The efficacy and safety of risperidone for the treatment of geriatric psychosis

Quetiapine in the elderly with parkinsonism and psychosis

In the present open prospective study the effects of quetiapine were investigated in two elderly patients with parkinsonism and psychosis. Treatment induced a marked antipsychotic effect that coincided with an improvement of general motor functioning. These findings support the idea that quetiapine may be preferentially of use in the elderly with parkinson’s disease and psychotic symptoms.

Use of first- and second-generation antipsychotic medications in older patients with schizophrenia in Asia (2001-2009)

OBJECTIVE

This study examined the prescribing patterns of several first- (FGAs) and second-generation antipsychotic (SGAs) medications administered to older Asian patients with schizophrenia during the period between 2001 and 2009.

METHOD

Information on hospitalized patients with schizophrenia aged 65 or older was extracted from the database of the Research on Asian Psychotropic Prescription Patterns (REAP) study (2001-2009). There were no older patients in Thailand, therefore data on 467 patients in eight Asian countries and territories including China, Hong Kong SAR, India, Japan, Korea, Malaysia, Singapore, and Taiwan were analysed. Cross-sectional socio-demographic data, clinical characteristics and antipsychotic prescriptions were assessed using a standardized protocol and data collection procedure.

RESULTS

Of the 467 patients, 192 patients (41.1%) received FGAs only, 166 (35.5%) received SGAs only and 109 (23.3%) received a combination of FGAs and SGAs. Of the FGAs, haloperidol was the most commonly used (31.3%; mean 9.4 ± 6.7 mg/day), followed by chlorpromazine (15.4%; mean 126.4 ± 156.4 mg/day) and sulpiride (6.6%; mean 375.0 ± 287.0 mg/day). Of the SGAs, risperidone was the most commonly used (31.5%; mean 4.5 ± 2.7 mg/day), followed by olanzapine (13.1%; mean 13.6 ± 6.5 mg/day), quetiapine (7.3%; mean 325.0 ± 237.3 mg/day) and aripiprazole (1.9%; mean 17.6 ± 7.7 mg/day).

CONCLUSIONS

FGAs and higher doses of certain SGAs (risperidone, olanzapine and quetiapine) were still commonly dispensed to older Asian patients with schizophrenia. Considering older patients' reduced tolerability of potentially severe side effects associated with FGAs and higher doses of certain SGAs, continuing education and training addressing the rational use of antipsychotics in this population is clearly needed.

Elderly patients with schizophrenia and depression: diagnosis and treatment

BACKGROUND

The treatment of older patients with schizophrenia and depressive symptoms poses many challenges for clinicians. Current classifications of depressive symptoms in patients with schizophrenia include: Major Depressive Episodes that occur in patients with schizophrenia and are not classified as schizoaffective disorder, Schizoaffective Disorder, and Schizophrenia with subsyndromal depression in which depressive symptoms do not meet criteria for Major Depression. Research indicates that the presence of any of these depressive symptoms negatively impacts the lives of patients suffering from schizophrenia-spectrum disorders.

PURPOSE

The purpose of this paper is to review the literature related to older patients with schizophrenia-spectrum disorders and co-occurring depressive symptoms, and to guide mental health professionals to better understand the diagnosis and treatment of depressive symptoms in patients with schizophrenia.

CONCLUSIONS

The treatment of elderly patients with schizophrenia and depressive symptoms includes first reassessing the diagnosis to make sure symptoms are not due to a comorbid condition, metabolic problems or medications. If these are ruled out, pharmacological agents in combination with psychosocial interventions are important treatments for older patients with schizophrenia and depressive symptoms. A careful assessment of each patient is needed in order to determine which antipsychotic would be optimal for their care; second-generation antipsychotics are the most commonly used antipsychotics. Augmentation with an antidepressant medication can be helpful for the elderly patient with schizophrenia and depressive symptoms. More research with pharmacologic and psychosocial interventions is needed, however, to better understand how to treat this population of elderly patients.

