DEAR DR. ROACH: I have been taking 25 mg of amitriptyline for sleep for several years; I am 79 and have noticed occasional difficulty remembering some facts. I read that this drug can affect cognition. I don’t believe that amitriptyline is really effective in helping me sleep, so I have discontinued its use, believing that the risk outweighs the benefit. What do you think? — G.L.D.
ANSWER: Amitriptyline is on the list of drugs to be avoided in older people. It has strong anticholinergic properties, meaning that it can cause dry mouth, vision changes, difficulty urinating, confusion and memory impairment. I do not generally use it in my older patients. Twenty-five milligrams is a small dose, but some people might be susceptible to the cognitive effects even at this low of a dose.
Sleep experts are increasingly recommending cognitive behavioral therapy for insomnia as the best choice to avoid the many side effects of sleep medications, which are more common and dangerous in older adults.
DEAR DR. ROACH: I am a 72-year-old man who has had a history of increasing back and neck pain over the years, culminating in discectomy and fusion surgeries with definite improvement in both locations. Some level of pain remains but is tolerable and does not prevent impediments to daily activities.
Prior to the surgeries, I was prescribed various medications over the years to control the pain — but with very little benefit. These included different NSAIDs and antidepressants. Following surgery, I was provided with a short regimen of oxycodone, which provided no pain relief at all.
Have you encountered other patients for whom no medication provided any pain relief? If so, what did you provide to help relieve some level of their pain? — J.A.
ANSWER: I have never had a patient where pain could not be improved with pain medications, although the amount needed sometimes would have been considered excessive in nearly all other instances. Some people have a low level of an enzyme called CYP2D6, which activates opioid pain medicines, while other people take medicines that block this enzyme. Opioids like oxycodone are very powerful medications but are seldom a good choice for chronic back pain. It is likely that the high doses you would need to get pain relief would cause side effects.
Anti-seizure medications, such as gabapentin or oxcarbazepine, are sometimes used. Cannibinoids are helpful in some people. Although I believe its use should be limited to experts, ketamine may be helpful in some people with chronic pain. Certainly, a pain management expert would be an invaluable consultant.
