Atypical antipsychotics in elderly patients with dementia or schizophrenia: review of recent literature

Histone deacetylase 1 regulates haloperidol-induced motor side effects in aged mice

BACKGROUND

Antipsychotic drugs prescribed to elderly patients with neuropsychiatric disorders often experience severe extrapyramidal side effects. Previous studies from our group suggest that changes in histone modifications during aging increase the risk for antipsychotic drug side effects, because co-administration of antipsychotics with class 1 histone deacetylase (HDAC) inhibitors could mitigate the severity of motor side effects in aged mice. However, which HDAC subtype contributes to the age-related sensitivity to antipsychotic drug side effects is unknown.

METHODS

In this study, we overexpressed histone deacetylase type 1(HDAC1) in the striatum of 3-month-old mice and knocked down HDAC 1 in the striatum of 21-month-old mice by microinjection of AAV9-HDAC1-GFP or AAV9-CRISPR/Cas9-HDAC1-GFP vectors. Four weeks after the viral-vector delivery, the typical antipsychotic drug haloperidol was administered daily for 14 days, followed by motor function assessments through the open field, rotarod, and catalepsy behavioral tests.

RESULTS

Young mice with overexpressed HDAC1 showed increased cataleptic behavior induced by haloperidol administration, which is associated with the increased HDAC1 level in the striatum. In contrast, aged mice with HDAC1 knocked down rescued locomotor activity, motor coordination, and decreased cataleptic behavior induced by haloperidol administration, which is associated with decreased HDAC1 level in the striatum.

CONCLUSIONS

Our results suggest that HDAC1 is a critical regulator in haloperidol-induced severe motor side effects in aged mice. Repression of HDAC1 expression in the striatum of aged mice could mitigate typical antipsychotic drug-induced motor side effects.

Does antipsychotic drug use increase the risk of long term mortality? A systematic review and meta-analysis of observational studies

Antipsychotics (AP) are widely used to treat schizophrenia and other psychiatric disorders. However, the association between the AP use and mortality risk is controversial. We searched PubMed, EMBASE, MEDLINE, PsycINFO, CINAHL, the Cochrane Library and four Chinese databases from inception to June 2016. All observational cohort or case–control studies reporting data on mortality outcomes in individuals exposed to AP drugs were included. This systematic review included 68 studies involving 4,812,370 participants. Sixty-seven studies reported confounding factors, the most common being age, sex, race, concomitant medications, and comorbidities. For all-cause mortality, current users of AP and conventional antipsychotics (CAP) had higher mortality risk than did non-AP users [AP users: RR, 1.50; 95% CI, 1.12 to 1.99; CAP users: RR, 1.53; 95% CI, 1.16 to 2.04]. However, the association between the current use of atypical antipsychotics (AAP) and the mortality was of borderline significance, and there was no significant difference for past users of AP. Mortality was higher in current CAP users than in current AAP users. For cardiac death and sudden death, current AP and CAP users also had higher mortality risk than non-AP users. A subgroup analysis showed a possible increased risk in patients with Parkinson’s, but not in those with dementia, Alzheimer’s disease, schizophrenia, delirium or stroke. An increased risk of all-cause mortality for patients ≧65 years may also exist. AP exposure is associated with an approximately 1.5-fold increased mortality risk. This increased risk may be particularly prominent in patients with Parkinson’s and those over 65 years old. Further studies are required to evaluate the mortality risk for individual AP drugs and diseases.

Informed consent in dental care and research for the older adult population: A systematic review

BACKGROUND

Ethics in health care and research is based on the fundamental principle of informed consent. However, informed consent in geriatric dentistry is not well documented. Poor health, cognitive decline, and the passive nature of many geriatric patients complicate this issue.

METHODS

The authors completed this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The authors searched the PubMed (MEDLINE), Web of Science, PsycINFO, and Cochrane Library databases. The authors included studies if they involved participants 65 years or older and discussed topics related to informed consent beyond obtaining consent for health care. The authors explored informed consent issues in dentistry and other biomedical care and research.

RESULTS

The authors included 80 full-text articles on the basis of the inclusion criteria. Of these studies, 33 were conducted in the United States, 29 addressed consent issues in patients with cognitive impairment, 29 were conducted in patients with medical conditions, and only 3 involved consent related to dental care or research.

