Pharmacological Overview in Geriatrics: Pharmacodynamics, Pharmacokinetics, Laboratory Monitoring

  • Poh Choo HowEmail author
  • Glen Xiong


The goal of pharmacological treatment in geriatric psychiatry is to reduce adverse effects and maximize effectiveness, with the fewest number of medications. To achieve this goal, one must recognize the many pharmacokinetic and pharmacodynamic changes of aging that have a significant impact on geriatric psychopharmacology in the inpatient setting. Pharmacological treatment within the inpatient geriatric psychiatry unit or medicine unit, should include reconciliation of medication lists, along with the review/revision/rationalization of medication regimens. Guidelines specific to prescribing for the geriatric inpatient are reviewed in this chapter, including parsimonious prescribing, appropriate laboratory testing, recognizing the impact of medical co-morbidities, and vigilance for drug-drug interactions and adverse effects.


Pharmacokinetics Absorption Distribution Metabolism Elimination Pharmacodynamics Polypharmacy Drug-drug interaction 


  1. 1.
    Centers for Disease Control and Prevention. The state of aging and healthy in America. Atlanta, GA: Createspace Independent Publisher; 2013.Google Scholar
  2. 2.
    Bartels SJ, Fortuna KL, Naslund JA. Serious mental disorders in older adults: schizophrenia and other late-life psychoses. In: Segal DL, Gualls SH, Smyer MA, editors. Aging and mental Health. 3rd ed. Hoboken: Wiley-Blackwell; 2018. p. 265.Google Scholar
  3. 3.
    Inventor B, Henricks J, Rodman L, Imel J, Holemon L, Hernandez F. The impact of medical issues in inpatient geriatric psychiatry. Issues Ment Health Nurs. 2005;26(1):23–46.PubMedCrossRefGoogle Scholar
  4. 4.
    Bartol TG. MedScape. [Online]; 2015 [cited 2017 Dec 3. Available from:
  5. 5.
    Farrell B, Szeto W, Shamji S. Drug-related problems in the frail elderly. Can Fam Physician. 2011;57:168–9.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Xiong GL, Javaheri A, Wiechers IR. Psychopharmacology principles. In: Hategan A, Bourgeois JA, Hirsch CH, editors. On-call geriatric psychiatry. Switzerland: Springer; 2016. p. 31–44.CrossRefGoogle Scholar
  7. 7.
    Ronaldson PT, Bauer B, El-Kattan AF, Shen H, Salphati L, Louie SW. Highlights from the American Association of Pharmaceutical Scientists/International Transporter Consortium Joint Workshop on drug transporters in absorption, distribution, metabolism, and excretion: from the bench to the bedside. Clin Pharmacol Ther. 2016;100(5):419–22.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Carlo AD, Alpert JE. Geriatric psychopharmacology: pharmacokinetic and pharmacodynamic considerations. Psychiatr Ann. 2015;45(7):336–41.CrossRefGoogle Scholar
  9. 9.
    Oesterhald JR. Transports. In: Wynn GH, Oesterhald JR, Cozza KL, Armstrong SC, editors. Clinical manual of drug interaction: principles for medical practice. Washington, DC: American Psychiatric Publishing; 2009. p. 43–60.Google Scholar
  10. 10.
    Lagneau F, Perbet S, Delefosse D, Wernet A, Stocco J, Marty J. Drugs pharmacokinetics in ICU patients: consequences of hypoalbuminemia upon drugs monitoring and dosing scheme. Intensive Care Med. 2004;30(6):1247.PubMedCrossRefGoogle Scholar
  11. 11.
    Lampon N, Tutor JC. Apparent clearance of valproic acid in elderly epileptic patients: estimation of the confounding effect of albumin concentration. Ups J Med Sci. 2012;117(1):41–6.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Pollock B, Forsyth C, Bies R. The critical role of clinical pharmacology in geriatric psychopharmacology. Clin Pharmacol Ther. 2009;85(1):89–93.PubMedCrossRefGoogle Scholar
  13. 13.
    Wauthier V, Verbeeck RK, Calderon PB. The effect of ageing on cytochrome p450 enzymes: consequences for drug biotransformation in the elderly. Curr Med Chem. 2007;14(7):745–57.PubMedCrossRefGoogle Scholar
  14. 14.
    McIntyre RS, Baghdady NT, Banik S, Swartz SA. The use of psychotropic drugs in patients with impaired renal function. Prim Psychiatry. 2008;15(1):73–88.Google Scholar
  15. 15.
    Crone CC, Gabriel GM, DiMartini A. An overview of psychiatric issues in liver disease for the consultation-liaison psychiatrist. Psychosomatics. 2006;47(3):188–205.PubMedCrossRefGoogle Scholar
  16. 16.
    O’Sullivan ED, Hughes J, Ferenbach DA. Renal aging: causes and consequences. J Am Soc Nephrol. 2017;28:407–20.PubMedCrossRefGoogle Scholar
  17. 17.
    Aymanns C, Keller F, Maus S, Hartmann B, Czock D. Review on pharmacokinetics and pharmacodynamics and the aging kidney. Clin J Am Soc Nephrol. 2010;5(2):314–27.PubMedCrossRefGoogle Scholar
  18. 18.
    ElDesoky ES. Pharmacokinetic-Pharmacodynamic crisis in the elderly. Am J Ther. 2007;14(5):488–98.PubMedCrossRefGoogle Scholar
  19. 19.
    Darowski A, Chambers SC, Chambers DJ. Antidepressants and falls in the elderly. Drugs Aging. 2009;26(5):381–94.PubMedCrossRefGoogle Scholar
  20. 20.
