable to the acute neuro-
toxic and dyskinetic effects these drugs can cause. The parkinson-like syndrome is the
most common. lLate-onset hyperkinesis, or tardive dyskinesia is often irreversible, particu-
larly in older persons with a history of treated psychosis.

Central nervous system stimulants are mainly helpful in cutting down tricyclic therapy lag
time, but they can increase depression-related anorexia and induce short-lived mood eleva-
tion which is followed by severe emotional decline. Possible cardiovascular side effects make
them a poor choice for elderly patients. Lithium is effective only in prophylaxis of endoge-
nous depression and should not be used to treat reactive depressions. A lowered renal
lithium clearance in elderly patients necessitates a careful monitoring for lithium toxicity.

Multiple system decompensation in elderly persons leads to a greater likelihood of their re-
ceiving multiple drug prescriptions. They are at greater risk for the occurrence of dan-
gerous or treatment-impairing drug interactions. Many of the antidepressant agents, when
used in combination with other drugs, can either block the transport of other drugs to their
site of action, alter the excretion rate of the other drugs, alter their mediator activity, or
interfere with their absorption from the gastrointestinal tract.

Fann, W.E.; Wheless, J.C.; and Richman, B.W. Treating the aged with psychotropic drugs.
The Gerontologist, 16:322-328, 1976.

e The diagnosis and treatment of mental disturbances in the elderly are usually either incor-
rect or incomplete in nature. Insufficient attention is paid to the fact that chronic brain
syndrome (cbs), or senility, is only one psychiatric disorder occurring in this population.
Functional psychoses, affective disorders, and neuroses are as likely to be found in the
elderly as they are in other age groups. When psychotropic drugs are applied to a cbs-
diagnosed elderly patient and some improvement follows, it is not due to any real change
in brain tissue function but rather to a beneficial effect upon other present psychiatric con-
ditions.

When late paraphrenia develops in the elderly patient, it is important to distinguish whether
it is caused by chronic brain syndrome or whether it accompanies a depressive state. Only
chronic brain syndrome paraphrenia should be treated with antipsychotic medications. The
phenothiazines are the most frequently used because of their ability to reduce symptomatic
intensity in agitated, delusional, and hallucinating senile patients. As patients over age

65 have a great reduction in their ability to metabolize antipsychotic drugs, a lowered initial
dosage level is not only adequate but far safer than levels administered to patients under
age 65. Potential side effects due to physiological accumulation include dry mouth, urinary
retention, constipation, nasal congestion, aggravation of glaucoma, drowsiness, lethargy,
hypotension, and extrapyramidal symptoms. The elderly are especially vulnerable to the
development of tardive dyskinesia, a syndrome including involuntary choreo-athetoid move-
ments of the face, mouth, tongue, extremities, and trunk muscle groups. Even after medi-
cation withdrawal these symptoms may continue for an indefinite period, even becoming
permanent in some instances. The use of phenothiazines in the particularly susceptible aged
population can lead to a vicious circle of prescribing higher dosage levels to counteract what
are actually drug-induced states of confusion and delirium.

Depression in elderly patients is most often treated by lowered starting doses of tricyclic
antidepressants. Elderly persons who are restless and agitated receive the type which in-
cludes a sedative. Older patients with retarded depression are treated for the secondary
problems of hypoactivity and hypomentation with a nonsedative tricyclic agent. Due to the
2- to 4-week lag time before results are apparent, these drugs are more useful in mild to
moderate depression. They also possess potentially dangerous atropine-like and antiadrener-
gic actions. The inherent toxicity of monoamine oxidase inhibitors and their ability to poten-
tiate pressor amines, along with the action of several unrelated drugs, e.g., anesthetics,
barbiturates, adrenal coricosteroids, ganglion blocking agents, morphine, atropine, and 4-
amino-quinoline compounds, causes them to be used less frequently. Also, the antidepres-
sive and hypotensive effects of MAO inhibitors are potentiated by diuretics. However, the
effectiveness of MAO inhibitors in the treatment of geriatric depression may still prove
promising as elderly depression and the aging process itself are correlated with high MAO

77
''activity. Stimulant compounds are unpromising as antidepressants as their beneficial effects
disappear quickly, drug tolerance or dependence is likely to occur, and they have potent
pressor effects,

Numerous sedative, muscle relaxant, or anticonvulsant compounds have been clinically effec-
tive in treating anxiety in elderly patients. Chlordiazepoxide (Librium), a benzodiazepine,
is frequently used due to its relative safeness. These agents can produce dependency and
withdrawal symptoms which unfortunately mimic the onset of psychosis in elderly patients.
Glaucoma can also be an unwanted side effect. Rauwolfia alkaloids possess some value as
anxiolytics, particularly when blood pressure or pulse rate reduction is desirable, but gas-
trointestinal bleeding may occur along with other unwanted side effects. The use of any
anxiolytic agent is very likely to cause a secondary clinical depression, especially in patients
who have a history of affective illness episodes.

Fracchia, J., et al. Combination drug therapy. Journal of the American Geriatric Society, 13:
508-511, 1975,

 

e Data were gathered for a typical month on the most frequently used psychotropic drugs in
278 male and 624 female long-term, hospitalized psychogeriatric patients aged 60 years and
over. T-tests were conducted to ascertain the significance of mean dosage differences for
drugs used separately and in combinations. For females the use of 11 drugs was compared.
The average multidrug dosage of 10 agents was higher than the single-drug dosage. It
was significantly higher in four drugs: fluphenazine (Prolixin) and chlorprothixene
(Taractan), t=2.95 and 2.78, p=.01; and thiothixene (Navane) and perphanazine (Trilafon),
t=1.98 and 1.96, p.10. The average single-drug dosage of haloperidol (Haldol) was insig-
nificantly higher than its average in combination. Only five drugs were compared for male
patients, but the same general trend was in evidence. The average multidrug dosage of
chlorpromazine (Thorazine) was significantly higher than the single-drug dosage (t=2.71,
p=.01).

Greenblatt, D.J.; Shader, R.I.; and Koch-Weser, J. Psychotropic drug use in the Boston area.
Archives of General Psychiatry, 32:518-521, 1975.