CONCLUSIONS

Informed consent is a neglected topic in geriatric dental care and research. Substantial knowledge gaps exist between the understanding and implementation of consent procedures. Additional research in this area could help address contemporary consent issues typically encountered by dental practitioners and to increase active participation from the geriatric population in dental care and research.

PRACTICAL IMPLICATIONS

This review is the first attempt, to the authors' knowledge, to identify informed consent issues comprehensively in geriatric dentistry. There is limited information in the informed consent literature covering key concepts applicable to geriatric dentistry. Addressing these gaps could assist dental health care professionals in managing complex ethical issues associated with geriatric dental patients.

Antipsychotic Use and Risk of Nursing Home Admission Among Dual-Eligible Medicare Beneficiaries: A Propensity-Matched Study

Background

Objective

Methods

Results

Conclusion

Yokukansan (TJ-54) for treatment of very-late-onset schizophrenia-like psychosis: an open-label study

BACKGROUND

Although schizophrenia affects all age groups, late or very-late-onset schizophrenia-like psychosis has not been well studied, and various treatment issues remain unresolved. The objective of the present study was to evaluate the efficacy and safety of yokukansan (TJ-54), Japanese herbal medicine, monotherapy in a diagnostically homogenous group of elderly patients without cognitive impairment suffering from very-late-onset schizophrenia.

METHODS

Forty patients of mean age 73.1±4.8 years, fulfilling both the recent consensus criteria for very late-onset schizophrenia-like psychosis and the DSM-IV-TR criteria for schizophrenia, were assessed by the brief psychiatric rating scale, the clinical global impression scale-severity, and positive and negative syndrome scale at baseline and after 4 weeks administration of TJ-54 (2.5-7.5 g/day). In addition, abnormal movements were evaluated with the Simpson-Angus scale, Barnes Akathisia scale, and abnormal involuntary movement scale.

RESULTS

A highly significant (p<0.001) improvement on all measures of psychotic symptomatology was observed in all patients. TJ-54 was very well tolerated by the patients, and no clinically significant adverse effects were observed. Scores on all abnormal movement scales did not differ significantly prior to and after TJ-54 treatment.

CONCLUSION

Preliminary results indicate that TJ-54 appears to be an efficacious and safe herbal medicine for treatment of very-late-onset schizophrenia-like psychosis.

Risk of death in dual-eligible nursing home residents using typical or atypical antipsychotic agents

BACKGROUND

Antipsychotic use among dual-eligible nursing home residents is a concern for cost and safety considerations.

OBJECTIVE

To examine the comparative risk of death in dual-eligible elderly nursing home residents using typical and atypical agents.

METHODS

A retrospective cohort design matched on propensity score was used to examine the risk of death due to antipsychotic use among dual-eligible nursing home residents 65 years or older from four states. New typical and atypical users in nursing homes were followed for 6 months after the exposure without any censoring. The risk of death was modeled using the Cox proportional model and the extended Cox hazard model stratified on matched pairs based on propensity score.

RESULTS

The unadjusted mortality rate was 18.42% for atypical antipsychotic users and 24.06% for typical antipsychotic users. The Cox proportional-hazards regression model revealed significant increased risk of death [hazard ratio (HR), 1.41; 95% confidence interval (CI), 1.27-1.57] among typical users when compared with atypical users. The extended Cox model, used due to the violation of proportional hazards assumption, revealed that risk of death was nearly twice as great among typical antipsychotic users within 40 days of antipsychotic treatment (HR, 1.81; 95% CI, 1.49-2.18) when compared with atypical users. However, moderate increase in risk (HR, 1.24; 95% CI, 1.09-1.42] was observed for 40-180 days of typical antipsychotic exposure.

CONCLUSIONS

The use of typical antipsychotic agents was associated with highest risk of all-cause mortality within 40 days of typical antipsychotic use when compared with atypical use, and the risk decreased after 40 days among dual-eligible elderly nursing home residents.

Plasma clozapine and norclozapine in relation to prescribed dose and other factors in patients aged 65 years and over: data from a therapeutic drug monitoring service, 1996-2010

OBJECTIVE

To investigate the effect of dose and other factors on plasma clozapine concentrations in patients aged 65 years and over.

