Risk of death in elderly users of conventional vs. atypical antipsychotic medications

Medicaid's prior authorization program and access to atypical antipsychotic medications

State Medicaid programs use prior authorization (PA) to control drug spending by requiring that specific conditions be met before allowing reimbursement. The extent to which PA policies respond to new developments concerning medication safety is not known. In April 2005 the Food and Drug Administration (FDA) issued an advisory describing increased mortality among elderly people with dementia taking atypical antipsychotics. More than a year later, no state had changed its PA policy in response. We discuss the roles of Medicaid and other insurers in responding to emerging drug safety issues and their challenges in weighing drug risks and benefits.

Effect of Antipsychotic Medication Use on Memory in Patients With Alzheimer’s Disease: Assessing the Potential Risk for Accelerated Recent Autobiographical Memory Loss

Autobiographical memory loss is a common and disturbing problem for individuals with Alzheimer's disease (AD). Patients with AD who are taking antipsychotic medications may be at further risk for loss of recent autobiographical memory because of the potential anticholinergic side effects of antipsychotics. The purpose of this post hoc, descriptive study was to compare the recent autobiographical memory scores of patients with AD taking antipsychotics to those who were not taking antipsychotics. The study population was composed of 35 patients with moderate-stage AD. Patients who were taking antipsychotics scored significantly worse on a recent autobiographical memory measure compared with patients who were not taking antipsychotics. This study provides further evidence for judicious use of antipsychotic medications with AD patients.

Decision analysis model evaluating the cost-effectiveness of risperidone, olanzapine and haloperidol in the treatment of schizophrenia

PURPOSE

To evaluate the cost-effectiveness of three antipsychotic medications (olanzapine, risperidone and haloperidol) in the treatment of schizophrenia using the Positive and Negative Symptom Scale.

STUDY DESIGN AND METHODS

A decision analysis model was created to evaluate the cost-effectiveness of two atypical antipsychotics (risperidone and olanzapine) and haloperidol. Outcome probabilities were determined from published clinical trials. The main dependent variable of interest was to compare the incremental cost-effectiveness ratios (ICER) of the atypical antipsychotic with haloperidol, and also to compare the ICER of olanzapine and risperidone. Sensitivity analyses were conducted for olanzapine and risperidone to determine the effects of altering drug cost, efficacy and re-hospitalization rate on total costs.

RESULTS

Risperidone and olanzapine were dominant strategies compared with haloperidol (less costly and more effective). Risperidone was also dominant when compared with olanzapine. A one-way sensitivity analysis for efficacy indicated that the efficacy of risperidone would need to decrease by approximately 3% from the base-case in order for olanzapine and risperidone to have equal total costs. In a two-way sensitivity analysis varying both the cost of olanzapine and risperidone, the difference in drug costs between them would have to increase from $2.12 per day to $4.12 per day in order to have equal total costs. In terms of varying re-hospitalization rates, the re-hospitalization rate for risperidone would have to increase from 3% to 33% greater than the re-hospitalization rate for olanzapine in order to have equal total direct costs.

CONCLUSION

Based on this decision model, atypical antipsychotics were a dominant strategy over haloperidol primarily because of increased efficacy and lower re-hospitalizations. The ICER indicated that risperidone was dominant over olanzapine because of lower drug costs and increased number of responders, which leads to decreased total costs.

Comparison of the risk of adverse events between risperidone and haloperidol in delirium patients

The aim of this study was to determine the risk of adverse events for risperidone and haloperidol in delirium patients. The authors conducted a retrospective study with medical records of 266 Japanese delirium inpatients who were referred to them between July 2001 and May 2005. Information on gender, age, delirium, drug therapy, adverse events, death, and other relevant factors was collected and analyzed for each patient. As a primary antipsychotic drug for the treatment of delirium, risperidone was used in 93 patients; oral haloperidol was used in 95; and intravenous or intramuscular haloperidol was used in 61. The incidence of adverse events was 6.5% for risperidone, 31.4% for oral haloperidol, and 32.8% for haloperidol injection. The incidence of death during delirium was 3.2% for risperidone, 2.1% for oral haloperidol, and 13.1% for haloperidol injection. The incidence of death within 1 year after the onset of delirium was 30.1% for risperidone, 29.5% for oral haloperidol, and 45.9% for haloperidol injection. Between risperidone, oral haloperidol, and intravenous or intramuscular haloperidol the incidence of adverse events was significantly lowest for risperidone, and the incidence of death during delirium was significantly highest for intravenous or intramuscular haloperidol. The use of haloperidol as a first-line drug in delirium patients who can receive the drug orally will not contribute to the establishment of drug therapy for delirium based on risk-benefit assessment of the therapy.

Managing delirium in hospitalized elderly patients

This review highlights the key elements of guidelines developed for the management of delirium. Experts and expert panels in several countries have presented their own guidelines, which have similarities but also differences in their emphases. The essential elements in the management of delirium are appropriate detection and diagnosis, assessment and treatment of underlying conditions, symptom management, environmental and supportive interventions, post-delirium care and follow-up, and paying attention to risk factors and prevention. The level of evidence behind each recommendation of the guidelines is discussed, as well as some of the typical pitfalls in the care of patients with delirium. Although rigorous randomized intervention trials on full-blown delirium are still scarce, we have some trials suggesting how to manage each dimension of the care of delirium.

Managing risk when considering the use of atypical antipsychotics for elderly patients with dementia-related psychosis

In 2005, responding to several studies, the FDA issued a black box warning on atypical (second generation) antipsychotic medications, noting that the drugs may increase the risk of cerebrovascular adverse events in elderly patients with dementia-related behavior disturbances. The black box warning has raised concern for clinicians, among whom atypical antipsychotics have gained favor for having a more tolerable side-effect profile than many other pharmacological treatment options. Complicating this concern are studies suggesting that other medications may have similar risks and a dearth of unbiased head-to-head studies comparing different treatment options. To effectively manage risk when treating elderly patients with dementia-related psychosis, physicians, patients, and caregivers must consider both acute risks (such as danger of bodily harm to the patient and others) and long-term risks (such as placement in a restrictive nursing home). If an atypical antipsychotic is chosen, additional risk management may be warranted. This paper presents a brief overview of relevant concerns and suggests some techniques to help minimize and manage risk, such as increased monitoring, informed consent, and thorough documentation. A sample clinical risk management form and a sample letter to the primary care physician are provided to help guide clinicians in improving their risk management practices when working with elderly patients suffering from dementia-related psychosis and related behavioral difficulties.