 

e The Boston Collaborative Drug Surveillance Program conducted interviews with 25,258 con-
secutively admitted patients aged 20- to 75-years-old during the first 10 months of 1972 to
determine their use of prescribed psychotropic drugs prior to hospitalization. Patients with
primary psychiatric diagnoses, those with psychogenic disorders, and those unable to identi-
fy drugs taken were excluded, leaving a population of 24,633 patients. Patients who were
taking an identifiable antidepressant, antianxiety agent, antipsychotic, hypnotic, or stimu-
lant were considered psychotropic drug users. Of the 24,633 patients analyzed, 5,079 or
20.6 percent reported taking a psychotropic drug at least once in the 3-month period prior
to their interview. Women used these drugs more frequently than men (25 percent versus
15 percent), and use was highest in the 50 to 59 age group (women, 28 percent; men, 17
percent). The lowest female users were age 20 to 29 (19 percent), and 70- to 75-year-old
and 60- to 69-year-old females were the second and third lowest, respectively (20 percent
and 24 percent). The lowest male users were also age 20 to 29 (9 percent), and 70- to
75-year-old and 60- to 69-year-old males were the second and fifth lowest, respectively (12
percent and 16 percent).

Harenko, A. A comparison between chlormethiazole and nitrazepam as hypnotics in psycho-
geriatric patients. Current Medical Research and Opinion, 2:657-663, 1975.

@ The hypnotic effects of chlormethiazole and nitrazepam were compared in a double-blind
crossover study of 68 hospitalized demented elderly patients, averaging 77 years of age
with a range of 62 to 91 years. Medications, consisting of two tablets nitrazepam 5 mg =
10 ml placebo mixture (syrup) and two tablets placebo = 10 ml chlormethiazole 5 percent
mixture (syrup), were crossed over on alternate weeks. Six patients dropped out com-
pletely because of side effects or the manifestation of diseases, and 18 patients had to inter-
rupt medication for 1 to 3 days. Twenty-one interruptions or discontinuations occurred
during nitrazepam treatment, of which 15 were due to severe "hangover" effects. Two
patients refused to take chlormethiazole because of its foul taste. Six of the forty-four

78
''uninterrupted cases experienced side effects, five of whom had muscular weakness, nausea,
and worsening mental condition.

Over the 308-night test period, no significant differences pertaining to onset of sleep were

noted in the 44 patients. Sleep more frequently lasted over 6 hours a night during chlor-

methiazole treatment, a significantly higher difference of 244 out of 308 nights compared to

163 out of 308 nights during nitrazepam treatment (x?=46.35, p 0.001). Also, significantly

more patients (36) were observed with "hangover" effects during nitrazepam treatment than
during chlormethiazole treatment (2). A 10-mg dose of nitrazepam was judged to be at least
two times higher than necessary for use in elderly patients. Excluding the 6 patients who

dropped out, an overall judgment of suitability for 62 patients resulted in 37 cases assessed
as faring better with chlormethiazole, 11 cases with nitrazepam, and 14 cases who could do

equally well with either one.

Ingman, S.R., et al. A survey of the prescribing and administration of drugs in a long-term
care institution for the elderly. Journal of the American Geriatrics Society, 13:309-316,
1975.

 

e On August 1, 1971, a survey was made of the prescribing and administering of drugs in a
Connecticut nursing home as it pertained to residents. Primary focus was on the use of
neuroactive drugs--anxiolytics, neuroleptics, antidepressants, psychostimulants, hypnotics,
analgesics, skeletal muscle relaxants, antiparkinson drugs, autonomic agents, and cerebral
stimulants in--severely brain-damaged persons, ambulatory and relatively self-sufficient
residents, extended care unit patients, and recently hospitalized patients.

Doctors prescribed an average of 2.1 neuroactive drugs per patient but only an average
1.3 was administered. Analgesics and neuroleptics were prescribed the most frequently;
phenothiazine derivatives (43 cases) and salicylates (37 cases) were the particular drugs
most commonly prescribed.

Of the total 272 neuroactive drug prescriptions, 131 were actually administered, 145 were
prescribed on a discretionary (p.r.n.) basis, and 96 (66 percent) of the p.r.n. group were
not administered. Patients with relatively superior mentation and a greater measure of inde-
pendence were prescribed significantly more neuroleptic substances (i.e., single chemical
entities) and neuroleptic drugs than were patients with lower mentation and a greater amount
of dependency (p < .05). There were 23 prescriptions for propoxyphene compound, a not-
recommended drug by AMA Drug Evaluation standards. Fifty-four patients (41 percent)
received prescriptions for fixed-dose combinations of drugs, which are frowned upon as an
illogical drug therapy procedure. Variations in prescribing patterns among physicians were
evident even when records of physicians with approximately the same number of patients
were compared.

When the average number of all drugs prescribed on August 1, 1971 (4.9+6.3), was com-
pared with the average number prescribed on October 1, 1970 (5.8+3.17), a significant aver-
age decline of 0.8 drug prescribed per patient had occurred (p < .001). The decline was
subsequent to the implementation of the JCAH recommended monthly rewriting of drug
orders. A decrease of 0.14 p.r.n. drug occurred as well as a decrease of 0.27 fixed drug
per patient. However, there was an increase in the number of drugs received per patient,
rising from an average 2.55 (SD=2.3) to an average 2.9 (SD=1.4) drugs per patient.

These results are based on the records of 112 patients who were in the nursing home on
both dates.

Kral, V.A. An overview of psychopharmacology of old age. Psychopharmacology Bulletin, 12:
51-52, 1976.

 

e The functional psychoses, i.e., endogenous depressions, manic states, and the schizophrenic
late paraphrenias, are the mental disorders of the aged most benefited by psychopharma-
cological treatment. Due to lessened metabolic efficiency and likely concurrent organic
disease in these patients, the smallest yet effective dosage level of psychotropic drugs
should be administered and the prescribing physician should be aware of all simultaneously
prescribed drugs so as to avoid harmful drug interactions. Combinations of psychotropic

79
''drugs should be used only after each drug has been introduced separately to assess toler-
ance.

Tricyclic antidepressants and the monoamine oxidase inhibitors are both used to treat
endogenous depressions and must be administered at individually established levels. The
therapeutic effects of tricyclics appear from 4 to 21 days after initial treatment, and admin-
istration should continue until all target symptoms show definite improvement. A gradual
tapering off is required, and a reduced maintenance dose for several months is often neces-
sary.