METHOD

Audit of clozapine therapeutic drug monitoring data, 1996-2010.

RESULTS

There were 1930 samples [778 patients, 363 men aged (median, range) 67 (65-100) years and 415 women aged 68 (65-90) years]. There was no significant difference in the mean plasma clozapine concentration between men (0.56 mg/l) and women (0.58 mg/l), although the mean dose was higher in men (323 mg/d) than women (264 mg/d). The higher proportion of men (46%) compared with women (37%) smokers could explain this finding. Overall, 32% of samples had plasma clozapine below, and 37% above, a target range of 0.35-0.60 mg/l. Overall, the median dose decreased from 300 (65-70 years) to 200 mg/d (age 85 years and over). However, prescription of >350 mg/d was associated with a 50% likelihood that the plasma clozapine would exceed 0.60 mg/l. For a subgroup of 196 patients (114 men, 82 women), mean plasma clozapine was significantly higher after age 65 despite significantly lower dosage.

CONCLUSION

Clozapine dosage in elderly patients should be reviewed regularly to minimise the risk of adverse effects.

Health management of older persons with chronically medicated psychotic disorders: the results of a survey in France

BACKGROUND

The medical care of elderly patients with psychotic disorders is a matter of major concern. The aim of the study was to investigate health conditions and treatment of elderly patients with psychotic disorders in France.

METHODS

The SAGE (Schizophrenia AGEd) study (observational, cross-sectional) was a survey conducted among 123 physicians in France, regarding prescriptions of antipsychotic drugs in elderly patients (≥60 years) suffering from psychotic disorders. The survey was based on a questionnaire addressing the mental and somatic health management of the patients.

RESULTS

Data from 930 patients (mean age: 70.4 years) were collected. Most patients (58.5%) suffered from schizophrenia, 20.8% had delusional disorder and 20.6% hallucinatory chronic psychosis (very-late-onset schizophrenia-like psychosis). 70.8% of them were outpatients, while 29.2% were inpatients. The severity of psychotic symptoms was assessed in 97.8% of patients, but cognitive function was only evaluated in 41.6%. Some 46.5% of patients were treated with atypical antipsychotics alone, 36.2% with classical antipsychotics alone and 17.3% received a combination of both, atypical and classical antipsychotics; 36.3% patients were given antiparkinsonian medication, of whom only 17.8% as preventive treatment; 51.1% of patients had somatic comorbidities, particularly cardiovascular disorders (34.0%). Evaluation of renal and/or liver function to adjust the dose of treatment was done in only 32.1% of patients. Over the previous 12 months, almost half of the patients had had no ECG, glycemia or creatininemia investigated and HDL-cholesterol and triglycerides were available for less than one-third of them.

CONCLUSIONS

Antipsychotic and antiparkinsonian drug prescriptions in French aged psychotic patients follow only partially the clinical guidelines and recommendations of consensus conferences. Moreover, cognitive, cardiac and metabolic aspects are not fully managed as expected.

Are atypical antipsychotics safer than typical antipsychotics for treating behavioral and psychological symptoms of dementia?

Atypical antipsychotics seem to be preferable than conventional agents in treating psychological symptoms of dementia (BPSD), because they have substantially lower risks of extrapyramidal neurological effects with lower reported rates of parkinsonism and tardive dyskinesia. However, in the course of time, with the increase in their use, more and more side effects have been reported. The benefits and risks of antipsychotic treatment should be carefully evaluated according to the co-morbidity and the severity of the psychological and behavioral symptoms and their impact on the individual elderly patient. It is recommended to keep those medications in the lower range of therapeutic doses. Due to the complexity of the individual patient, no guidelines have been yet established. Therefore, clinical judgment should be used in applying the dose and the type of those drugs.