Adverse childhood experiences and prescribed psychotropic medications in adults

BACKGROUND

Prescription drugs are one of the fastest growing healthcare costs in the United States. However, the long-term influence of child abuse and related traumatic stressors on prescriptions for psychotropic medications in adults has not been described. This study assessed the relationship of eight adverse childhood experiences (ACEs) to rates of prescriptions for psychotropic medications throughout adulthood. These ACEs included: abuse (emotional, physical, or sexual), witnessing domestic violence, growing up with substance abusing, mentally ill, or criminal household members, and parental separation/divorce.

METHODS

Data about ACEs were collected between 1995 and 1997 from adult health maintenance organization patients; prescription data were available from 1997 to 2004. The number of ACEs (ACE Score: maximum 8) was used as a measure of cumulative traumatic stress during childhood. The relationship of the score to rates of prescribed psychotropic drugs was prospectively assessed among 15,033 adult patients eligible for the follow-up phase of the study (mean follow-up: 6.1 years). Data were analyzed in 2006. Multivariate models were adjusted for age, race, gender, and education.

RESULTS

Prescription rates increased yearly during the follow-up and in a graded fashion as the ACE Score increased (p for trend <0.001). After adjusting compared with persons with an ACE Score of 0, persons with a score of equal to or more than 5 had a nearly threefold increase in rates of psychotropic prescriptions. Graded relationships were observed between the score and prescription rates for antidepressant, anxiolytic, antipsychotic, and mood-stabilizing/bipolar medications; rates for persons with a score of equal to or more than 5 for these classes of drugs increased 3-, 2-, 10-, and 17-fold, respectively.

CONCLUSIONS

The strong relationship of the ACE Score to increased utilization of psychotropic medications underscores the contribution of childhood experience to the burden of adult mental illness. Moreover, the huge economic costs associated with the use of psychotropic medications provide additional incentive to address the high prevalence and consequences of childhood traumatic stressors.

Neither atypical nor conventional antipsychotics increase mortality or hospital admissions among elderly patients with dementia: a two-year prospective study

BACKGROUND

Antipsychotics are widely used to manage behavioral disorders in patients with dementia. Recently, serious concerns have been raised about the stroke and mortality risk of atypical antipsychotics when administered to patients with dementia.

AIM

The aim of this study was to examine the impact of atypical and conventional antipsychotics on mortality and hospital admissions among Finnish elderly institutionalized patients with dementia in a two-year follow up and to compare their prognosis with that of nonusers.

PATIENTS AND METHODS

The authors examined 254 very frail patients with dementia, mean age 86 years, from seven Finnish nursing homes and two hospitals in 1999-2000. Medical records provided information on the use of daily antipsychotic medication; central registers confirmed mortality for up to two years.

RESULTS

Nearly one-half (48.4%) of the patients used antipsychotic medication: 37.4% received conventional neuroleptics (N = 95) and 11.0% received atypical antipsychotics (N = 28). The mean number of hospital admissions was higher among the nonusers than among the users of conventional or atypical antipsychotics. Of the users of atypical antipsychotics (risperidone, olanzapine), 32.1% died within 2 years. The respective figures for users of conventional neuroleptics were 45.3%, and for the nonusers, 49.6%. In the Cox proportional hazard model, a high number of medications and the use of physical restraint predicted higher mortality at two years. The use of atypical antipsychotics showed lower risk of mortality, if any. The respective test for conventional antipsychotics was nonsignificant.

CONCLUSION

Among these frail and very old patients with dementia, neither the use of atypical antipsychotics nor the use of conventional neuroleptics increased mortality or hospital admissions. The use of restraints, however, doubled the risk of mortality.

Risk of death associated with the use of conventional versus atypical antipsychotic drugs among elderly patients

BACKGROUND

Public health advisories have warned that the use of atypical antipsychotic medications increases the risk of death among elderly patients. We assessed the short-term mortality in a population-based cohort of elderly people in British Columbia who were prescribed conventional and atypical antipsychotic medications.

METHODS

We used linked health care utilization data of all BC residents to identify a cohort of people aged 65 years and older who began taking antipsychotic medications between January 1996 and December 2004 and were free of cancer. We compared the 180-day all-cause mortality between residents taking conventional antipsychotic medications and those taking atypical antipsychotic medications.

RESULTS

Of 37 241 elderly people in the study cohort, 12 882 were prescribed a conventional antipsychotic medication and 24 359 an atypical formulation. Within the first 180 days of use, 1822 patients (14.1%) in the conventional drug group died, compared with 2337 (9.6%) in the atypical drug group (mortality ratio 1.47, 95% confidence interval [CI] 1.39-1.56). Multivariable adjustment resulted in a 180-day mortality ratio of 1.32 (1.23-1.42). In comparison with risperidone, haloperidol was associated with the greatest increase in mortality (mortality ratio 2.14, 95% CI 1.86-2.45) and loxapine the lowest (mortality ratio 1.29, 95% CI 1.19-1.40). The greatest increase in mortality occurred among people taking higher (above median) doses of conventional antipsychotic medications (mortality ratio 1.67, 95% CI 1.50-1.86) and during the first 40 days after the start of drug therapy (mortality ratio 1.60, 95% CI 1.42-1.80). Results were confirmed in propensity score analyses and instrumental variable estimation, minimizing residual confounding.

INTERPRETATION

Among elderly patients, the risk of death associated with conventional antipsychotic medications is comparable to and possibly greater than the risk of death associated with atypical antipsychotic medications. Until further evidence is available, physicians should consider all antipsychotic medications to be equally risky in elderly patients.

Conceptualizing Alzheimer's disease as a terminal medical illness

Alzheimer's disease is a common illness of the elderly population, with an estimated prevalence of 4.5 million people in the United States and 24.3 million worldwide. Despite current pharmaceutic advances in delaying disease progression, there is no cure. This article reviews the evidence for conceptualizing Alzheimer's disease as a terminal medical illness. Discussed are principles of palliative care as applied to the patient with Alzheimer's disease and the patient's family.

Safety and efficacy of anticonvulsants in elderly patients with psychiatric disorders: oxcarbazepine, topiramate and gabapentin

Few controlled studies are available to guide the clinician in treating potentially assaultive elderly individuals with psychiatric disorders. Safety concerns limit the use of benzodiazepines and antipsychotic medications in the elderly individual, making anticonvulsants an attractive alternative. This paper reviews three specific anticonvulsants for this purpose: gabapentin, oxcarbazepine and topiramate, describing safety and efficacy in elderly patients with severe agitation from psychosis or dementia. Gabapentin, renally excreted, with a half-life of 6.5-10.5 h, may cause ataxia. Oxcarbazapine, hepatically reduced, may cause hyponatremia, and topiramate may cause significant cognitive impairment. Nonetheless, these are important medications to consider in the treatment of agitation.