Central nervous system side effects, such as ataxia, somnolence, and lassitude, occur with
equal frequency in aged and younger patients. It is still questionable whether the drugs'
anticholinergic action or an age-linked stress reaction is the causal agent in an acute con-
fusional state occasionally occurring in elderly patients. The antidepressive effect of MAOIs
is rapidly apparent, causing mood improvement but no allaying until later, and sometimes
temporarily increasing the experience of anxiety. Treatment with MAOIs contraindicates

the use of anesthetics and incurs the risk of hypotension in users. Combining antidepres-
sants with a neuroleptic to treat agitated depressions can result in accident causing ortho-
static hypotension and cerebral vascular accidents. Side effects are potentiated by the
combined anticholinergic actions of tricyclic and the phenothiazines.

Lithium carbonate, although a successful treatment for manic states, is contraindicated in
patients with compromised renal, hepatic, cardiovascular, and thyroid function. Complete
recovery will occur in 3 weeks without serious side effects if the proper dosage is estab-
lished and continued and serum lithium levels are monitored frequently. Without either
careful monitoring or cautious patient selection, tremulousness, drowsiness, confusion, and
extrapyramidal signs will occur. Aged schizophrenic patients, whose treatment is very
similar to that for younger patients, share the risk of developing a neuroleptic-induced
Parkinson syndrome. Often occurring shortly after therapy commencement, it is sometimes
preceded or accompanied by a peculiar restless state. Although very responsive to tradi-
tional antiparkinsonian medication, the combined anicholinergic action of both medications
can produce an acute confusional state. Therefore the medication cannot be used in a pre-
ventive manner and its use should be discontinued a few weeks after initial awareness of
symptoms. Tardive dyskinesia is a neuroleptic-induced side effect presenting serious treat-
ment difficulties and warranting a discontinuation of medication when feasible. Depressive
or paranoid episodes accompanying a dementing process are treatable with antidepressants
and/or tranquilizers, but their side effects may be more troublesome in such cases. A
superimposed state of acute confusion warrants treatment with a neuroleptic along with the
infusion of glucose.

Lamy, P.P. Geriatric drug therapy. Clinical Medicine, 81:52-57, 1974.

The elderly patient frequently suffers from a multitude of morbid conditions or diseases at
a time in life when reserve functional capacity, energy metabolism, and enzymatic processes
are greatly reduced. The capacity to absorb, distribute, metabolize, and excrete drugs is
very often impaired, resulting in an increase of adverse drug effects. Persons aged 70 to
79 experience adverse drug reactions at a rate seven times greater than persons aged 20

to 29 years, and the rate for those aged 60 to 70 years is twice that for persons aged 30
to 40 years. Age-related reduction in gastric juice acidity, a slowed stomach emptying rate,
and a reduction in intestinal blood flow can lead to a delay or reduction in drug absorption.

Drug distribution can be affected by circulatory disturbances and the decreasing activities
of several enzymes can hamper drug metabolism. Aging is accompanied by a decrease in
kidney size, glomeruli, and tubule cells, and glomerular filtration rate, renal flow, and
tubular secretion capacity fall below normal levels. Renal pathology and resulting dimin-
ished renal function is the norm in elderly persons, and water imbalance along with general
metabolism imbalances are frequently found. Reduced peristaltic activity, leading to con-
stipation and diarrhea can also alter the elimination of drugs, especially those which exhibit
enterohepatic circulation,

The establishment of drug dosage levels for the elderly patients is frequently accomplished
by aiming at a uniform medium level which is often either too high or too low for at least
half the population. There is no formula which can be followed for every patient, but the

80
''aim should be to arrive at the minimal effective dosage level. When prescribing antidepres-
sants for elderly patients, lower than usual dosage levels are essential to avoid adverse
reactions. Sedatives rust be used with extreme caution in elderly persons. Barbiturates
are generally contraindicated as they may cause severe and unexpected durg toxicity. A
dependency liability is incurred with meprobamate and glutethimide use, and patients taking
20 or more tablets of the latter have a mortality rate of 45 percent. Paraldehyde, although
unpalatable, is rapid, safe, and effective whereas chloral hydrate is a potential cardio-
inhibitor and a gastric irritant.

Elderly patients with arteriosclerotic cerebral vessels or chronic obstructive pulmonary
disease should not be administered sedatives which depress cardiac or respiratory function,
and the insomnia which can occur due to an overly full bladder should not be treated with
sedatives. When a decrease in anxiety, psychomotor activity, hallucinations, and delusions
is needed, large initial, followed by smaller, doses of the phenothiazines are helpful. How-
ever, neurotic reactions, simple endogenous depression, and acute disturbances are not
benefited by them. Possible dose-related side effects of the phenothiazines are jaundice,
agranulocytosis, dermatitis, and photosensitivity, besides a general tendency to cause a
high rate of extrapyramidal reactions and hypotension. Potentiation of epilepsy and mental
depression, lowered body temperature, and exaggeration of cerebral anoxia can also occur,
as well as irreversible parkinsonian symptoms. The phenothiazines and also chlordiazepox-
ide and diazepam can depress thyroid function, and small doses of the latter two are re-
quired to prevent ataxia development.

Lamy, P.P., and Kitler, M.E. Drugs and the geriatric patient. Journal of the American Geria-
trics Society, 19:23-33, 1971.

 

e A survey of drug prescribing patterns centered upon 33 geriatric cardiac patients in a
teaching hospital, 30 ambulatory patients over age 65, and 30 patients over 65 admitted to
a geriatric care hospital. Although all drugs prescribed were found to be administered
within the range of recommended dosage levels, there was no general reduction made be-
cause of the patients' elderly status. Barbiturates, particularly in combinations, were fre-
quently administered to the ambulatory patient, whereas hospitalized patients received
chloralhydrate on the rare occasions when barbiturates were prescribed.

Lamy, P.P., and Vestal, R.E. Drug prescribing for the elderly. Hospital Practice, 1976. pp.
111-118.

e Social Security Administration statistics show that during 1974 the aged population spent
about $2.26 billion, or more than 20 percent of the national total, on drugs and drug sun-
dries even though they comprise only 10 to 15 percent of the total population. Including
renewals, they averaged over 13 prescriptions a year per capita, spending close to $100
for prescribed and over-the-counter drugs. The mere factor of multiple drug use, even
when correctly prescribed at proper dosage levels, involves a strong possibility of toxic
reactions, and studies have shown that drug-induced illness occurs with much greater fre-
quency among elderly hospitalized patients.

