From the Guidelines
The recommended approach for mood stabilization in the elderly involves individualized and appropriate treatments, considering the risk of adverse effects, comorbidities, and the presence of behavioral and psychological symptoms, with a preference for non-pharmacological interventions such as exercise, psychotherapy, and behavioral interventions. When pharmacotherapy is necessary, selective serotonin reuptake inhibitors (SSRIs) are effective and well-tolerated in older adults with dementia, with options like venlafaxine, vortioxetine, and mirtazapine being safer in terms of drug interactions 1.
Key considerations in managing mood stabilization in the elderly include:
- Non-pharmacological treatments as the first line of intervention, which can help alleviate depressive symptoms and improve mental health 1
- Avoiding antidepressants with an anticholinergic burden, such as tricyclics, especially in older adults with frailty and dementia 1
- Considering the potential benefits of interventions targeting frailty, which can positively affect depression, such as programs focused on physical activity, nutrition optimization, social engagement, and cognitive stimulation 1
- The use of SSRIs as first-line treatments for agitation in individuals with vascular cognitive impairment (VCI) and depression, given their effectiveness in reducing overall neuropsychiatric symptoms and agitation 1
In terms of specific pharmacological interventions, the use of SSRIs like venlafaxine, vortioxetine, and mirtazapine is recommended due to their safer profile in terms of drug interactions 1. It's also important to note that atypical antipsychotics may be used as adjuncts but require careful monitoring for metabolic effects and movement disorders 1.
Overall, the approach to mood stabilization in the elderly should prioritize individualized care, non-pharmacological interventions when possible, and careful selection of pharmacotherapy to minimize risks and maximize benefits, as supported by the most recent and highest quality evidence 1.
From the FDA Drug Label
Consideration should be given to a slower rate of dose titration and a lower target dose in the elderly and in patients who are debilitated or who have a predisposition to hypotensive reactions [see Clinical Pharmacology (12. 3)] . When indicated, dose escalation should be performed with caution in these patients. Elderly patients should be started on quetiapine fumarate tablets 50 mg/day and the dose can be increased in increments of 50 mg/day depending on the clinical response and tolerability of the individual patient.
The recommended approach for mood stabilization in the elderly is to start with a lower dose and titrate slowly. For quetiapine, the initial dose is 50 mg/day, which can be increased in increments of 50 mg/day based on clinical response and tolerability.
- Key considerations:
- Slower rate of dose titration
- Lower target dose
- Caution with dose escalation
- Monitoring for clinical response and tolerability 2
From the Research
Mood Stabilization in the Elderly
- The approach to mood stabilization in the elderly involves the use of various medications, including lithium, anticonvulsants, and atypical antipsychotics 3, 4, 5.
- Lithium is a well-established mood stabilizer, but its use in the elderly requires careful consideration due to its narrow therapeutic window and potential for adverse effects 4, 5.
- Low-dose lithium (≤0.5 mM) may be beneficial for mood stabilization in the elderly, with potential benefits for cardiovascular, musculoskeletal, metabolic, and cognitive function, as well as inflammatory and antioxidant processes 3.
Combination Therapies
- Combination therapies, such as lithium augmentation with other mood stabilizers or antipsychotics, may be effective for mood stabilization in the elderly 5, 6.
- The use of combination therapies can help reduce the side effect burden and improve compliance, as each medication can be given at a lower dose 5.
- Common combination therapies include lithium with valproic acid, lamotrigine, or atypical antipsychotics, such as quetiapine or olanzapine 6.
Off-Label Use of Medications
- Some medications, such as second-generation antipsychotics (SGAs), may be used off-label for mood stabilization in the elderly, despite limited evidence for their efficacy in this population 7.
- Italian psychiatrists reported frequent off-label use of SGAs, such as aripiprazole and olanzapine, for depressive episodes and maintenance treatment of bipolar disorder 7.
- The use of off-label medications requires careful consideration of the potential benefits and risks, as well as alternative treatment options 7.