Reference drug programs: effectiveness and policy implications

In the current economic environment, health care systems are constantly struggling to contain rapidly rising costs. Drug costs are targeted by a wide variety of measures. Many jurisdictions have implemented reference drug programs (RDPs) or similar therapeutic substitution programs. This paper summarizes the mechanism and rationale of RDPs and presents evidence of their economic effectiveness and clinical safety. RDPs for pharmaceutical reimbursement are based on the assumption that drugs within specified medication groups are therapeutically equivalent and clinically interchangeable and that a common reimbursement level can thus be established. If the evidence documents that a higher price for a given drug does not buy greater effectiveness or reduced toxicity, then under RDP such extra costs are not covered. RDPs or therapeutic substitutions based on therapeutic equivalence are seen as logical extensions of generic substitution that is based on bioequivalence of drugs. If the goal is to achieve full drug coverage for as many patients as possible in the most efficient manner, then RDPs in combination with prior authorization programs are safer and more effective than simplistic fiscal drug policies, including fixed co-payments, co-insurances, or deductibles. RDPs will reduce spending in the less innovative but largest market, while fully covering all patients. Prior authorization will ensure that patients with a specified indication will benefit from the most innovative therapies with full coverage. In practice, however, not all patients and drugs will fit exactly into one of the two categories. Therefore, a process of medically indicated exemptions that will consider full coverage should accompany an RDP. In the current economic environment, health care systems are constantly struggling to contain rapidly rising costs. Drug costs are targeted by a wide variety of measures. Many jurisdictions have implemented reference drug programs, and others are considering them. This paper summarizes the mechanism and rationale of RDPs, presents evidence of their economic effectiveness and clinical safety, and concludes with some practical implications of implementing RDP policies.

Readers should systematically assess methods used to identify, measure and analyze confounding in observational cohort studies

OBJECTIVE

To describe techniques used to address confounding in published observational studies.

STUDY DESIGN AND SETTING

A systematic literature review identified studies using administrative or registry data to investigate health effects of drug therapies. Studies published from January 2001 to December 2005 came from BMJ, New England Journal of Medicine, Lancet, Annals of Internal Medicine, and JAMA. A structured abstraction form was used to collect information about confounding.

RESULTS

The search identified 29 studies. Twenty-two studies (76%) had 10,000 or more subjects and 18 (62%) used a mortality outcome. None mentioned use of a literature search to identify confounders, however, 28 (97%) listed confounders included, and 26 (90%) listed confounders not included in the study. Eighteen (62.1%) discussed the validity of confounder data. Most (22, or 76%) studies included a table with the distribution of confounders but none used effect size to assess imbalance between comparison groups. Almost all studies used regression techniques (28, or 97%); fewer used stratification (16, or 55%) or matching (four, or 14%) to address confounding. Eleven (40%) studies discussed sensitivity analyses.

CONCLUSION

Published cohort studies routinely include a list of potential confounders but there is room for improvement in confounder identification, measurement, and analysis.

Statins in elderly patients with acute coronary syndrome: an analysis of dose and class effects in typical practice

OBJECTIVE

To compare the effectiveness of statins of different treatment intensity used to treat elderly patients with acute coronary syndrome (ACS) in typical care settings.

DESIGN

Retrospective cohort study using linked hospital and pharmacy claims data.

SETTING

Statewide pharmacy benefits programmes in Pennsylvania and New Jersey.

PARTICIPANTS

18,311 Medicare patients discharged alive after ACS who received a prescription for a statin within 90 days of hospital discharge.

MAIN OUTCOME MEASURES

Using multivariable and propensity-matched Cox proportional hazards regression models, patients who were prescribed high-intensity and moderate-intensity statins were compared based on the drug-dose combination that they initially received. Individual drug-dose combinations were also compared. Our primary outcome was the composite of all-cause death or recurrent ACS.

RESULTS

Patients who received moderate-intensity statins were as likely to experience a primary outcome as patients treated with high-intensity statins (adjusted HR 1.02, 95% CI 0.96 to 1.08). Propensity matching did not change the results. Individually, all moderate-intensity statins were as effective as high-intensity atorvastatin with the exception of lovastatin (adjusted HR 1.22, 95% CI 1.09 to 1.36). Similarly, all high-intensity statins seem as effective as high-intensity atorvastatin but the CIs surrounding these estimates were wide.

CONCLUSIONS

This analysis of elderly patients with ACS treated in typical care settings does not demonstrate the superiority of high-intensity over moderate-intensity statin treatment or significant differences among individual statins.

Delirium: guidelines for general hospitals

OBJECTIVE

Delirium is highly prevalent in general hospitals but remains underrecognized and undertreated despite its association with increased morbidity, mortality, and health services utilization. To enhance its management, we developed guidelines covering all aspects, from risk factor identification to preventive, diagnostic, and therapeutic interventions in adult patients.

METHODS

Guidelines, systematic reviews, randomized controlled trials (RCT), and cohort studies were systematically searched and evaluated. Based on a synthesis of retrieved high-quality documents, recommendation items were submitted to a multidisciplinary expert panel. Experts scored the appropriateness of recommendation items, using an evidence-based, explicit, multidisciplinary panel approach. Each recommendation was graded according to this process' results.

RESULTS

Rated recommendations were mostly supported by a low level of evidence (1.3% RCT and systematic reviews, 14.3% nonrandomized trials vs. 84.4% observational studies or expert opinions). Nevertheless, 71.1% of recommendations were considered appropriate by the experts. Prevention of delirium and its nonpharmacological management should be fostered. Haloperidol remains the first-choice drug, whereas the role of atypical antipsychotics is still uncertain.

CONCLUSIONS

While many topics addressed in these guidelines have not yet been adequately studied, an explicit panel and evidence-based approach allowed the proposal of comprehensive recommendations for the prevention and management of delirium in general hospitals.

Factors related to potentially harmful behaviors towards disabled older people by family caregivers in Japan

OBJECTIVE

The purpose of the present study was to examine factors related to potentially harmful behaviors (PHB) by family caregivers towards their older family members.

METHODS

Four hundred and twelve pairs of disabled older adults and their family caregivers participated in the study. All of these disabled older adults were users of visiting nursing services under the public Long-Term Care insurance system, who resided in one of the eight catchment areas of visiting nursing services in Kyoto Prefecture, Japan. The caregivers were asked to complete questionnaires in relation to their PHB towards their older family members, caregiver burden, patient-caregiver kinship, behavioral disturbances of their older adult, age and sex. Visiting nurses obtained the following information regarding the older adults: the severity of dementia; the severity of physical impairment; age and sex.