Prescribing drugs for the elderly patient is both complicated and hazardous. Age-
associated decrements in physiologic function as well as the effects of illness or trauma
erase the reliability of the "average" dose for the "average" patient and require the phys-
ician to be able to weigh benefit and risk using a different set of parameters than s/he
would apply to younger patients. Above all, s/he must approach the treatment of geriatric
patients with a sense of caution accompanied by an awareness of knowledge that is available
to help him/her formulate treatment regimens.

Because much research must still be done in order to fully understand the effects of aging
on pharmacokinetics, quantitative answers to specific problems of dosage and drug selection
are not yet available.

Learoyd, B.M. Psychotropic drugs and the elderly patient. The Medical Journal of Australia,
1L¢1131-1133,. 1972.

 

81
''e The Medical and Psychogeriatric Unit of the North Ryde Psychiatric Centre of North Ryde,
New South Wales, reviewed case notes for all 236 patients over age 65 who had been ad-
mitted during the past 2 years to learn how many admissions had been the result of psy-
chotropic drug intoxication. Thirty-seven, or 16 percent, met the criteria of having been
administered psychotropic drugs prior to admission and then developing disturbed behavior
with or without physical symptoms. Further, in the Centre this behavior must have sub-
sided when these patients were removed from drugs followed by a discharge on a much
smaller drug regimen. When admitted, seven of these patients were suffering from simple
drug intoxication, and their confused mental state had often led to self-administered over-
doses. Sixteen patients had, in addition to the above, incurred secondary effects from
drug intoxication such as hypotensive syncope, related falls and three fractures, respira-
tory depression and associated chest infections, and urinary retention or gastrointestinal
ileus. The remaining 14 patients had reactions which manifested as restlessness, agitation,
paranoia, and aggression. Multiple psychotropic drug therapy was the rule, as only four
patients were administered on drug alone. It is postulated that these admissions were made
necessary because of elderly patients' reduced tolerance to the combinations of drugs, and
because of ignorance about the effects that lead to further medication and increasing dete-
rioration. Although the association was not as clearcut, it was estimated that another 4
percent of the 236 patients had been admitted mainly because of drug effects. Study find-
ings lead to the postulation that many elderly admissions to general hospitals are for ill-
nesses precipitated by excessive use of psychotropic drugs.

McKenney, J.M., and Harrison, W.L. Drug-related hospital admissions. American Journal of

Hospital Pharmacy, 33:792-795, 1976.

e In a 2-month survey and analysis of the association between hospital admissions and drug-
related problems there were a total of 216 admissions to a general medical ward, of which
59 (27.3 percent) were linked in some manner to drug usage. Seventeen percent of all
patients were age 60 to 69, and 19 percent were age 70 or over. Their representation in
the drug-linked admissions population, 15 percent and 11 percent, respectively, was not
significantly different, nor was that of all other age groups. The age group 40 to 49 had
the highest representation and comprised a quarter of the subpopulation. Adverse drug
reactions (7.9 percent) and noncompliance (10.5 percent) seemed to be the major precipitat-
ing factors in hospital admissions for these 59 patients. Another 24 (11,1 percent) of the
59 patients had adverse drug reactions, but they did not cause their admission. Inade-
quate thereapy, improper or erroneous drug use and drug overdose had a somewhat weaker
association with hospital admission.

Merlis, S. The use of oxazepam in elderly patients. Diseases of the Nervous System, 36:27-29,
1975.

e Oxazepam is a particularly effective and safe benzodiazine medication for use in elderly pa-
tients because of the following properties and characteristics: efficient absorption patterns,
rapid metabolism to a psychopharmacologically inactive substance, favorable biotransforma-
tion characteristics, a wide margin of safety, and beneficial excretion patterns. Other
characteristics surrounding its limited potential drug interactional effects with other thera-
peutic agents contribute to its efficacy without increased side effects. Earlier studies of
oxazepam use in several hundred institutionalized geriatric subjects showed significantly
superior overall results in reducing anxiety and tension occurring alone or anxiety concur-
rent with depression when compared with patients receiving another drug or placebo. In
doses averaging 30 to 50 mgs daily, side effects were less prevalent than with other treat-
ments, and vertigo, sedation, and nausea appeared less frequently. Some inhibition of hos-
tility and aggressive behavior was evidenced, and paradoxical reactions, which sometimes
occur with chlordiazepoxide use, rarely happened. Ambulatory noninstitutionalized elderly
patients have also shown a high tolerance of oxazepam. It is useful in elderly patients who
have sleep problems such as early awakening or restlessness at night. It possesses a short
duration of action and at proper dosage levels there is no sedative or hangover effect in
the morning.

Petersen, D.M., and Thomas, C.W. Acute drug reactions among the elderly. Journal of Geron-
tology, 30:552-556, 1975.

82
''e Data were gathered for 60 persons age 50 and over who were admitted to a Dade County,
Florida, hospital emergency room because of acute, nonfatal drug reactions during 1972.
Ranging from 50 to 80 years old and averaging 59.6 years, they comprised only 5.4 percent
of the total 1,128 overdose admissions whose average age was 27.6 years. Females outnum-
bered males (68.4 percent versus 31.6 percent) in the aged group and were more concen-
trated in the aged group than in the total population (68.4 percent versus 58.6 percent).
Blacks comprised only 15 percent of the aged admissions compared to 33 percent of the
total admissions. For both the aged group and all admissions, white females were the race/
sex grouping most likely to be admitted, comprising 61.7 percent of aged admission and
38.4 percent of all admissions.

Comparisons with 1970 Dade County census data showed that although the aged group was
not overrepresented in total county emergency room admissions for acute drug reactions,
over age 50 females (68.7 percent versus 55.3 percent) as well as white, over age 50 fe-
males (61.7 percent versus 51.4 percent). Similarly, blacks exceeded their Dade County
distribution (15.0 percent versus 7.2 percent), black males (8.3 percent versus 3.3 per-
cent) slightly more than black females (6.7 percent versus 3.9 percent). Aged admissions,
though more likely to have reported multiple substance use prior to acute drug reaction
(31.9 percent versus 23.5 percent of all admissions), were less likely to report alcohol use
(8.3 percent versus 10.9 percent). The proportion,of the aged group reporting their over-
dose as an attempt at suicide (35.0 percent) was only slightly greater than the 33.7 percent
reported for all admissions.

