Alternative agents for the elderly should be considered for delirium, Parkinson’s disease

There are many effective prescription and non-prescription treatments for delirium, Parkinson’s disease, allergic rhinitis, and other conditions in older adults, according to pharmacists and physicians who presented at the American Geriatrics Society Annual Scientific Meeting in Orlando, Fla., in mid May.

Todd Semla, PharmD, clinical pharmacy specialist with the Department of Veteran Affairs and associate professor in the Feinberg School of Medicine at Northwestern University; Joseph T. Hanlon, PharmD, professor with the Department of Medicine (Geriatrics) at the University of Pittsburgh; and Kenneth Schmader, MD, chief of the Department of Geriatrics at Duke University School of Medicine, presented alternatives to high-risk medications in older patients.

“We spoke about alternatives to the first generation of antihistamines for people with seasonal allergic rhinitis, alternatives to treat Parkinson’s, and alternatives to medicines to treat insomnia,” Semla told Drug Topics after the panel presentation. “Initial prescribers would want to use something like a benzodiazepine or non-benzodiazepine hypnotic for insomnia, which is worrisome in elderly patients because of the risk of falling.”

Semla and colleagues also researched non-pharmacologic interventions for insomnia and other conditions. “For people who have sleep complaints, rather than jumping to one of the drugs that could be a problem, we can try behavioral cognitive therapy techniques, help patients make lifestyle changes, and improve sleep patterns,” Semla said.

Pharmacists and physicians can also review older adults’ medications to make improvements. “Because they are taking an OTC decongestant [that possibly caused the insomnia], they can avoid stimulating medications or beverages,” Semla said.

As alternatives to first-line antihistamines, Semla recommends intranasal steroids and saline sprays. The saline sprays are “very therapeutic, depending on frequency and severity of complaints,” Semla said.

To treat Parkinson’s symptoms, Semla sought out alternatives to first-line, anticholinergic medications that “the Cochrane Review says are mildly effective for tremor.” Sema noted, “In older people, tremor is not the most debilitating symptom. We are more concerned with gait/walking disturbances and those symptoms respond better to dopamines.” He suggested that a carbidopa/levodopa combination would be more effective, with “fewer side effects such as bad dreams.”

Meanwhile, Hanlon spoke about alternatives to highly anticholinergic antipsychotics such as olanzapine, which can worsen cognitive function in those with dementia and delirium. Hanlon said antipsychotics are a last resort and should only be prescribed for specific symptoms in patients with dementia or delirium.

Alternative anti-seizure medications were also discussed. “We are looking to some of the newer agents, such as lamotrigine. We have a good understanding of how the drug is handled by older people; there is evidence that it works well in older adults,” Semla said.