American Association for Geriatric Psychiatry President Bruce Pollock,
M.D., Ph.D., discusses the urgent need for more clinical evidence for
geriatric psychopharmacotherapy at the association's annual meeting in
Elderly patients make up a large and growing portion of psychiatric
medication users and suffer more adverse reactions than younger adults, yet
research pays little attention to this unique population.
Geriatric psychopharmacology presents both serious challenges and vast
opportunities to clinicians and academics. Bruce Pollock, M.D., Ph.D.,
president of the American Association for Geriatric Psychiatry (AAGP),
discussed the paucity of clinical evidence to guide safe and effective
treatment of elderly patients with mental illness in his plenary speech,"
Medicine and Toxicity: Dose and Intent," at the AAGP annual
meeting in March in Orlando.
Pollock is chair of neuropsychiatry and professor and head of the
University of Toronto's Division of Geriatric Psychiatry. He emphasized that
adverse drug reactions (ADRs) pose significantly higher risks to older
patients, and as much as 20 percent of hospital admissions of people over age
70 have been blamed on ADRs. Of all the medications routinely taken by the
elderly, psychoactive drugs and anticoagulants are the most commonly
associated with preventable ADRs and result in millions of dollars in health
care expenses and significant suffering, he noted.
Elderly patients are more sensitive to the side effects of many drugs
because of physiological changes of aging, he added. The pharmacokinetics in
elderly patients are more variable and unpredictable, sometimes resulting in
dangerously high drug concentrations from "normal" adult doses of
In addition, elderly people often have more comorbid conditions that affect
their organ systems and in turn their physiological response to psychoactive
drugs than do other populations. They also tend to take more medications for
thesse multiple illnesses, which greatly increases the risk of drug-drug
However, there is a dearth of high-quality clinical evidence on both
efficacy and safety specifically clarifying the appropriate doses of
pharmacotherapy in this vulnerable population. "It's a public-health
scandal that medications are not adequately researched in the bulk of patients
who will be taking them," Pollock said. He cited a U.S. Government
Accountability Office report released in September 2007, which noted that the
Food and Drug Administration (FDA) does not devote enough effort to evaluating
drug applications for treatment in elderly patients.
Although the FDA's guidelines require pharmaceutical companies to include a"
Geriatric Use" section in product labeling, this section is
usually very short and often contains few patient data from clinical trials,
Pollock commented. This is primarily because clinical trials designed to seek
FDA approval often exclude a large subset of elderly patients who are sicker
and more frail, have more comorbidities, and have lower socioeconomic status.
Data are particularly thin on the very old, namely those above age 80.
Physicians are often left with the trial-and-error approach to treating these
patients whose care is the most complicated.
In addition, Pollock emphasized that clinicians must take a rational and
careful approach to prescribing medications for geriatric patients. Because of
the high risk of toxicity associated with most drugs in the frail elderly, it
is crucial "to be very clear why we are giving a particular medicine and
what we expect to happen," he told Psychiatric News in a
subsequent interview. In other words, clinicians should avoid prescribing more
and more drugs simply to treat the side effects caused by other drugs.
In his plenary speech, Pollock urged psychiatrists early in their careers
to become involved in geriatric research. "The positive side is that
there is such a huge deficit of information that almost any [research] we do
in a systematic fashion will have a huge impact," he said.
He cited a study he cowrote with Charles Reynolds, M.D., and others on the
effectiveness of maintenance antidepressants in older patients as an
"The study had only 116 subjects," he noted, "and it was
published in the New England Journal of Medicine."
Pollock concluded that in his term as the AAGP president he would"
continue the advocacy for expanding the evidence base, practice
networks, and funding for late-life research from NIMH and other federal
agencies, so that more older adults are included in clinical
Pollock's other priorities include advocating for mental health parity
legislation and securing additional incentives, such as student loan repayment
legislation, to encourage more young practitioners and researchers to enter
the geriatric psychiatry specialty. ▪