Legally available drugs, whether attainable by prescription or over the counter, were
responsibile for all admissions among the aged group. The particulars of attainment were
not available. Of every 10 of these drugs, 8 were psychotropic, either sedatives or tran-
quilizers, and one was a nonnarcotic analgesic. In descending order, Valium, Tuinal, phe-
nobarbital, and Darvon were the most frequently abused. Among the aged group, whites
and females were more likely to have overdosed on tranquilizers, sedatives, and nonnarcotic
analgesics. Twenty percent of the admissions under age 50 had abused illicit substances.

Rada, R.T., and Kellner, R. Thiothixene in the treatment of geriatric patients with chronic
organic brain syndrome. Journal of the American Geriatrics Society, 14:105-107, 1976.

e@ Forty-two hospitalized geriatric patients (21 male) with chronic organic brain syndrome (24
nonpsychotic) were randomly assigned to treatments in a double-blind, placebo-controlled
4-week study of the efficacy and safety of thiothixene (Navane) treatment. The mean age
was 75.5 years, and duration of illness averaged 5.3 years. Demographic characteristics
and the chronicity of illness did not significantly differ between the thiothixene and placebo
group. Using a starting dosage of 2 mg three times daily during the first two weeks,
which could then be increased to 5 mg three times daily, produced virtually no statistically
significant improvement in the thiothixene group. The few side effects which occurred were
mild in nature and developed in only seven thiothixene patients, compared to six placebo
patients who experienced side effects.

’

Salzman, C., et al. Psychopharmacologic investigations in elderly volunteers: Effect of diazepam
in males. Journal of the American Geriatrics Society, 13:451-457, 1975.

e Forty healthy elderly male volunteers over the age of 60 participated in a 2-week, double-
blind study of diazepam (DZ) during which 20 were randomly assigned to a group receiving
12 mg of DZ daily and 20 received placebo (PBO). Various psychological scales and motor
functioning tests were administered and mean change scores for both groups, statistically
compared by t-test, were obtained by subtracting predrug ratings from l-week and 2-week
scores.

Data were available for 38 patients. Overall analysis of significant results suggests that

an increase in fatigue and decreases in memory and motor functions are produced by a daily
12 mg dose of DZ. After the 2-week period results from a revised MMPI depression scale
showed a significantly higher number (9) of the 18 DZ recipients reporting decreased depres-
sion scores compared to only 2 of the 20 PBO recipients (p=.02).

83
''Salzman, C., and Shader, R.I. Psychopharmacology in the aged--Research considerations in
geriatric psychopharmacology. Journal of Geriatric Psychiatry, 7:165-184, 1974.

 

e The evaluation of drug effect in the elderly centers around the research problems of bio-
logic variability, age, gender, dose, toxicity, polypharmacy, placebo effect, initial severity
of symptoms, capacity to respond to drugs, and age-related problems of rating drug effect.
Biologic and physiologic functioning among elderly persons who are the same chronological
age can vary greatly according to the number and severity of chronic diseases and patho-
logical processes present at any one time. This lack of biologic homogenity is a threat to

the validity of research results unless given due consideration in research program design.

Various psychotropic drug studies utilizing elderly subjects have found a differential re-
sponse to treatment occurring in males and females, as well as in relatively younger and
older aged subjects, suggesting that it is important to conduct a separate data analysis by
gender and age so that these intrasample findings are revealed rather than cancelled out
and overlooked in a total sample analysis. There is also evidence for a need to conduct
separate treatment data analyses of patients who exhibit either high or low initial levels of
symptoms.

Findings from numerous studies suggest that patients exhibiting a high level of the target
symptom or symptoms will show the greatest improvement following drug therapy, and an
examination of only the overall "mean" drug effect can act to cancel out these variations.
Elderly subjects are likely to be patients on various multiple drug regimens which are cap-
able of affecting the action of psychotropic drugs. Also, elderly persons have a heightened
sensitivity to the sedative side effects of psychotropic agents which may result in hamper-
ing their clinical efficacy. The elderly are also particularly vulnerable to potential extra-
pyramidal and hypotensive side effects caused by many antipsychotic and antidepressant
drugs.

It is wise for the researcher to establish dosage guidelines and learn of potential toxicity
through a small preliminary pilot study. He should also be aware that high placebo
response rates are common among attention-starved, elderly subjects, and one study's
results suggest that it increases with the presence of psychopathology, institutionalization,
and age. Any marginally greater improvement with active drug treatment over that with
placebo is worthy of attention.

The choice of rating scales to use for evaluation of drug effects in geriatric populations
must be made with the variability of elderly subjects in mind. Although rating a relatively
healthy and cooperative geriatric patient is similar to rating younger populations, there still
exists a reduced attention span and a decreased tolerance for ambiguity. Very few scales
have been designed especially for geriatric patients in the areas of behavioral, mood, and
cognitive function rating.

Salzman, C., and Shader, R.I. Responses to psychotropic drugs in the normal elderly. In:
Psychopharmacology and Aging. New York: Plenum Press, 1973. pp. 159-168.

e One hundred health volunteers over the age of 60 participated in a l-week, double-blind
study of mood-altering drugs administered in typical doses. Twenty-five subjects each were
randomly assigned to treatment groups where they received either 2 mg t.i.d. of diazepam,
15 mg t.i.d. of phenobarbital, 5 mg t.i.d. of methylphenidate or a placebo three times each
day. Psychological scales were administered before and after the study period, and the
Bonferroni multiple comparison test was used to analyze mean change scores for the entire
sample and for each sex. Each active drug was compared independently against placebo.
Few statistically significant results were found. Diazepam showed a significant overall trend
toward increasing both friendliness and fatigue and had a significant antidepressant effect
on males. In females, diazepam and methylphenidate both significantly increased friendli-
ness over placebo. Methylphenidate was found to be the best antidepressant and antianxi-
ety agent for females, whereas diazepam was the more effective drug for males.

Salzman, C.; Shader, R.I.; and Van Der Kolk, B.A. Clinical psychopharmacology and the elder~
ly patient. New York State Journal of Medicine, 76:71-77, 1976.

 

84
''e Alterations in somatic functioning that occur due to the aging process can change the clini-
cal and toxic effects of drugs or other agents. Changes in the gastrointestinal tract slow
down and impair drug absorption and cause increased atropinergic sensitivity. The aging
cardiovascular system can reduce or delay drug circulation and cause increased sensitivity
to orthostatic stress. Albumin fraction is decreased in the aging hematopoietic system.