RESULTS

More than 30% of the caregivers admitted PHB towards their older family members. The most frequently reported PHB included verbal aggression (16.8%) and ignoring (13.6%). A logistic regression analysis revealed that adult children (OR = 2.69, 95%CI = 1.23-5.89, p = 0.013) and caregivers of disabled older people with behavioral disturbances (OR = 3.61, 95%CI = 1.65-7.90, p < 0.01) were more likely to show PHB.

CONCLUSIONS

In the present study, PHB towards the older people by family caregivers was associated with patients' behavioral disturbances and patient-caregiver kinship, i.e. an adult child as a caregiver. These findings should be taken into account when planning strategies to prevent PHB by family members.

Treatment Strategies for the Behavioral Symptoms of Alzheimer's Disease: Focus on Early Pharmacologic Intervention

The impact of behavioral symptoms associated with Alzheimer's disease is substantial. These symptoms contribute to diminished quality of life for patients and caregivers and increase the cost of care in nursing homes. Early recognition of behavioral symptoms and appropriate treatment are important for successful management. Nonpharmacologic strategies remain the cornerstone of the management of Alzheimer's disease-related behavioral symptoms. However, nonpharmacologic strategies may not be effective for problem behaviors, and pharmacologic intervention may be necessary. Relevant articles were identified through various MEDLINE searches with no date restrictions, with an emphasis on recent studies that used cholinesterase inhibitors and memantine. Additional reports of interest were identified from the reference lists of these articles. To facilitate cross-study analyses in the review of cholinesterase inhibitors and memantine, the database search was limited to randomized, placebo-controlled trials that used the Neuropsychiatric Inventory to assess behavioral symptoms of Alzheimer's disease. Overall, evidence from trials of cholinesterase inhibitors and memantine suggests that when these agents are optimized for the various stages of Alzheimer's disease, they can also prevent the emergence of neuropsychiatric symptoms. Although results from the literature are not uniformly positive, cholinesterase inhibitors have been shown to produce significant improvements in behavioral symptoms in patients with both mild- to-moderate and moderate-to-severe Alzheimer's disease. Evidence also indicates that memantine might be of benefit as an adjunct to long-term cholinesterase inhibitor treatment in patients with moderate-to-severe Alzheimer's disease and that memantine monotherapy may have some beneficial effects on behavior in patients with mild-to-moderate disease. Of importance, although no direct comparisons have been performed, these agents seem to have an improved safety and tolerability profile compared with the frequently used antipsychotic drugs. When nonpharmacologic strategies are deemed insufficient to ease problem behaviors in patients with Alzheimer's disease, treatment with cholinesterase inhibitors, alone or in combination with memantine as appropriate for the stage of disease, may be considered as a first-line option in the early pharmacologic management of Alzheimer's disease-related behavioral symptoms.

Memantine in the treatment of mild-to-moderate Alzheimer's disease

Memantine is the first and only medication that has been approved by European, US and Canadian regulatory agencies for the treatment of moderate-to-severe Alzheimer's disease (AD). It is an NMDA receptor antagonist that works to prevent excitotoxicity and cell death, which are mediated by the excessive influx of calcium during a sustained release of glutamate. Preclinical studies of memantine reveal that it has the potential to improve memory and learning processes after impairment has occurred, as well as to prevent further neuronal damage. Although memantine has been considered for the treatment of earlier AD, it has not yet been approved for this. Randomized controlled trials of memantine in the treatment of mild-to-moderate AD have demonstrated small treatment effects in measures of cognition, global assessment and behavior favoring the use of memantine. However, the differences between treatment groups were not consistently significant. Two ongoing long-term trials are further investigating the efficacy of memantine in the treatment of mild-to-moderate AD.

Recognizing delirium superimposed on dementia: assessing nurses' knowledge using case vignettes

Delirium is a serious and prevalent problem that occurs in many hospitalized older adults. Delirium superimposed on dementia (DSD) occurs when a delirium occurs concurrently with a pre-existing dementia. DSD is typically underrecognized by medical and nursing staff. The current study measured nursing identification of DSD using standardized case vignettes, and the Mary Starke Harper Aging Knowledge Exam (MSHAKE). Results revealed that the nurses in this study had a high level of general geropsychiatric nursing knowledge as measured by the MSHAKE, yet had difficulty recognizing DSD compared to dementia alone and delirium alone. Only 21% were able to correctly identify the hypoactive form of DSD, and 41% correctly identified hypoactive delirium alone in the case vignettes. Interventions and educational programs designed to increase nursing awareness of DSD symptoms could help to decrease this gap in nursing knowledge.

Treatment of Cognitive Decline and Psychiatric Disturbances Associated With Alzheimer's Dementia

Alzheimer's dementia (AD) is the most common type of dementia. In addition to the cognitive and functional disturbances that happen as the disease progresses, other psychological disturbances may manifest. Depression, insomnia, anxiety, and psychosis are among several psychological conditions which can occur concomitantly with AD. These changes can result in decreased quality of life for both patients and caregivers, increase caregiver burden, and impact the decision to place a patient with AD into a long-term care facility. An evidence-based review of the literature was performed to ascertain if a specific recommendation for pharmacotherapy can be made based on current research in this specific patient population.

Palliative Care for the Older Adult

The majority of deaths in the United States occur in the geriatric population. These older adults often develop multiple chronic medical problems and endure complicated medical courses with a variety of disease trajectories. Palliative care physicians need to be skilled in addressing the needs of these frail elders with life-limiting illness as they approach the end of life. Although geriatrics and palliative medicine share much in common, including an emphasis on optimizing quality of life and function, geriatric palliative care is distinct in its focus on the geriatric syndromes and on the provision of care in a variety of long-term care settings. Expertise in the diagnosis and management of the geriatric syndromes and in the complexities of long-term care settings is essential to providing high-quality palliative care to the elderly patient. This paper is a practical review of common geriatric syndromes, including dementia, delirium, urinary incontinence, and falls, with an emphasis on how they may be encountered in the palliative care setting. It also highlights important issues regarding the provision of palliative care in different long-term care settings.

Analysis of observational studies in the presence of treatment selection bias: effects of invasive cardiac management on AMI survival using propensity score and instrumental variable methods

CONTEXT

Comparisons of outcomes between patients treated and untreated in observational studies may be biased due to differences in patient prognosis between groups, often because of unobserved treatment selection biases.

OBJECTIVE

To compare 4 analytic methods for removing the effects of selection bias in observational studies: multivariable model risk adjustment, propensity score risk adjustment, propensity-based matching, and instrumental variable analysis.

DESIGN, SETTING, AND PATIENTS

A national cohort of 122,124 patients who were elderly (aged 65-84 years), receiving Medicare, and hospitalized with acute myocardial infarction (AMI) in 1994-1995, and who were eligible for cardiac catheterization. Baseline chart reviews were taken from the Cooperative Cardiovascular Project and linked to Medicare health administrative data to provide a rich set of prognostic variables. Patients were followed up for 7 years through December 31, 2001, to assess the association between long-term survival and cardiac catheterization within 30 days of hospital admission.