Cyproterone to treat aggressivity in dementia: a clinical case and systematic review

Aggressivity is a common problem in the management of elderly patients with dementia. Medications currently used to diminish aggressive behaviour in dementia can have problematic side effects. We present a case and systematic review of the current knowledge about the use of cyproterone acetate to treat aggressivity (excluding hypersexuality related behaviours) in dementia. An 82-year-old man required psychiatric inpatient admission due to agitation and aggressivity and was diagnosed with Alzheimer's disease. After failed trials of atypical antipsychotics (quetiapine 100 mg/day and risperidone 1 mg/day), drugs for dementia (memantine 20 mg/day and rivastigmine 9 mg/day) and benzodiazepines (lorazepam 0.5-1 mg prn) he was started on cyproterone acetate titrated up to 50 mg twice daily. After two weeks he was calmer and did not express aggressivity. Two months later he was discharged to a community placement where he subsequently remained settled on cyproterone. We reviewed literature on the use of cyproterone in aggressivity (excluding hypersexuality) associated with dementia. We searched the main medical databases including articles in English, Spanish, French and Italian. Only one randomized double-blind trial was found, comparing cyproterone with haloperidol (n = 27). Cyproterone was more effective controlling aggressivity and had lower incidence of side effects. In the one uncontrolled naturalistic observational study identified (n = 19), cyproterone was associated with significant reductions in aggressivity without causing major side effects. Further literature was limited to theoretical discussions. Despite there being evidence to support our observations of a useful role for cyproterone in aggressivity in dementia, further studies are needed to establish the efficacy and safety of this therapeutic option.

Predictors of adherence to atypical antipsychotics (risperidone or olanzapine) in older patients with schizophrenia: an open study of 3(1/2) years duration

OBJECTIVE

Although the evidence base for the use of antipsychotics in older people with schizophrenia is generally of low quality, it tends to support the use of atypical antipsychotics. Only limited information regarding longer term adherence to these apparently more effective drugs is available. The aim of this study was to determine predictors of adherence to risperidone or olanzapine in patients over 60.

METHODS

Patients receiving care from old age psychiatrists for their schizophrenia were randomised to treatment with olanzapine or risperidone and were followed for up to 3(1/2) years. Kaplan-Meier curves were generated to assess the univariate effect of randomisation drug on long-term adherence and Cox regression adjusted for baseline variables which may have affected adherence.

RESULTS

In total, 60.6% of the 66 patients in the study were still taking their randomised drug by the end of the interval in which they remained under observation (64.7% olanzapine and 56.3% risperidone). This difference was non-significant. No baseline variable was associated with an increased risk of non-adherence, though the delivery form of pre-randomisation drug (oral or depot) was weakly (p = 0.054) associated with patients originally on depot being less likely to be adherent to an atypical drug.

CONCLUSIONS

Overall adherence with atypical medication was good with almost two-thirds of the patients remaining on their randomisation drug for the interval in which they were under observation. Patients taken off depot were less likely to be adherent but there was no significant difference in adherence between olanzapine and risperidone. Scrutiny of the survival curves suggested that non-adherence is an early event in treatment and patients adherent at 6 months were likely to remain adherent over a longer time period.

Psychotropic medication use among older adults: what all nurses need to know

Psychotropic medications are commonly administered to elderly clients to manage behavior and psychiatric symptoms. These drugs are known to have potentially serious side effects, to which older adults are more vulnerable. Nurses care for older adults in many different practice settings but have varying degrees of knowledge about these kinds of medications. The purposes of this article are to (a) provide information to geriatric nurses in all settings about how the most commonly prescribed psychotropic medications (i.e., anxiolytic, antidepressant, and antipsychotic drugs) differentially affect older adults; (b) examine recent concerns about the use of psychotropic medications with older adults; and (c) discuss nursing implications for those administering psychotropic medications to older adults.

Sensitivity to antipsychotic drugs in older adults

Antipsychotic medications are widely used to manage psychotic and behavioral disorders in older adults, including primary psychotic disorders such as schizophrenia, and psychosis and behavioral disturbances associated with dementia. These two broad diagnostic indications are associated with contrasting recommended treatment durations, with the former requiring indefinite treatment across the life span. Antipsychotic drug dosing for schizophrenia is based primarily on studies of younger patients and thus may not apply to older adults. It is critically important to address the effects of aging on antipsychotic dosing given the recent emergence of data that suggest a critical role for age-related sensitivity to these drugs. Antipsychotic drugs are not only associated with somatic and neurological adverse effects but also increased all-cause mortality and sudden cardiac death in this vulnerable population. This review focuses on the sensitivity of older adults to adverse effects from antipsychotic medications and the current pharmacokinetic and pharmacodynamic explanatory models of susceptibility. Implications of recent research findings for individualized pharmacotherapy are discussed.

