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Clinical Atlas Prestige · Evidence-first

Psych VivasOld age psychiatry — psychopharmacology

Psych Vivas · Old age psychiatry — psychopharmacology

Prescribing psychotropics in older adults — structured clinical viva

Fellowship viva covering PIM frameworks, start-low-go-slow-but-go, anticholinergic TCA risk, SSRI sodium/QTc/bleeding, antipsychotic caution, and integrated falls/QTc safety.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the old-age psychiatry registrar. A GP sends a 79-year-old man with mild cognitive impairment, depression, AF on apixaban, and two recent falls. Medications include temazepam 10–20 mg PRN, amitriptyline 50 mg at night for 'sleep and pain', and the GP asks whether to start quetiapine 50 mg for 'evening agitation' and citalopram 40 mg for mood. Discuss your approach to Beers/STOPP review, PK/PD, specific drug choices and doses, antipsychotic black-box issues if dementia evolves, QTc and bleeding/falls risks, and a monitoring plan.

Interpretation

Reveal interpretation

This is a polypharmacy safety and formulation viva, not a request to rubber-stamp three new CNS drugs. Reconcile indications: temazepam and amitriptyline are high-yield Beers/STOPP problems (falls, anticholinergic load, sedation) in someone with falls and cognitive impairment. "Evening agitation" needs DICE-style assessment (pain, delirium, environment, undertreated depression, benzo effects) before any antipsychotic.[2][8][7]

Do not start quetiapine 50 mg as first response for vague agitation — especially with emerging cognitive impairment and fall risk; if dementia-related severe aggression later needed an antipsychotic, black-box mortality/stroke framing, lowest dose, short course and review date apply.[3] Prefer deprescribing temazepam/TCA pathway with non-drug sleep strategies and pain review.[2]

If syndromal depression is confirmed, choose a safer antidepressant than high-dose citalopram: e.g. sertraline 25 mg orally then 50 mg, with sodium monitoring and bleeding vigilance on anticoagulation; avoid citalopram 40 mg in older adults given QT labelling concerns. ECG and electrolyte awareness for any QT-risk plan.[4][5][6] PK/PD ageing (Mangoni) justifies lower starts and slower titration but not under-treatment of major depression.[1][6]

Key points

Deprescribe before you stack

Temazepam and amitriptyline are often higher yield to stop than quetiapine is to start.

Black-box is not optional rhetoric

Antipsychotics in dementia increase death risk versus placebo in RCT meta-analysis — time-limit and document.

Start low, go slow, but go

Token SSRI micro-doses without titration are not safer geriatric care when depression is severe.
[1] [2] [3] [6]

References

  1. [1]Mangoni AA, Jackson SHD Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications Br J Clin Pharmacol, 2004.PMID 14678335
  2. [2]By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults J Am Geriatr Soc, 2023.PMID 37139824
  3. [3]Schneider LS, Dagerman KS, Insel P Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials JAMA, 2005.PMID 16234500
  4. [4]Fabian TJ, Amico JA, Kroboth PD, et al. Paroxetine-induced hyponatremia in older adults: a 12-week prospective study Arch Intern Med, 2004.PMID 14769630
  5. [5]Funk MC, Beach SR, Bostwick JR, et al. QTc Prolongation and Psychotropic Medications Am J Psychiatry, 2020.PMID 32114782
  6. [6]Malhi GS, Bell E, Bassett D, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders Aust N Z J Psychiatry, 2021.PMID 33353391
  7. [7]Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons Arch Intern Med, 2009.PMID 19933955
  8. [8]O'Mahony D, O'Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2 Age Ageing, 2015.PMID 25324330