    Stegemann S, Ecker F, Maio M, Kraahs P, Wohlfart R, Breitkreutz J, et al. Geriatric drug therapy: neglecting the inevitable majority. Aging Res Rev. 2010;9(4):384–98.CrossRefGoogle Scholar
  21. 21.
    Graff-Guerreo A, Rajji TK, Mulsant BH, Nakajima S, Carvaggio F, Suzuki T, et al. Evaluation of antipsychotic dose reduction in late-life schizophrenia: a prospective dopamine D2/3 receptor occupancy study. JAMA Psychiatry. 2015;72(9):927–34.CrossRefGoogle Scholar
  22. 22.
    de Leon J. Paying attention to pharmacokinetic and pharmacodynamic mechanisms to progress in the area of anticholinergic use in geriatric patients. Curr Drug Metab. 2011;12(7):635–46.PubMedCrossRefGoogle Scholar
  23. 23.
    Aging Brain Program of the Indiana University Center for Aging Research. Aging Brain Care. [Online]; 2012 [cited 2017 12 3. Available from:
  24. 24.
    The American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63:2227–46.CrossRefGoogle Scholar
  25. 25.
    Fabian TJ, Amico JA, Kroboth PD, et al. Treatment of depression in the elderly: effect of physical illness on response. Int J Geriatr Psychiatry. 1997;12:1189–94.CrossRefGoogle Scholar
  26. 26.
    Oslin DW, Tenhave SF, Sterim JE, et al. Probing the safety of medications in the frail elderly: evidence from a randomized clinical trial of sertraline and venlafaxine in depressed nursing home residents. J Clin Psychiatry. 2003;64:875–82.PubMedCrossRefGoogle Scholar
  27. 27.
    Skinner MH, Kuan HY, Skerjanec A, et al. Effect of age on the pharmacokinetics of duloxetine in women. Br J Clin Pharmacol. 2004;57:54–61.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Howard WT, Warnock JK. Risk factors for falls during treatment of late-life depression. J Clin Psychiatry. 1996;156:2017–8.Google Scholar
  29. 29.
    Joo JH, Lenze EJ, Mulsant BH, et al. Risk factors for falls during treatment of late-life depression. J Clin Psychiatry. 1996;57:238–40.Google Scholar
  30. 30.
    Alexopolous GS. Pharmacotherapy for late-life depression. J Clin Psychiatry. 2011;72(1):e04.Google Scholar
  31. 31.
    Fraser LA, Liu K, Naylor KL, et al. Falls and fractures with atypical antipsychotic medication use: a population-based cohort study. JAMA Intern Med. 2015;175:450–2.PubMedCrossRefGoogle Scholar
  32. 32.
    Ramcharran D, Qiu H, Schuemie MJ, Ryan PB. Atypical antipsychotics and the risk of falls and fractures among older adults: an emulation analysis and an evaluation of additional confounding control strategies. J Clin Psychopharmacol. 2017;37(2):162–8.PubMedCrossRefGoogle Scholar
  33. 33.
    Brissos S, Veguilla MR, Taylor D, Balanza-Martinez V. The role of long-acting injectable antipsychotics in schizophrenia: a critical appraisal. Ther Adv Psychopharmacol. 2014;4(5):198–219.PubMedPubMedCentralCrossRefGoogle Scholar
  34. 34.
    Hassamal S, Waller S, Reese K, Testa C. Reversible valproic-acid induced parkinsonism and cognitive impairment in an elderly patient with bipolar I disorder. Turk J Psychiatry. 2016;27(3):213–7.Google Scholar
  35. 35.
    Tada H, Ogihara T, Nakamura T, Sasayama D, Sugiyama N, Takahashi Y, et al. A case of severe parkinsonism in an elderly person induced by valproic acid. Psychogeriatrics. 2017;17(1):394–5.CrossRefGoogle Scholar
  36. 36.
    Mahmoud F, Tampi RR. Valproic-acid induced parkinsonism in the elderly: a comprehensive review of the literature. Am J Geriatr Pharmacother. 2011;9(6):405–12.PubMedCrossRefGoogle Scholar
  37. 37.
    Kuo YC, Lin YC, Chen PH. Emerging hyperkalemia following valproic acid use in an elderly patient with late-onset mania. J Clin Psychopharmacol. 2016;36(4):394–5.PubMedCrossRefGoogle Scholar
  38. 38.
    Holroyd S, Overdyke JT. Hyperammonemia associated with valproic acid use in elderly psychiatric patients. J Neuropsychiatry Clin Neurosci. 2012;24(3):372–4.PubMedCrossRefGoogle Scholar
  39. 39.
    Mittal V, Muralee S, Tampi RR. Valproic acid-induced hyperammonemia in the elderly: a review of the literature. Case Rep Med. 2009;2009. Scholar
  40. 40.
    Kaufman DW, Kelly JP, Rosenberg L, Anderson TE, Mitchell AA. Recent patterns of medication use in the ambulatory adult population of the United States: the Slone survey. J Am Med Assoc. 2002;287(3):337–44.CrossRefGoogle Scholar
  41. 41.
    Rochon PA, Gurwitz JH. The prescribing cascade revisited. Lancet. 2017;389(10081):1778–80.PubMedCrossRefGoogle Scholar
  42. 42.
    Dolder C, Szymanski B, Wooton T, McKinsey J. Pharmacist interventions in an inpatient geriatric psychiatry unit. Am J Health Syst Pharm. 2008;65(19):1795–6.PubMedCrossRefGoogle Scholar
  43. 43.
    Yazgan IC, Greenwald BS, KRemen NJ, Strach J, Kramer-Ginsberg E. Geriatric psychiatry versus general psychiatry inpatient treatment of the elderly. Am J Psychiatr. 2004;161:352–5.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.University of California, Davis, Department of Psychiatry & Behavioral SciencesSacramentoUSA

Personalised recommendations