Dosing of antipsychotics in schizophrenia across the life-spectrum

Age effects on dosing of antipsychotics in schizophrenia and mechanisms underlying those effects have not been well understood. The objective of this article is to review the literature regarding effects of age on antipsychotic dosing in schizophrenia and potential mechanisms underlying the age-related antipsychotic sensitivity. According to prescription surveys, age appears to have biphasic effects on prescribed antipsychotic dose. The dose increased with age through the third decade, subsequently plateaued, and decreased after the fifth decade. The first half of this inverted U-shaped relationship may be attributable to a deterioration process in the early phase of schizophrenia and the contribution of 'tachyphylaxis' of antipsychotics on the dopaminergic system. The following age-related decline in prescribed dose is likely associated with physiological aging. Recent data suggest that this increased antipsychotic sensitivity with age comes from age-related functional decline in the dopaminergic system, including endogenous dopamine level and dopamine receptor density. Although the evidence on potential mechanisms underlying age effects on antipsychotic dosing is still limited, alterations in the dopaminergic system due to aging and chronic exposure to this drug may contribute to the inverted U-shaped relationship between dose and age. This age-related antipsychotic sensitivity highlights the importance of finding the lowest possible effective dose of antipsychotic drugs as patients age to enhance therapeutic effects as well as minimize their side effects.

Amisulpride doses and plasma levels in different age groups of patients with schizophrenia or schizoaffective disorder

Because of a unique pharmacodynamic profile, amisulpride seems appropriate for treatment of elderly patients with schizophrenia. In a large-scale naturalistic therapeutic drug monitoring study, daily amisulpride dose, trough and dose-corrected amisulpride plasma levels, co-medication, clinical effectiveness (CGI) and side effects (UKU) were compared between age groups in 395 patients with schizophrenia or schizoaffective disorder (46% women; mean age 39.1 +/- 14.2 years, range 18-83 years) under amisulpride therapy. Mean amisulpride doses (574 +/- 269 mg/day), plasma levels (304 +/- 274 ng/mL), dose-corrected amisulpride plasma levels (C/D ratios, 0.52 +/- 0.41 ng/mL:mg), clinical response (at least moderate improvement, 71.6%), and side effects (any side effect, 32.2%; extrapyramidal symptoms, 14.9%) were comparable between age groups (P > 0.25). At higher age, significantly more benzodiazepines (P = 0.04), non-benzodiazepine hypnotics (P = 0.004) and non-psychotropic medications (P < 0.0001) were prescribed. The naturalistic study showed higher C/D ratios in women (P = 0.019) and a slight increase of C/D ratios with age (P = 0.026), but no substantial age-dependent effects on amisulpride doses or plasma levels. In patients above 60 years, clinical response was associated with lower amisulpride plasma levels (P = 0.016) at comparable doses. Neither the age-dependent decrease of amisulpride clearance nor the significantly higher prevalence of co-morbidity and co-medication seem to be the reasons for definite clinical concerns against amisulpride treatment of elderly if contraindications are seriously taken.

Amisulpride for the treatment of very-late-onset schizophrenia-like psychosis

BACKGROUND

Although schizophrenia affects all age groups, late or very-late-onset schizophrenia-like psychosis has not been well studied and various treatment issues remain unresolved. The objective of the present study was to evaluate the efficacy and safety of amisulpride monotherapy in a diagnostically homogeneous group of elderly patients without cognitive impairment suffering from very-late-onset schizophrenia.

METHODS

Twenty-six patients of mean age 76.2 +/- 5.8 years, fulfilling both the recent consensus criteria for very late-onset schizophrenia-like psychosis and the DSM-IV-TR criteria for schizophrenia, were assessed by the Brief Psychiatric Rating Scale, the Clinical Global Impression Scale and the Positive and Negative Syndrome Scale at baseline and five weeks following amisulpride (50-200 mg/day) administration; also, the presence of abnormal movements was evaluated with the Simpson-Angus Scale, the Barnes Akathisia Scale, and the Abnormal Involuntary Movement Scale.