In the nervous system a decrease in neuronal tissue causes an increased sensitivity to clin-
ical and toxic effects and also to side effects produced by the cholinergic blocking prop-
erties of certain drugs, such as neuroleptics and antidepressant agents. These drugs
commonly cause blurred vision or a dry mouth, and the loosening of porcelain dental fillings
is not unusual. Symptoms accompanying glaucoma or benign prostatic hypertrophy may be
aggravated. Decreased gastrointestinal and bladder motility are less common, but possibly
dangerous, side effects.

Potentially serious cardiovascular side effects can result from use of certain neuroleptics.
Phenothiazines and the structurally related tricyclic antidepressants can cause occurrences

of orthostatic hypotension, particularly in susceptible older persons with elevated blood pres-
sure and resultant decreased elasticity of the arterial wall. Older people with impaired car-
diovascular functioning are also more predisposed to arrythmia, a further side effect of both
phenothiazines and tricyclic antidepressants.

Central nervous system disturbances are particularly prevalent in elderly neuroleptic users.
Sedation, paradoxical excitement, delirium, dementia, assaultiveness, delusions, and hallu-
cinations also occur with greater frequency in elderly patients taking psychoactive drugs.
As no neuroleptic is free from side effects, and their clinical efficacy is about equal, choice
of treatment should be based on knowledge of their differential production of sedative,
hypotensive and extrapyramidal side effects, and the treatment needs and overall condition
of each elderly patient. Tricyclic antidepressants are also approximately equal in effective-
ness. Except for the risk in very old patients of producing severe hypotension or arryth-
mias, they are preferred in the treatment of elderly depression. They have potentially
serious side effects, and they interact with many of the medical drugs that older persons
commonly are administered.

The benzodiazepines are currently considered the drug treatment of choice for anxiety in
both young and old patients. Elderly patients are more susceptible, however, to sedative
side effects, making these drugs suitable for the treatment of mild insomnia as well. The
hypnotic flurazepam as well as chlorpromazine or thioridazine in small doses is also extreme-
ly useful and safe. Generally, elderly patients should not be treated with babiturate and
nonbarbiturate sleeping medications other than the benzodiazepines. Polypharmacy should
be avoided as much as possible in order to prevent dangerous drug interactions.

Synder, B.D., and Harris, S. Treatable aspects of the dementia syndrome. Journal of the
American Geriatrics Society, 14:179-184, 1976.

e Detailed case histories are presented of four geriatric patient referees to a general hospital
from long-term care facilities due to the exhibiting of behavioral disturbances. The diag-
nosis of untreatable dementia was incorrect for two of these patients, one who had been
administered five psychoactive drugs concurrently before hospital admission. The case his-
tories illustrate the importance of proper diagnosis and exemplify improper, incomplete, and
unsafe treatment as well as high-quality care which is thoughtfully planned and delivered
with the individual patient in mind. The point is made that everything possible should be
done to help both dementia, otherwise behaviorally impaired, demented and nondemented
patients maintain their maximum level of overall health and independence.

Swanson, D.W.; Weddige, R.L.; and Morse, R.M. Abuse of prescription drugs. Mayo Clinic
Proceedings, 48:359-367, 1973.

e A study was made of 225 patients ranging from 16 to 77 years old whose abuse of prescrip-
tion medicines caused them to need inpatient psychiatric treatment between July 1, 1966,
and July 1, 1972. Mean patient age was 45 years and 123, or 55 percent, of patients were
females. Patients were categorized by the drug they abused into a sedative, analgesic,
tranquilizer, stimulant, or miscellaneous grouping. The distribution by age decades and

85
''by sex was fairly even excepting that significantly more females (18) than males (6) had
abused tranquilizers (p < 0.05), and the mean age of stimulant abusers was only 34.3 years,
their ages ranging from 21 to only 53 years. The age at onset of drug abuse ranged from
14 to 73 years with a mean of 36.5. The duration of abuse ranged from 6 months to 35
years, and averaged 12.5 years. More patients abused sedatives and analgesics than the
other categories.

86
''APPENDIX A

RESEARCHERS INVOLVED IN PSYCHOACTIVE
DRUG USE BY THE ELDERLY

Aagaard, George N., M.D., Chairman, National Drug Spotlight Program National Advisory Com-
mittee (1973), and Professor of Medicine and Pharmacology and Head of the Division of
Clinical Pharmacology, University of Washington, School of Medicine, Seattle, Washington.

Asnes, Daniel P., M.D., Psychiatrist-in-charge, Geriatric Unit, McLean Hospital, Belmont,
Massachusetts.

Ayd, Frank J., Jr., M.D., Director of Professional Education and Research,’ Taylor Manor Hos-
pital, Ellicott City, Maryland.

Balter, Mitchell, Ph.D., Chief, Special Studies Section, Psychopharmacology Research Branch,
National Institute of Mental Health, Rockville, Maryland [(301) 443-3946].

Basen, Michelle M., Public Health Analyst, Services Research Branch, Division of Resource
Development, National Institute on Drug Abuse, Rockville, Maryland.

Brands, Alvira, D.Sc., Program Analyst, Mental Health Care and Service Financing Branch,
Division of Mental Health Service Programs, Room 11-95, National Institute of Mental Health,
Rockville, Maryland [ (301) 443-3657].

Brody, Stanley J., J.D., Professor, Departments of Physical Medicine and Rehabilitation and
Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
[ (215) 243-5765].

Butler, Robert N.,°Ph.D., Director, National Institute on Aging, National Institute of Mental
Health, Washington, D.C.

Carpenter, Linda, Coordinator, Rational Behavior Training Section, University of Kentucky
Medical Center, Lexington, Kentucky [(606) 233-5000].

Cervera, A.A., M.D., Samuell Clinic, Dallas, Texas.
Cherkin, Arthur, M.D., Selpulveda Veterans Administration Hospital, Los Angeles, California.

Cheung, Alan, Pharmacist D., Associate Clinical Professor, School of Pharmacy, University of
Southern California, Los Angeles, California [ (213) 226-2561].

Clark, Walter, Assistant Chief, Mental Health Education Branch, Division of Scientific and Public
Information, National Institute of Mental Health, Rockville, Maryland [(301) 443-4573].

Cohen, Dr. Gene, Chief, Center for Studies of Mental Health for Aging, National Institute of
Mental Health, Rockville, Maryland [(301) 443-3823].

Cohen, Sidney, M.D., Department of Psychiatry, Neuropsychiatric Institute, UCLA School of
Medicine, Los Angeles, California [(213) 825-0400].

Cole, Jonathan, M.D., Boston State Hospital, 591 Morton Street, Boston, Massachusetts.

