HomeBlogHealthcare ProviderGuidelines for Depression Treatment in the Geriatric Population Guidelines for Depression Treatment in the Geriatric Population July 9, 2019Healthcare Provider Treating seniors for depression is very different than treating a younger population. Seniors often face multiple diseases – which may mean multiple medications to manage. According to the National Center for Health Statistics, more than 89% of older people use at least one prescription and more than 68% use three or more prescriptions in any given month. Those statistics might not include over the counter (OTC) supplements or vitamins that they may be taking as well. Taking multiple medications at the same time, or polypharmacy, can be problematic because often the patients are seeing various specialists for differing ailments. Since no single provider is typically responsible for managing the patient’s complete medication profile, drug/drug interactions could occur. To help effectively manage this issue, two guidelines have been published to assist physicians in making critical medication decisions. Identifying Potentially Inappropriate Medications via the Beers Criteria Since 2011, The Beers Criteria® has been regularly updated by the American Geriatrics Society to catalogue medications known to cause adverse drug reactions in elderly patients. By using evidence-based methodology, the Beers Criteria accounts for the pharmacologic properties of drugs in addition to the physiologic changes of aging. Updated in January 2019, the AGS Beers Criteria describes Potentially Inappropriate Medications (PIMS) that have been documented with evidence, suggesting that they should either be: Avoided by most older people (outside of hospice and palliative care settings); Avoided by older people with specific health conditions; Avoided in combination with other treatments because of the risk for harmful “drug-drug” interactions; Used with caution because of the potential for harmful side effects; or Dosed differently or avoided among people with reduced kidney function, which impacts how the body processes medicine You can read more information on the updated AGS Beers Criteria for PIMS, which was recently published in the Journal of the American Geriatrics Society, here: DOI: 10.1111/jgs.15767. Finding Alternatives via START/STOPP Criteria START/STOPP Criteria is intended to be used in conjunction with the Beers Criteria. START is an acronym for the Screening Tool to Alert doctors to the Right Treatment. STOPP stands for the Screening Tool of Older Persons’ Prescriptions. Like the Beers Criteria, START/STOPP criteria lists the PIMS. Unlike the Beers Criteria, it also stratifies them by potentially inappropriate use and indication, documents the clinical concern, and lists recommended therapeutic alternatives. Using Pharmacogenomics to Inform Medication Selection There is a third uniquely individualized tool that may help healthcare providers – pharmacogenomics. Pharmacogenomic tests, like GeneSight® Psychotropic, can identify genetic variations that may impact a patient’s medication response. To illustrate how pharmacogenomics can be used in the elderly population, consider venlafaxine (Effexor®) as an example. There are several CYP450 enzymes involved in breaking down venlafaxine to its metabolites. The most significant pathway is shown here, where venlafaxine is broken down into its active metabolite desvenlafaxine: The most important enzyme in this pathway is CYP2D6. CYP2D6 poor metabolizers may have increased serum concentrations of venlafaxine compared to patients who are more efficient CYP2D6 metabolizers. A study in the European Journal of Clinical Pharmacology detailed how researchers Waade and colleagues examined the effects of CYP2D6 phenotype status on serum drug concentrations of venlafaxine. They found that a patient’s CYP2D6 phenotype (or activity level) was associated with measured serum levels of venlafaxine. For example, in patients under 40 years of age, poor metabolizers had higher serum concentrations than intermediate metabolizers. In this study, intermediate metabolizers were called heterozygous extensive metabolizers (HEM) and had higher serum concentrations than extensive metabolizers. As the chart below illustrates, in the poor metabolizer (PM) group, there is a difference in serum concentration between age groups. Venlafaxine serum concentration was more than 7 times higher in the elderly poor metabolizers than it was in poor metabolizers under the age of 40. As a result, elderly individuals who are poor metabolizers could experience a pronounced reduction in medication clearance. Case Study and More from Our Series on Treating Depression in Seniors The Beers criteria, the STOPP/START criteria, and the GeneSight test are just a few of the many tools that can help healthcare providers treat and manage multiple medications in the geriatric population. Our webinar series has a number of videos devoted to treating depression in seniors, including an introduction to pharmacogenomics and a case study. The guidelines chalk talk and the entire series is also available on our YouTube channel. Our articles are for informational purposes only and are reviewed by our Medical Information team, which includes PharmDs, MDs, and PhDs. Do not make any changes to your current medications or dosing without consulting your healthcare provider. The GeneSight test must be ordered by and used only in consultation with a healthcare provider who can prescribe medications. As with all genetic tests, the GeneSight test results have limitations and do not constitute medical advice. The test results are designed to be just one part of a larger, complete patient assessment, which would include proper diagnosis and consideration of your medical history, other medications you may be taking, your family history, and other factors. If you are a healthcare provider and interested in learning more about the GeneSight test, please contact us at 855.891.9415. If you are a patient, please talk with your doctor to see if the GeneSight test may be helpful. 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Patient Hints To Help You Have A Better New Year The holidays have ended, and a new year has begun—a time when many embrace a fresh start by setting New Year’s resolutions. This year, why not consider s... Read more
Patient Movement as Medicine: Solutions for Anxiety Moving forward. It sounds like a nice idea, especially when you’re feeling stuck deep in the throes of an anxiety spiral. But it turns out that physically m... Read more
Patient Weight-Loss Drugs and Mental Health: What You Need to Know New medications for weight loss seem to be flying off pharmacy shelves these days. But could they be linked to mental health conditions? Researchers are ... Read more
Patient 3 million patients (and counting!) have now taken the GeneSight test! We’re thrilled to share that 3 million patients (and counting!) have now taken the GeneSight test! We're so grateful to the dedicated healthcare providers who... Read more
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Healthcare Provider How Clinicians Can Help Support Their Patients Who Are Being Bullied How Clinicians Can Help Support Their Patients Who Are Being Bullied Acts of bullying can cause feelings of fear, loneliness and sadness, as well as depressi... Read more
Patient Cyberbullying: Unique Challenges and Impacts ‘We lost our daughter to cyberbullying.’ McKenna Brown was an accomplished hockey player and scholar, known for her kindness, when she became the target of int... Read more
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Patient The Impact of Gratitude on Depression and Anxiety “Say ‘Thank you,” a mother reminds her young kiddo. “T.G.I.F.!” we cheer at the end of a long week. We know it’s important to be thankful. But do we ... Read more
Patient The Silent Thief: The 5 Things Depression Can Steal “Depression is a thief,” writes Abhinav Chaurasia, a marketing automation specialist in an essay on LinkedIn. “It steals your joy, your motivation, and your abi... Read more
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