Zusammenfassung
Die Polypharmazie mit Psychopharmaka bei älteren Menschen mit und ohne psychische Erkrankungen ist weit verbreitet und spielt im Praxis- und Klinikalltag eine wichtige Rolle. Im vorliegenden Buchkapitel werden Nutzen und Risiken, Indikationen und der Rahmen für evidenzbasierte Kombinationstherapien mit Psychopharmaka bei alten Menschen beschrieben.
Die weltweite Lebenserwartung steigt kontinuierlich an und die Anzahl der zu erwartenden gesunden Lebensjahre > 50 Jahre in der EU nimmt dank verbesserter Lebensbedingungen und den Fortschritten der Medizin ebenfalls erheblich zu. Eine Vielzahl von chronischen somatischen und psychischen Erkrankungen lässt sich heute zumindest symptomatisch so effektiv behandeln, dass unsere Lebensqualität dadurch nachhaltig gefördert wird. Dieser Multimorbidität wird einerseits durch überwiegend fach- und organspezifische Therapieansätze effektiv begegnet und begünstigt andererseits eine Kumulation von Arzneimittelverordnungen. Hinzu kommt, dass besonders im Alter symptombezogene Medikamentenverordnungen bei psychischen Beschwerden ohne ausreichende evidenzbasierte Grundlage weit verbreitet sind.
Die so entstehende Polypharmazie steht nicht automatisch für eine intensive State-of-the-art-Therapie, sondern wird oft gleichzeitig durch die Verordnung von nicht indizierten und eine Unterversorgung mit indizierten Arzneimitteln geprägt. So lässt sich der überproportionale Einsatz von Psychopharmaka wie die oft kombinierte Verordnung von Antipsychotika bei Demenzkranken besser verstehen, deren Nutzen-Risiko-Profil in dieser Indikation als kritisch gilt. Psychische Nebenwirkungen können außerdem übersehen werden und die Verordnung von weiteren psychotropen Substanzen fördern.
Alte Menschen nehmen beim Start mit Psychopharmaka in der Regel bereits Medikamente wegen somatischer Komorbiditäten ein, reagieren empfindlicher auf erwünschte und unerwünschte Arzneimitteleffekte und versorgen sich oft aus dem OTC-Bereich mit pharmakologisch aktiven Substanzen. Die Praxis der Polypharmazie im Alter verlangt deshalb, dass regelmäßig auf eine vollständige Medikamentenliste geachtet wird, Verordnungen auf ihre Praktikabilität geprüft, neue Medikamenten langsam gestartet und ausdosiert, die Indikationen regelmäßig kritisch evaluiert werden und die speziellen Nebenwirkungsprofile der eingesetzten Substanzen geläufig sind. Der Gebrauch von Listen potenziell inadäquater Medikamente für alte Menschen (www.priscus.de) stellt eine wertvolle Entscheidungshilfe für den klinischen Alltag dar.
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Ibach, B. (2016). Gerontopsychiatrie. In: Messer, T., Schmauß, M. (eds) Polypharmazie in der Behandlung psychischer Erkrankungen. Springer, Vienna. https://doi.org/10.1007/978-3-7091-1849-8_6
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