Q:  How do Older Patients Respond Differently from Younger Ones to Treatment?

Dear Dr. Phelps,

I very much appreciate your website. My husband of 40 years is 72 and has never taken any psychiatric medication. He has had lifelong rapid mood swings, but only now is willing to get help. How do older patients respond differently from younger ones to treatment? If he begins medication, should he begin more gradually? Thank you.


Dear Nancy --

True, older folks do respond differently, compared to younger people. In general, we use smaller doses, of nearly anything.  The maxim in geriatric psychiatry is "start low and go slow".

Where is the "cut off"? There is no clear rule for this.  In general, I start to adjust for age somewhere around 55, and certainly by age 60.

In bipolar disorder treatment, there are a few specific differences when treating people over 60.  First, there is a general belief that lithium is trickier to use an older people and somewhat to be avoided on that basis. 

Secondly, divalproex (Depakote) seems to work particularly well, at surprisingly low doses, usually without any trouble in terms of side effects. Whereas in young people, divalproex usually doesn't do much until people reach 1000 mg;  in older folks, 750 mg is enough to be quite effective, and sometimes as little as 500 mg.  Instead of starting with 500 mg and going up, I might start as low as 125 mg at night, or twice daily, and go up by 125 mg steps per week (unless I was in a hurry).  They make a specific version of the 125 mg pill, called "sprinkles", which is said to have a better smoother absorption pattern over 24 hours (less peak and valley).

Finally, although this just might be personal experience, I have had surprisingly good luck with risperidone at very low doses, whereas it has very little value, in my view, in people less than 55 years old or so. It can act too much like an antidepressant in younger people, whereas that little bit of antidepressant effect seems to mix in well for older people, who are less prone to manic- side symptoms (that change with age is a well- accepted finding) .

So whereas my usual starting medications for a 30-year-old with "rapid mood swings" include most prominently lamotrigine and lithium; for a 60-year-old, the most prominent are divalproex and risperidone -- the latter particularly if there is a substantial degree of agitation or sleep disturbance; if not, lamotrigine is still a strong candidate (though not with divalproex, they have an interaction).

Unfortunately, just as with pregnancy, geriatric use of medications is not very well studied.  So you could easily see another psychiatrist and find a different set of opinions, which might be as or even more valid.  But the "start low and go slow" maxim is a very well accepted principle. 

Good luck with finding a psychiatrist or medical specialist with whom you can work comfortably on this.  I hope things go well, and quickly.

Dr. Phelps

Published November, 2009