RESULTS

A highly significant (p < 0.001) improvement on all measures of psychotic symptomatology was observed in all patients. Amisulpride was very well tolerated by the patients and no clinically significant adverse effects were observed. Scores on all abnormal movement scales did not differ significantly prior to and after amisulpride treatment.

CONCLUSION

Preliminary results indicate that amisulpride appears to be an efficacious and safe atypical antipsychotic for the treatment of very-late-onset schizophrenia-like psychosis.

Combination therapy with amisulpride and antidepressants: clinical observations in case series of elderly patients with psychotic depression

Psychotic depression is classified as a clinical subtype of major depressive disorder. The combination of an antidepressant with an antipsychotic agent has been demonstrated to be efficacious for the treatment of psychotic depression. However, in elderly patients with psychotic depression, little information is available on the efficacy of such combinations. Therefore, we have evaluated combination treatment for 5 weeks with amisulpride and antidepressants in non-demented elderly patients with psychotic depression. Eleven patients were treated with either citalopram 20-40 mg/day (n=5) or mirtazapine 30-60 mg/day (n=6), and amisulpride 75-100 mg/day for 5 weeks. Clinical status was evaluated at baseline and after 3 and 5 weeks using the Brief Psychiatric Rating Scale (BPRS), the Hamilton Depression Rating Scale--17 items (HDRS) and the Clinical Global Impression Scale (CGI-S). In 5 of the 11 patients there was remission of depression, while in another 5 patients there was partial remission of depression and in one patient there was no remission. Finally, there was resolution of psychotic symptoms in all the patients involved. One patient developed tremor and rigidity but insisted on continuing with the drug since her psychopathology has improved considerably after the addition of amisulpride to antidepressant treatment. In conclusion, some of the elderly patients with psychotic depression may benefit from the combination of amisulpride and antidepressant pharmacotherapy.

Safety and tolerability of oral paliperidone extended-release tablets in elderly patients with schizophrenia: a double-blind, placebo-controlled study with six-month open-label extension

OBJECTIVE

The objective of this multicenter, international study was to evaluate safety and tolerability of paliperidone extended-release (ER) tablets in elderly (age > or =65 years) patients with schizophrenia. The authors conducted a 6-week, double-blind, randomized, placebo-controlled, optional 24-week open-label extension study. Interventions consisted of flexible, once-daily doses of paliperidone ER (3-12 mg/day; 6-mg starting dose, adjusted in 3-mg dose increments) or placebo (2:1) during double-blind treatment and paliperidone ER only during open-label treatment. Measurements included adverse events, laboratory tests, physical examinations, 12-lead electrocardiograms, movement disorder rating scales, Positive and Negative Syndrome Scale, and Clinical Global Impression scale. The study was not powered to show statistical differences.

RESULTS

Patients (N = 114) were predominantly female (73%); mean age was 70 years (double-blind phase). Concomitant disease presence was consistent with that of an older population. During the double-blind phase, discontinuation rates resulting from adverse events were similar between groups (paliperidone ER: 7%, placebo: 8%) as were incidences of treatment-emergent adverse events (paliperidone ER: 67%, placebo: 71%). Serious adverse events occurred in 3% of the paliperidone ER- and 8% of the placebo-treated patients. Elevated prolactin levels occurred in approximately one half of patients. No prolactin- or glucose treatment-related adverse events or noteworthy mean changes in body weight (0 kg [standard deviation: 2.1] and 0 kg [standard deviation: 2.3] for paliperidone ER and placebo, respectively) were observed. Safety and tolerability results in the extension were consistent with the shorter-term results. Efficacy measures did not show consistent statistical improvement between treatment groups.

CONCLUSION

Paliperidone ER (3-12 mg/day) treatment over a 30-week period was generally well-tolerated and may improve symptom severity in elderly patients with schizophrenia.

Minimizing antipsychotic medication obviated the need for enema against severe constipation leading to paralytic ileus: a case report

OBJECTIVE

To report the usefulness of antipsychotic dose-reduction for avoiding paralytic ileus in a patient with chronic schizophrenia and comorbid dementia.