MAIN OUTCOME MEASURE

Risk-adjusted relative mortality rate using each of the analytic methods.

RESULTS

Patients who received cardiac catheterization (n = 73 238) were younger and had lower AMI severity than those who did not. After adjustment for prognostic factors by using standard statistical risk-adjustment methods, cardiac catheterization was associated with a 50% relative decrease in mortality (for multivariable model risk adjustment: adjusted relative risk [RR], 0.51; 95% confidence interval [CI], 0.50-0.52; for propensity score risk adjustment: adjusted RR, 0.54; 95% CI, 0.53-0.55; and for propensity-based matching: adjusted RR, 0.54; 95% CI, 0.52-0.56). Using regional catheterization rate as an instrument, instrumental variable analysis showed a 16% relative decrease in mortality (adjusted RR, 0.84; 95% CI, 0.79-0.90). The survival benefits of routine invasive care from randomized clinical trials are between 8% and 21%.

CONCLUSIONS

Estimates of the observational association of cardiac catheterization with long-term AMI mortality are highly sensitive to analytic method. All standard risk-adjustment methods have the same limitations regarding removal of unmeasured treatment selection biases. Compared with standard modeling, instrumental variable analysis may produce less biased estimates of treatment effects, but is more suited to answering policy questions than specific clinical questions.

Pharmacotherapy for behavioral and psychological symptoms of dementia in the elderly

PURPOSE

The use of atypical antipsychotics for maximizing clinical efficacy and overall health in patients with neuropsychiatric symptoms of dementia is discussed.

SUMMARY

Psychotic and behavioral symptoms are common among older patients with dementia, and an accurate diagnosis can be obscured by complex presentation of symptoms and comorbidities. When initiating pharmacotherapy in this patient population, it is important to consider the increased presence of comorbidities and the additive pharmacologic effects of concomitantly administered drugs. Atypical antipsychotics are among the most well-studied therapeutic classes of psychoactive medications and are frequently utilized for treating psychotic symptoms and agitation in the elderly. These medications have distinct pharmacologic profiles with different liabilities for adverse effects such as sedation, metabolic disturbances, and anticholinergic effects. Recent findings from the Clinical Antipsychotic Trials of Intervention Effectiveness-Alzheimer's Disease (CATIE-AD) study demonstrate that although these agents have some efficacy, their adverse effects may limit their utility in patients.

CONCLUSION

The adverse effect profile should be an important consideration for clinicians selecting an atypical antipsychotic for use in this population.

Psychotropic use in community residential care facilities: A prospective cohort study

BACKGROUND

Psychotropic medication use in community residential care (CRC) facilities has been reported to be similar to that found in nursing homes before the implementation of the Omnibus Budget Reconciliation Act of 1987.

OBJECTIVES

The objectives of this study were to (1) describe patterns of psychotropic medication use at baseline and after 1 year of follow-up in adult residents aged > or =65 years supported by Medicaid in CRC facilities, (2) describe the quality of psychotropic use, and (3) examine the relationship between psychotropic use and resident and facility characteristics.

METHODS

This was a planned analysis of a larger prospective cohort study conducted in CRC facilities (assisted living, adult family home, adult residential care) in a 3-county area in the state of Washington. Interviews and state Medicaid databases were used to collect resident characteristics (demographic data, medication use, activities of daily living, self-reported health, and frequency of memory and behavior problems) and facility characteristics (type, staffing, and occupancy rates). Residents were classified as users or nonusers of psychotropic medications. Suboptimal psychotropic use was defined as use of agents with a higher side-effect profile (tertiary amine tricyclic antidepressants, long-acting benzodiazepines, and low-potency conventional antipsychotics). Logistic regression was used to examine characteristics associated with any psychotropic use at baseline.

RESULTS

The typical resident was a white woman, aged 83 years, receiving 7 medications. Nearly half (46.8%) of all residents used > or =1 psychotropic medication at baseline, whereas 16.7% used multiple agents. Antidepressants accounted for the greatest amount of psychotropic use (31.2%). Suboptimal antidepressants, sedative/anxiolytics, and antipsychotics were used by 19.3%, 16.7%, and 7.3% of medication users in each class, respectively. Only age (odds ratio [OR] = 0.97; 95% CI, 0.35-1.00), number of medications (OR = 1.06; 95% CI, 1.00-1.11), and the Revised Memory and Behavior Problems Checklist score (OR = 2.03; 95% CI, 1.28-3.23) were associated with psychotropic use at baseline.

CONCLUSIONS

Psychotropic medication use was high in CRC facilities (46.8%), with antidepressants being the most frequently used drugs. Use of suboptimal (19.3% of antidepressant users, 16.7% of sedative/anxiolytic users, 7.3% of antipsychotic users) and multiple psychotropics (16.7%) was low.

Delirium in Older Adults With Cancer: Implications for Practice and Research

PURPOSE/OBJECTIVES

To provide a comprehensive review of the literature and existing evidence-based findings on delirium in older adults with cancer.

DATA SOURCES

Published articles, guidelines, and textbooks.

DATA SYNTHESIS

Although delirium generally is recognized as a common geriatric syndrome, a paucity of empirical evidence exists to guide early recognition and treatment of this sequelae of cancer and its treatment in older adults. Delirium probably is more prevalent than citations note because the phenomenon is under-recognized in clinical practice across varied settings of cancer care.

CONCLUSIONS

Extensive research is needed to formulate clinical guidelines to manage delirium. A focus on delirium in acute care and at the end of life precludes identification of this symptom in ambulatory care, where most cancer therapies are used. Particular emphasis should address the early recognition of prodromal signs of delirium to reduce symptom severity.

IMPLICATIONS FOR NURSING

Ongoing assessment opportunities and close proximity to patients' treatment experiences foster oncology nurses' mastery of this common exemplar of altered cognition in older adults with cancer. Increasing awareness of and knowledge delineating characteristics of delirium in older patients with cancer can promote early recognition, optimum treatment, and minimization of untoward consequences associated with the historically ignored example of symptom distress.

Antipsychotics and cognitive decline in Alzheimer's disease: the LASER-Alzheimer's disease longitudinal study

OBJECTIVE

To investigate in a longitudinal cohort of people with Alzheimer's disease whether taking antipsychotics is associated with more rapid cognitive deterioration.