Davis, John, Director of Research, Illinois State Psychiatric Institute, Chicago, Illinois, Univer-
sity of Chicago, School of Medicine.

Dunham, Katherine, Southern Illinois University, 411 E. Broadway, East St. Louis, Illinois
[(618) 271-4400].

87
''Eisdorfer, Carl, Ph.D., M.D., Chairman, Department of Psychiatry and Behavioral Sciences,
School of Medicine, University of Washington, Seattle, Washington [(206) 543-3750].

English, Tom, Alcohol and Drug Coordinator, Joseph W. Johnson, Jr., Mental Health, Moccasin
Bend Road, Chattanooga, Tennessee.

Fann, William E., M.D., Professor of Psychiatry, Associate Professor of Pharmacology, Baylor
College of Medicine; Chief, Psychiatry Service, Veterans Administration Hospital, Houston,

Texas.

Friedel, Robert, M.D., Vice Chairman, Department of Psychiatry and Behavioral Science, School
of Medicine, University of Washington, Seattle, Washington [(206) 543-1570].

Gaetano, Ronald, Pharmacist, Broome County Drug Awareness Center, 22 Park Place, Johnson
City, New York [ (607) 798-7182].

Gerber, Carl, M.D., Chief of Staff, Veterans Administration Hospital, Tacoma, Washington [ (206)
588-2185].

Gershon, Sam, M.D., Department of Psychiatry and Neurology, New York University Medical
Center, New York, New York [(212) 679-3200, extension 3520].

Godes, Thomas H., Pharmacist Director, Consultants of Pharmacy, 420 South 7th Street,
Minneapolis, Minnesota [(612) 333-4217 or 340-5454].

Greenblatt, David J., M.D., Assistant Professor, Harvard Medical School; Assistant in Medicine,
Clinical Pharmacology, Massachusetts General Hospital, Boston, Massachusetts.

Guttman, David, DSW, National Catholic School of Social Services, Catholic University of America,
Washington, D.C.

Haber, Paul, M.D., Assistant Chief Medical Director for Extended Care, Veterans Administration,
810 Vermont Avenue, N.W., Washington, D.C. [(202) 393-4120].

Hall, M.R.P., B.M., F.R.C.P. (Lond. Ed.), Professor of Geriatric Medicine, Faculty Medicine,
Southampton General Hospital, Tremona Road, Southampton S09 4XY, England.

Hammel, Maxine, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota [ (612)
376-5316].

Hollister, Leo E., M.D., Veterans Administration Hospital, 3801 Serra Boulevard, Palo Alto,
California [(415) 493-5000].

Holloway, Donald A., Pharm. D., The Methodist Retirement Home, Durham, North Carolina.

Jarvic, Lissy, M.D., Department of Psychiatry, UCLA Medical Center, Los Angeles, California
[(213) 825-3885].

Jarvic, Murray, M.D., Department of Psychiatry, UCLA Medical Center, Los Angeles, California
[(213) 825-2410].

Jefferson, Cherie, 120 Arch, St. Paul, Minnesota [(612) 227-6363].

Juni, Dr. Howard, Capitol Drug Center, 2023 E. County Road, White Bear Lake, Minnesota
[ (612) 777-8388].

Kabat, Dr. Hugh, University of Minnesota, School of Pharmacy, Department of Clinical Pharma-
cology, 115 Appleby Hall, Minneapolis, Minnesota [(612) 376-5312).

Kampf, Betty, M.D., Geriatric Coordinator, Overlook Mental Health Center, 5908 Lyons View
Drive, Knoxville, Tennessee.

Kane, Robert L., M.D., Associate Professor of Community Medicine, University of Utah, College
of Medicine, Salt Lake City, Utah.

88
''Klett, C. James, Ph.D., Central Neuropsychiatric Research Laboratory, Veterans Administration
Hospital, Perry Point, Maryland [(301) 642-2411, extension 353].

Lamy, Dr. Peter, Professor of Pharmacy, University of Maryland, School of Pharmacy, 636 W.
Lombard Street, Baltimore, Maryland [(301) 528-7592].

Leech, Shirley, M.D., Geriatric Consultant, U.T. Mental Health Center, P.O. Box 4947,
Knoxville, Tennessee.

Lehman, Heinz E., M.D., Clinical Director, Douglas Hospital, McGill University, Montreal,
Quebec, Canada [(514) 716-6131, extension 128].

Levine, Dr. Ruth, Boston University, School of Medicine, Boston, Massachusetts.

Libow, L.S., M.D., Chief, Geriatric Division, Department of Medicine, Mount Sinai City Hospital
Center, 79-01 Broadway, Elmhurst, New York.

Martilla, James, Pharmacist Director, Assistant Professor of Pharmacy, University of Minnesota,
318 Harvard Street, S.E., Minneapolis, Minnesota [(612) 376-5323].

McRae, Catherine E., Geriatric Services Section, State of Tennessee Department of Mental Health
and Retardation, 501 Union Building, Nashville, Tennessee.

Mehl, B., R.P., Assistant Director, Mount Sinai Hospital, New York, New York.

Montero, E.F., M.D., Central State Hospital, Petersburg, Florida; National Building, 908 S.
Florida Avenue, Lakeland, Florida.

Morrow, Gloria, Director of Research and Education, American Health Care Association, 1200 15th
Street, N.W., Washington, D.C. [(202) 833-2050].

Parker, Jerry, Director of Senior Health Programs, Augustana Hospital, 411 W. Dickens, Chicago,
Illinois [(312) 975-5056].

Pascarelli, Emil F., M.D., Director of Community Health Services, Department of Ambulatory
Care, Roosevelt Hospital, New York, New York.

Penna, Dr. Dick, Director of Professional Affairs Division, American Pharmaceutical Association,
2215 Constitution Avenue, Washington, D.C. [(202) 628-4410].

Petersen, David M., Ph.D., Department of Sociology, Georgia State University, 33 Gilmer Street
S.E., Atlanta, Georgia.

Phillipson, Richard V., M.D., Special Assistant for Scientific and Medical Affairs, Division of
Resource Development, National Institute on Drug Abuse, 5600 Fishers Lane, Rockville,
Maryland.

Prien, Robert, Ph.D., Psychopharmacology Research Branch, National Institute of Mental Health,
Rockville, Maryland [(301) 443-3524].

Raskin, Allen, Ph.D., Research Psychologist, Psychopharmacology Research Branch, National
Institute of Mental Health, Rockville, Maryland [(301) 443-3527].

