Psychiatry of old age
Many licensed psychotropic drugs are used for unlicensed indications when treating elderly people with mental health problems. Although at present there are no drugs specifically licensed for the treatment of psychotic and behavioural symptoms in patients with dementia, a postal questionnaire survey of 377 members of the Royal College of Psychiatrists’ Faculty of Old Age Psychiatry (recently renamed the Psychiatry of Old Age) found that most doctors had used psychotropic drugs for this indication.
Conventional and atypical antipsychotics were used for treating patients with delusions, hallucinations, agitation, wandering, aggression or sexual disinhibition; and antidepressants were employed in patients with anxiety and lability of mood (Scott et al, 2002). In a 1-week cross-sectional survey of 750 prescription cards for 400 elderly (aged 60–93 years) people receiving in-patient psychiatric care in 19 NHS trusts, atypical antipsychotics were prescribed to 42% of patients, of whom half had the diagnosis of a dementia (Beck et al, 2001).
Most people with dementia are unable to comprehend the reasons for using licensed drugs for unlicensed indications. Although it may be good practice to discuss a proposed unlicensed treatment with relatives or carers, it should be remembered that they do not have the right to consent to treatment on behalf of incapacitated adults. Detailed consideration of capacity is outside the scope of this article.
David S. Baldwin and Nick Kosky
David Baldwin is Reader in Psychiatry in the Clinical Neuroscience Division of Southampton University’s School of Medicine (University Department of Mental Health, Royal Southants Hospital, Brintons Terrace, Southampton SO14 0YG, UK. Email: dsb1@soton.ac.uk) and Honorary Consultant Psychiatrist with the Mood Disorders Service, Hampshire Partnership Trust. He was Chair of the working group of the Royal College of Psychiatrists’ Psychopharmacology Special Interest Group (PSIG) on unlicensed applications of licensed drugs in psychiatric practice. His research interests include the clinical pharmacology of anxiety and depressive disorders. He leads a tertiary referral service for patients with chronic and severe mood and anxiety disorders. Nick Kosky is Consultant Psychiatrist and Clinical Director of Dorset Primary Care Trust. He was a member of the PSIG working group. He is interested in teaching psychopharmacology to non-medical staff and delivering high-quality prescribing. He is part of a prison mental heath in-reach team.
Anonymous (1992) Prescribing unlicensed drugs or using drugs for unlicensed indications. Drug and Therapeutics Bulletin, 30, 97–99.[Medline]
Ansani, N., Sirio, C., Smitherman, T., et al (2006) Designing a strategy to promote safe, innovative off-label use of medications. American Journal of Medical Quality, 21, 255–261.[Abstract/Free Full Text]
Barbui, C., Danese, A., Guaiana, G., et al (2002) Prescribing second-generation antipsychotics and the evolving standard of care in Italy. Pharmacopsychiatry, 35, 239–243.[CrossRef][Medline]
Barnard, L., Young, A. H., Pearson, J., et al (2002) Systematic review of the use of atypical antipsychotics in autism. Journal of Psychopharmacology, 16, 93–101.[Abstract]
Beck, S., Paton, C., Euba, R., et al (2001) Atypical antipsychotics in the elderly. International Journal of Psychiatry in Clinical Practice, 5, 257–261.[CrossRef]