METHOD

From a sample of 224 people with Alzheimer's disease recruited as epidemiologically representative, those taking antipsychotic drugs for more than 6 months were compared with those who were not, in terms of change in three measures of cognition. The effects of potential mediators and confounders (demographic factors, neuropsychiatric symptoms, cognitive severity and cholinesterase inhibitors) were also examined.

RESULTS

No significant difference was observed in cognitive decline between those taking antipsychotics (atypical or any) and others on any measure of cognition. The only predictor of more cognitive decline was greater baseline cognitive severity (B = 3.3, 95% confidence interval 0.6 to 6.1, t = 2.4, p<0.05). Although mortality was higher in those treated with antipsychotics, this reflected their greater age and severity of dementia. The results were the same when the whole cohort was included rather than the select group with potential to change who had been taking antipsychotics continuously.

CONCLUSIONS

In this, the first cohort study investigating the effects of atypical antipsychotics on cognitive outcome in Alzheimer's disease, those taking antipsychotics were no more likely to decline cognitively over 6 months. Although clinicians should remain cautious when prescribing antipsychotic drugs to people with Alzheimer's disease, any increase in cognitive deterioration is not of the magnitude previously reported. There is a need for cohort studies that follow up patients from first prescription in clinical practice for a period of months rather than weeks to determine "real-life" risks and benefits.

Mortality among patients admitted to intensive care units during weekday day shifts compared with "off" hours

OBJECTIVE

To determine whether mortality rates among intensive care unit (ICU) patients differ according to the time of ICU admission, we compared the death rates for patients admitted during weekday day shifts and off hours (from 6:30 pm to 8:29 am the next day for night shifts, from Saturday 1:00 pm to Monday 8:29 am for weekends, and from 8:30 am to 8:29 am the following morning for public holidays).

METHODS

Retrospective cohort study of data collected prospectively from 23 ICUs located in the Paris metropolitan region, France. Between January 2000 and December 2003, 51,643 patients were admitted to these ICUs. Patients were grouped according to their day and time of admission and compared using univariable and multivariable analyses.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 51,643 patients admitted to ICUs, 33,857 (65.6%) were admitted during off hours. These latter patients were less critically ill than those admitted during day shifts, had fewer failed organs, required fewer support procedures, and their crude in-hospital mortality was lower (20.7 vs. 24.5%, p < .0001). After adjustment for initial disease severity, in-hospital mortality was not higher for off-hours admissions than weekday day admissions and even remained slightly lower (adjusted odds ratio, 0.93; 95% confidence interval, 0.87-0.98).

CONCLUSIONS

Admission during off hours is common. In our ICUs, off-hours admissions were not associated with higher mortality and might even be associated with a lower death rate.

Preference-based instrumental variable methods for the estimation of treatment effects: assessing validity and interpreting results

Observational studies of drugs and medical procedures based on administrative data are increasingly used to inform regulatory and clinical decisions. However, the validity of such studies is often questioned because available data may not contain measurements of many important prognostic variables that guide treatment decisions. Recently, approaches to this problem have been proposed that use instrumental variables (IV) defined at the level of an individual health care provider or aggregation of providers. Implicitly, these approaches attempt to estimate causal effects by using differences in medical practice patterns as a quasi-experiment. Although preference-based IV methods may usefully complement standard statistical approaches, they make assumptions that are unfamiliar to most biomedical researchers and therefore the validity of such analyses can be hard to evaluate. Here, we propose a simple framework based on a single unobserved dichotomous variable that can be used to explore how violations of IV assumptions and treatment effect heterogeneity may bias the standard IV estimator with respect to the average treatment effect in the population. This framework suggests various ways to anticipate the likely direction of bias using both empirical data and commonly available subject matter knowledge, such as whether medications or medical procedures tend to be overused, underused, or often misused. This approach is described in the context of a study comparing the gastrointestinal bleeding risk attributable to different non-steroidal anti-inflammatory drugs.

Recommendations for the diagnosis and management of Alzheimer's disease and other disorders associated with dementia: EFNS guideline

The aim of this international guideline on dementia was to present a peer-reviewed evidence-based statement for the guidance of practice for clinical neurologists, geriatricians, psychiatrists, and other specialist physicians responsible for the care of patients with dementia. It covers major aspects of diagnostic evaluation and treatment, with particular emphasis on the type of patient often referred to the specialist physician. The main focus is Alzheimer's disease, but many of the recommendations apply to dementia disorders in general. The task force working group considered and classified evidence from original research reports, meta-analysis, and systematic reviews, published before January 2006. The evidence was classified and consensus recommendations graded according to the EFNS guidance. Where there was a lack of evidence, but clear consensus, good practice points were provided. The recommendations for clinical diagnosis, blood tests, neuroimaging, electroencephalography (EEG), cerebrospinal fluid (CSF) analysis, genetic testing, tissue biopsy, disclosure of diagnosis, treatment of Alzheimer's disease, and counselling and support for caregivers were all revised when compared with the previous EFNS guideline. New recommendations were added for the treatment of vascular dementia, Parkinson's disease dementia, and dementia with Lewy bodies, for monitoring treatment, for treatment of behavioural and psychological symptoms in dementia, and for legal issues. The specialist physician plays an important role together with primary care physicians in the multidisciplinary dementia teams, which have been established throughout Europe. This guideline may contribute to the definition of the role of the specialist physician in providing dementia health care.

An outcome measure in schizophrenia: mortality

OBJECTIVE

To determine the current outcome of schizophrenia, with mortality rate as the outcome measure.

METHOD

Recent health, suicide, victim of violence, and mortality statistics were reviewed.

RESULTS

The general health of individuals with schizophrenia suffers from neglect, poor life style choices, and current treatments that increase death rates.

CONCLUSION

Mortality in schizophrenia is rising, and it is the responsibility of physicians and health care planners to intervene.

The switching of risperidone to olanzapine in elderly nursing-home patients with dementia: a retrospective study

BACKGROUND

The behavioral and psychological symptoms of dementia present a major challenge in the management of these patients. There is no Food and Drug Administration-indicated medication for the management of these symptoms. Even though atypical antipsychotics are considered safer than conventional antipsychotics, safety concerns have emerged.

INTRODUCTION

The FDA has issued warnings regarding the cardiac and metabolic side effects, cerebrovascular events, and, most recently, mortality risk. This study was conducted in 2003 when physicians were notified of the cerebrovascular risks of risperidone. Since then, similar warnings have been issued for olanzapine and aripiprazole.

METHODS

The medical records of 58 elderly dementia patients who were taking risperidone and were abruptly switched to olanzapine were reviewed. Clinical Global Impressions scale at assigned retrospectively at switch, and weeks 4-6 assessed treatment.