Rawlings, John, and Associates Pharmaceutical Services, Nampa Drug Pharmacy, Box 115, Nampa,
Idaho.

Reilly, Mary Jo, Editor, American Hospital Formulary Service, American Society of Hospital Phar-
macists, 4630 Montgomery Avenue, Washington, D.C.

Reis, Barry, Ph.D., Albany College of Pharmacy [(518) 445-7211].

Ross, Hilda, University of Miami, Institute for Study on Aging, Miami, Florida [(305) 284-4011].

89
''Rucher, T. Donald, Ph.D., Professor of Pharmacy Administration, Division of Administrative
and Social Sciences, College of Pharmacy, Ohio State University, Columbus, Ohio.

Sathananthan, Dr. G.L., New York University, Department of Psychiatry, New York, New York
[(212) 679-3919].

Schwartz, Doris, Associate Professor, Cornell-New York Hospital School of Nursing, New York,
New York.

Shader, Richard, M.D., Director, Psychopharmacology Research Laboratory, Massachusetts
Mental Health Center, Harvard Medical School, 25 Shattuck Street, Boston, Massachusetts
[(617) 277-4378].

Sielski, Lestor, Ed.D., University of West Florida, Social Welfare Department [(904) 476-9500].

Smith, Roberta, M.D., Geriatric Coordinator, Dede Wallace Mental Health Center, 223 Madison
Street, Madison, Tennessee.

Sprouse, Betsy, McBeath Institute on Aging and Adult Life, University of Wisconsin, 425 Henry
Mall, Madison, Wisconsin [ (608) 263-4020].

Stotsky, Bernard, M.D., St. Elizabeth's Hospital, Boston, Massachusetts.

Subby, Peg, Director, Hennepin County Alcohol and Drug Access and Intervention Unit, 1800
Chicago Avenue South, Minneapolis, Minnesota [(612) 348-8013].

Thomas, Doris Lang, M.S., Director of RPH Pharmacy, 515 Audubon Avenue, New York, New
York [(212) 7819800].

Thompson, W. Leigh, Professor, Case Western Reserve, School of Medicine, Department of Phar-
macology, Cleveland, Ohio.

Towery, Owen B., M.D., National Institute of Mental Health, Room 11-C 105, Parklawn Building,
5600 Fishers Lane, Rockville, Maryland.

Vestal, Robert, M.D., Research Fellow, School of Medicine, Vanderbilt University, Nashville,
Tennessee.

Ward, Elliott, Ph.D., Director, Alcohol and Drug Section, Department of Mental Health and
Mental Retardation, 501 Union Building, Nashville, Tennessee.

Wegner, Fred, Legislative Representative, NRTA-AARP, American Association of Retired Persons,
Washington, D.C. [(202) 293-2390].

Wolfe, John C., Ph.D., Executive Director, National Council of Community Mental Health Centers,
2233 Wisconsin Avenue, N.W., Washington, D.C. [(202) 337-7530].

Wynne, Ronald D., Ph.D., Codirector, Wynne Associates, Washington, D.C. [(202) 966-7273].

Zung, William, M.D., School of Medicine, Duke University, School of Medicine, Durham, North
Carolina [(919) 286-6359].

90
''APPENDIX B

PROGRAMS SPECIFICALLY DESIGNED TO INTERVENE
IN PSYCHOACTIVE DRUG MISUSE/ABUSE BY THE ELDERLY

Alcohol and Drug Abuse and the Elderly Task Force. Catherine McRae, Geriatric Services,
Tennessee Task Force, State of Tennessee, Department of Mental Health and Mental Retarda-
tion, 501 Union Boulevard, Nashville, Tennessee 37219.

Alcoholism, Inebriety, Drug Information and Referral Services (A.I.D.) of Hennepin Count js
Peg Subby, Director, 1810 Chicago Avenue, Minneapolis, Minnesota 55404.

Broome County Drug Awareness Center Programs. Ronald Gaetano, Director, 22 Park Lane,
Johnson City, New York 13790.

Bridgeway. Douglas Laurenzo, Social Service Coordinator, 22 27th Avenue, S.E., Minneapolis,
Minnesota 55414,

Camellia House Licensed Chemical Dependency Program. Patricia Hansen, Program Director,
Camellia House Convalescent and Nursing Home, 1620 Oak Park Avenue, N., Minneapolis,
Minnesota 55411.

DISC-Drugs and the Elderly Program. College of Pharmacy, University of Minnesota,
Minneapolis, Minnesota 55455,

Intervention Plus Program: Ebenezer Society. Ken McArthur, Coordinator, Ebenezer Society,
2523 Portland Avenue, Minneapolis, Minnesota 55404,

Management of Drug Abuse Among the Elderly: A Peer Counselor Approach. Priscilla R. Perry,
Director of the Institute for the Study of Aging, University of Miami, Coral Gables, Florida,
P.O. Box 248106 (through the Florida Drug Abuse Prevention and Education Trust, 10534 East
College Avenue, Tallahassee, Florida 32301).

' Northwestern Hospital Chemical Dependency Treatment Program. Reverend Phil Hansen, Pro-
gram Coordinator, Northwestern Hospital, 27th and Chicago Avenue, Minneapolis, Minnesota
55407,

Older Life Drug Experience Research (OLDER). Maxie C. Maultsby, M.D., Albert B. Chandler
. Medical Center, College of Medicine, Genter for Rational Behavior Therapy Training, Office of
Continuing Education, University of Kentucky, Lexington, Kentucky 40506.

Queen Treatment Program for the Chemically Dependent Elderly. Muriel L. Ganje, Administrator,
Queen Treatment Center, 300 Queen Avenue, N., Minneapolis, Minnesota 55405.

Ramsey County Senior Chemical Dependency Program. Cherie Jefferson, Program Coordinator,
544 West Central Avenue, Suite 1105, St. Paul, Minnesota 55103.

Seniors' Health Program: Augustana Hospital. Betsy Epstein, Health Education Seniors! Health
Program, Augustana Hospital and Health Gare Center, 411 West Dickens Avenue, Chicago,
Illinois 60614,

THEE DOOR, Substance Abuse Intervention. Carol Ann Cheek, Associate Executive Director,
1710 West Colonial Drive, Orlando, Florida 32894,

91 U.S. GOVERNMENT PRINTING OFFICE: 1979 281-265/1012 1-3
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