CASE SUMMARY

A 65-year-old in-patient developed severe paralytic ileus warranting a transfer to the general hospital. Constipation was very troublesome and he often needed enema to prevent intestinal obstruction. He had originally been treated with 24 mg of bromperidol, which was reduced to 4 mg, and other psychotropic treatments were simultaneously simplified. As a result, bowel habits improved and enema is now only rarely necessary. Constipation is a frequent adverse effect of antipsychotics and adjunctive psychotropics, which can be severe and may lead to life-threatening paralytic ileus. Dose-reduction obviated a necessity of enema against persistent constipation, while the patient's mental status remained under control. Assessment using the Naranjo probability scale revealed a definite causal relationship.

DISCUSSION

With an increasing number of elderly patients with schizophrenia, more cases of severe gastrointestinal motility problems from antipsychotic medication are to be expected. In this patient population dose-reduction of antipsychotics and simplification of concomitant psychotropics should be seriously considered.

Long-term safety and efficacy of long-acting risperidone in elderly psychotic patients

This subgroup analysis of the 6-month, open-label Switch to Risperidone Microspheres (StoRMi) trial evaluated long-term safety and efficacy of a direct conversion to risperidone long-acting injectable (RLAI) in 52 elderly patients (> or =65 years) with psychosis stabilized on oral or depot antipsychotic. Study outcomes included adverse events, movement disorder severity, psychiatric symptoms, functional ability, quality of life and patient satisfaction. Change in the Positive and Negative Syndrome Scale at endpoint was the primary efficacy measure. The most common dosage of RLAI used at endpoint was 25 mg every 14 days (60%). The trial was completed by 81% of patients, with six patients discontinuing treatment due to an adverse event. Tolerability was good and most side effects were mild to moderate. Serious adverse events occurred in 11 patients. Two of these (suicidal attempt, n = 1; exacerbation of disease, n = 1) were considered possibly related to RLAI. Conversion to RLAI resulted in significant improvements in movement disorder severity, psychiatric symptoms, functional status and patient satisfaction. Mean PANSS total decreased by 15.8 at endpoint, with 23 patients (46.9%) experiencing a > or =20% improvement. This post-hoc analysis supports that RLAI is well tolerated and safe in elderly patients with psychotic illnesses switched from stable antipsychotic regimens, and suggests possible efficacy, although inferences are limited.

Comparison of risk of cerebrovascular events in an elderly VA population with dementia between antipsychotic and nonantipsychotic users

INTRODUCTION

The credibility of an increased risk of cerebrovascular events (CVEs) in elderly patients with dementia being treated with second-generation antipsychotics (SGAs) is debatable. Although early published and unpublished data indicated a risk, much of the subsequent literature has not supported this initial finding. Previously published studies were flawed in part because they lacked a control group and did not stratify by dementia subtype. This study examined the risk of a CVE in patients diagnosed with Alzheimer or vascular dementia while being treated with SGA, first-generation antipsychotics, or no antipsychotic medication.

METHODS

Data from 14,029 patients aged 65 years and older were evaluated using patient information from Veterans Administration and Medicare databases. Patients who received care for dementia were categorized according to dementia subtype (vascular or Alzheimer) and antipsychotic use during an 18-month period. Patients were observed until they were admitted to a hospital for a CVE, stopped taking or switched antipsychotics, died, or until the 18-month observation period ended.

RESULTS

Overall, CVE risk did not differ whether patients were receiving a first-generation antipsychotic, SGA, or no antipsychotic therapy. However, patients with vascular dementia had an increased risk in hospitalization for a CVE. There was no increase in risk of a CVE for patients treated with quetiapine, olanzapine, or risperidone relative to haloperidol, or for patients receiving olanzapine or risperidone relative to quetiapine. Stratified subgroup analyses demonstrated no difference in risk for CVE-related admission patients with Alzheimer dementia among individual agents. However, patients with vascular dementia receiving risperidone, but not olanzapine or quetiapine, were found to be at decreased risk for CVE admission relative to haloperidol.

CONCLUSIONS

This study found no increase in overall risk for CVE-related hospital admission in patients treated with antipsychotic medications.

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.