RESULTS

Baseline and follow-up Clinical Global Impressions scale scores were essentially unchanged. Adverse events were mild to moderate in severity. Mean risperidone dose at switch was 1.54 mg/day (range: 0.25-6 mg/day). Mean olanzapine dose after the switch was 5.69 mg/day (range: 2.52-27.5 mg/day).

CONCLUSION

Most of the 58 patients were switched from risperidone to olanzapine without any deterioration in their clinical status. Even though it is generally not recommended in elderly patients, abrupt switching did not have any negative consequences in this group of patients.

Psychotropic medication use for behavioral symptoms of dementia

Behavioral disturbances associated with dementia are common and burdensome. Although no psychotropic medications are currently approved by the US Food and Drug Administration (FDA) to treat such behavioral symptoms, a variety of drug classes are commonly used for these purposes. Atypical antipsychotic medications may be somewhat effective and are generally considered the pharmacologic treatments of choice; however "black box" warnings have recently been added to their labels by the FDA, warning of significantly increased risks of short-term mortality. Older conventional antipsychotic medications may also be somewhat effective but appear to pose risks that can be at least as great as those of the newer atypical drugs. Although antidepressants, benzodiazepines, mood stabilizers, acetylcholinesterase inhibitors, and N-methyl-D-aspartate (NMDA) receptor antagonists may be considered, particularly in patients with specific types of symptomatology, even less is known about their effectiveness and safety. Also, although various psychotropic medications used for behavioral disturbances in dementia patients may be somewhat effective, they have been increasingly associated with important safety risks.

Memantine in the treatment of Alzheimer’s disease

Memantine is a moderate-affinity glutamate antagonist that primarily takes action at the N-methyl-D-aspartate receptor site. It has US FDA and European Medicines Agency approval for the treatment of moderate-to-severe Alzheimer’s disease. Memantine replaces Mg2+ at the N-methyl-D-aspartate receptor, blocking pathological glutamate activity but allowing normal glutamate action at this site. Consequently, calcium homeostasis is better maintained, reducing slow after hyperpolarization and preventing neuronal excitotoxicity and cell death. Clinical trials have shown that memantine is generally safe and well tolerated, and have provided evidence for its efficacy as assessed by cognitive, behavioral, functional and global measures. It has also been shown to be well tolerated and effective in the treatment of moderate-to-severe Alzheimer’s disease when patients received previous and ongoing treatment with donepezil. The tolerability and efficacy of memantine is under continued investigation in milder Alzheimer’s disease and other forms of dementia.

Mortality in elderly dementia patients treated with risperidone

Agitation, aggression, and psychosis are among the most troublesome behavioral and psychological symptoms of dementia (BPSD) and impair the lives of dementia patients and their caregivers. Atypical antipsychotics have been widely prescribed to improve these BPSD. However, in a number of trials with atypical antipsychotics, a consistent increase in overall mortality has been observed. The US Food and Drug Administration issued a warning for all atypical antipsychotics as a result of a meta-analysis of 17 placebo-controlled clinical trials using various atypical antipsychotics for the treatment of BSPD. To evaluate this mortality risk specifically for risperidone, 6 phase-2/3 double-blind trials comparing risperidone with placebo were analyzed. Data were obtained from Johnson & Johnson Pharmaceutical Research and Development. Hazard ratios with 95% confidence intervals were calculated to compare the relative mortality risk between patients treated with risperidone and those treated with placebo. In this meta-analysis, 1721 patients were included. In the pooled sample, the mortality was 4.0% with risperidone versus 3.1% with placebo (relative risk, 1.21; 95% confidence interval, 0.71-2.06) during treatment or within 30 days after treatment discontinuation. The most common adverse events associated with death were pneumonia, cardiac failure or arrest, or cerebrovascular disorder. No relationship was found between risperidone dose and mortality. In conclusion, this meta-analysis found a nonsignificant increase in mortality during treatment with risperidone in dementia patients. Larger studies would be needed to rule out a small increase in mortality in these patients. Careful assessments of potential benefits and risks should be made before prescribing risperidone for the treatment of BPSD.

Risperidone for the treatment of neuropsychiatric features in dementia

Neuropsychiatric features of dementia are a common and significant burden on patients and their carers. Management usually involves a combination of pharmacological and non-pharmacological approaches. Antipsychotics are the cornerstone of treatment; among the atypical antipsychotics, risperidone is the most studied. Several trials have confirmed the efficacy of risperidone in the treatment of neuropsychiatric features in dementia, especially for agitation and psychosis. Recent concerns over an increased cerebrovascular adverse event profile and overall mortality with use of antipsychotics have emphasised the need for a risk-benefit analysis for individual demented patients being treated for neuropsychiatric features of their disease.

Treatment of dementia: anything new?

PURPOSE OF REVIEW

The aim of this article is to discuss new data on presently approved drugs for dementia, such as cholinesterase inhibitors and memantine, and concerns regarding the use of antipsychotics for treating neuropsychiatric symptoms, as well as to summarize some relevant studies recently published on emerging therapies with potential disease-modifying effects.

RECENT FINDINGS

The main focuses of recent studies of cholinesterase inhibitors and memantine have been on efficacy and safety aspects in extended clinical trials, combined treatments or comparative analysis between agents, and also on potential neuroprotective effects and new indications. Other publications have assessed the evidence of efficacy and the increased risk of cerebrovascular events, rapid cognitive decline, and mortality with the use of antipsychotics in dementia, providing important information in relation to the controversy surrounding its use. Although more studies are warranted, a sizable literature on novel treatment options under investigation is currently available as a result of a better understanding of pathogenesis of dementia.

SUMMARY

So far, there is no established method to predict better responders or long-term benefits with currently approved drugs for treatment of dementia. Recent systematic reviews and new research on current treatment, however, provide valuable information for clinicians, and novel drugs under investigation reveal promising new therapeutic strategies.

Antipsychotic medication dispensing and associated odds ratios of death in elderly veterans and war widows, 2001

OBJECTIVES

To explore the odds ratios (ORs) of death associated with antipsychotic (AP) medications dispensed to elderly subjects.

METHOD

Subjects were veterans and war widows 65 years and older dispensed an AP drug in 2001 in NSW or ACT. For all subjects, dispensing records for AP medication, benzodiazepines, lithium, carbamazepine, sodium valproate and antidepressant medication were extracted and combined with age, gender and date of death. A study date was allocated, either the date of death or a random date from 1.5.01 to 31.12.01. Subjects dispensed an AP in 2001, but not dispensed an AP or other psychotropic medication in the 120 days prior to their study date, formed a reference group. Psychotropic dispensing in the 120 days prior to the study date was analysed using nested logistic regression models to produce ORs of death associated with various AP drugs. The ORs for risperidone, olanzapine and pericyazine were compared. Haloperidol ORs were established for those dispensed the drug 0-30 days prior to study date or 31-120 days prior to the study date.

RESULTS

The ORs associated with haloperidol, olanzapine, risperidone, pericyazine, thioridazine and chlorpromazine were significant when compared with the reference group. Odds ratios for all three haloperidol periods were significant when compared with olanzapine, risperidone and pericyazine 120 day ORs. Although there was a trend favouring olanzapine when compared with risperidone, the difference in the ORs failed to reach significance (p=0.066).

CONCLUSIONS

Haloperidol is associated with significantly higher mortality rates than other AP medication but it is not clear whether this represents drug toxicity or the medical conditions for which it was dispensed. There was no evidence that the conventional AP pericyazine was associated with a higher mortality rate than olanzapine or risperidone.

Antipsychotics and risk of first-time hospitalization for myocardial infarction: a population-based case-control study

BACKGROUND

Use of antipsychotics has been linked with an adverse cardiovascular risk factor profile and an increased risk of dysrhythmia and sudden cardiac death. However, detailed data on the association between use of antipsychotics and development of atherosclerotic disease are limited.

OBJECTIVE

To examine risk of hospitalization for myocardial infarction (MI) amongst users of antipsychotics compared with non-users.

DESIGN AND SUBJECTS

A population-based case-control study using data from hospital discharge registries in the counties of North Jutland, Viborg and Aarhus, Denmark, and the Danish Civil Registration System. We identified 21,377 cases of first-time hospitalization for MI and 106,885 sex- and age-matched non-MI population controls in the period 1992-2004. All prescriptions for antipsychotics filled prior to the date of admission for MI were retrieved from population-based prescription databases. We used conditional logistic regression to adjust for a wide range of covariates.

RESULTS

Current users of atypical [adjusted relative risk: 0.98, 95% confidence interval (CI): 0.88-1.09] and typical antipsychotics (adjusted relative risk: 0.99, 95% CI: 0.96-1.03) had no increased overall risk of being admitted to hospital for MI when compared with non-users of antipsychotics. These findings were consistent in all examined subgroups. Further, we found no association between the cumulative dose of antipsychotics and the risk of hospitalization for MI.

CONCLUSION

These findings do not support the hypothesis that use of antipsychotics and in particular atypical antipsychotics is associated with increased risk of MI.

Outcomes of antipsychotic drug use in community-dwelling elders with dementia

This study used administrative data from a large health care insurer in the southeast United States to describe the utilization pattern and health care outcomes of antipsychotic drug use in community-dwelling elders with dementia. Claims data from 959 unique cases were analyzed to address research aims. Overall, 27% of the sample was dispensed antipsychotic drugs, with the most prevalent type being atypical antipsychotic drugs. Individuals on any type of antipsychotic drug experienced more delirium, depression, hip fracture, falls, and syncope than those not on these drugs, even after controlling for age, sex, comorbidity, and number of other drugs prescribed. Implications for practice are discussed.

Cerebrovascular disease and dementia

Cerebrovascular disease (CVD) is an important cause of psychiatric disability in the elderly. Much of this disability can be attributed to dementia and lesser degrees of cognitive impairment, which result from strokes and other forms of cerebrovascular pathology. While vascular dementia is common, estimates of its frequency vary due to its clinical and pathologic heterogeneity, the challenges involved in its measurement and its frequent co-occurrence with Alzheimer's disease. Nevertheless the clinical features and natural histories of vascular dementia can be described, and risk factors have been identified and include hypertension, diabetes mellitus, hyperlipidaemia, other conditions that promote atherosclerosis, and rare genetic mutations. While vascular dementia is not curable, treatments are available. For example, a few recent clinical trials suggest that cholinesterase inhibitors have some efficacy. Our knowledge of the risk factors has also provided opportunities for the primary and secondary prevention of vascular dementia, and indicates promising avenues for research.

Use of atypical antipsychotics in neurodegenerative diseases

Behavioral and psychotic disturbances are common symptoms in neurodegenerative disorders, and can lead to caregiver stress, nursing home placement and mortality. There is an expanding literature evaluating the effects of atypical antipsychotic (AA) drugs for treating these problems. The results in both primary dementias and Parkinson’s disease suggest that not all AA drugs are equal in terms of efficacy or safety. Furthermore, Parkinsonian and other side effects of the AAs are important to consider when evaluating outcomes. The recent US FDA warning of increased mortality has increased uncertainty in using these drugs. This article reviews the AAs and their use in Parkinson’s disease, dementia with Lewy bodies, Alzheimer’s disease and other associated dementias.

Neuroleptic drugs in dementia: benefits and harm

Neuroleptic (antipsychotic) drugs are often used to treat psychiatric symptoms frequently seen in dementia, but their use is controversial. We present a new meta-analysis to assess the efficacy of these drugs for the treatment of psychiatric symptoms in Alzheimer's disease, and discuss the more limited evidence for their potential benefits in other dementias. We recommend that these treatments be limited to the short-term treatment of psychiatric symptoms associated with serious distress or risk.

Personality disorders and medical comorbidity

PURPOSE OF REVIEW

Personality disorders are not usually thought of as being associated with medical comorbidity. Research shows that medical comorbidity in personality disorders is clinically important.

RECENT FINDINGS

In general those with personality disorders do not feel as fit as others do. Also, those with personality disorders in addition to other psychiatric disorders, such as depression and antisocial personality disorder, are likely to have more health problems than those without personality disorders. People with active borderline personality disorder have been shown to have more medical problems than those with remitted borderline personality disorder. Personality disorders can complicate the course of chronic medical illnesses. Finally, the use of psychotropic medications is not unusual in personality disorders and in itself can be associated with medical illnesses.

SUMMARY

Clinicians caring for people with personality disorders need to be aware of possible medical comorbidity. More research is needed.

Epidemiological impact of antidepressant and antipsychotic drugs on the general population

PURPOSE OF REVIEW

To analyse the prevalence of and sex and age distribution associated with antidepressant and antipsychotic drug exposure in the general population and to highlight recent epidemiological findings concerning specific adverse outcomes associated with drug exposure.

RECENT FINDINGS

Epidemiological studies indicate high rates of second-generation antidepressant and antipsychotic drug use in the general population. The use is more prevalent among women than among men, and in older rather than in younger age groups. A new pattern of adverse outcomes has been described in individuals exposed to newer agents, including a possible risk of suicidal acts in adults receiving second-generation antidepressants, the risk of cerebrovascular events in older individuals receiving second-generation antipsychotics and the risk of metabolic disturbances in individuals exposed to specific second-generation antipsychotics.

SUMMARY

The assessment of, and attention to, the development of specific adverse reactions in individuals exposed to second-generation psychotropic drugs may improve treatment outcomes.