Co-occurring depressive symptoms in the older patient with schizophrenia

Clinicians treating older patients with schizophrenia are often challenged by patients presenting with both depressive and psychotic features. The presence of co-morbid depression impacts negatively on quality of life, functioning, overall psychopathology and the severity of co-morbid medical conditions. Depressive symptoms in patients with schizophrenia include major depressive episodes (MDEs) that do not meet criteria for schizoaffective disorder, MDEs that occur in the context of schizoaffective disorder and subthreshold depressive symptoms that do not meet criteria for MDE. Pharmacological treatment of patients with schizophrenia and depression involves augmenting antipsychotic medications with antidepressants. Recent surveys suggest that clinicians prescribe antidepressants to 30% of inpatients and 43% of outpatients with schizophrenia and depression at all ages. Recent trials addressing the efficacy of this practice have evaluated selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, fluvoxamine and citalopram. These trials have included only a small number of subjects and few older subjects participated; furthermore, the efficacy results have been mixed. Although no published controlled psychotherapeutic studies have specifically targeted major depression or depressive symptoms in older patients with schizophrenia, psychosocial interventions likely play a role in any comprehensive management plan in this population of patients.Our recommendations for treating the older patient with schizophrenia and major depression involve a stepwise approach. First, a careful diagnostic assessment to rule out medical or medication causes is important as well as checking whether patients are adherent to treatments. Clinicians should also consider switching patients to an atypical antipsychotic if they are not taking one already. In addition, dose optimization needs to be targeted towards depressive as well as positive and negative psychotic symptoms. If major depression persists, adding an SSRI is a reasonable next step; one needs to start with a low dose and then cautiously titrate upward to reduce depressive symptoms. If remission is not achieved after an adequate treatment duration (8-12 weeks) or with an adequate dose (similar to that used for major depression without schizophrenia), switching to another agent or adding augmenting therapy is recommended.We recommend treating an acute first episode of depression for at least 6-9 months and consideration of longer treatment for patients with residual symptoms, very severe or highly co-morbid major depression, ongoing episodes or recurrent episodes. Psychosocial interventions aimed at improving adherence, quality of life and function are also recommended. For patients with schizophrenia and subsyndromal depression, a similar approach is recommended.Psychosis accompanying major depression in patients without schizophrenia is common in elderly patients and is considered a primary mood disorder; for these reasons, it is an important syndrome to consider in the differential diagnosis of older patients with mood and thought disturbance. Treatment for this condition has involved electroconvulsive therapy (ECT) as well as combinations of antidepressant and antipsychotic medications. Recent evidence suggests that combination treatment may not be any more effective than antidepressant treatment alone and ECT may be more efficacious overall.

Chinese demented inpatients admitted following a suicide attempt: a case series

OBJECTIVE

Suicide attempt is rarely reported in dementia. This study explores the clinical and phenomenological aspects as well as the treatment of Chinese demented patients who have attempted suicide.

METHODS

During a 1-year period, demented patients admitted to a geropsychiatric unit as a result of suicide attempt were investigated for factors related to suicide attempt, such as motives and method.

RESULTS

In this 1-year survey, seven demented patients (11.7% of all demented patients) were admitted immediately following a suicide attempt. All seven patients had mild or moderate dementia. Three had significant clinical depression symptoms on admission. In all patients, delusions were the primary cause of suicide attempt. Their suicidal ideations were improved with antipsychotic and antidepressant treatment.

CONCLUSION

These cases, taken together, suggest that suicide attempt can occur in patients with dementia. It is important for clinicians to be aware of the risk of suicide in patients with dementia, especially those associated with delusions, even if they have no major depression or suicide attempt history. Antidepressants and antipsychotics may play a critical role in the treatment of suicide attempt in dementia.

Cardiovascular risks of atypical antipsychotic drug treatment

Atypical antipsychotics are the treatment of choice for patients with schizophrenia. They are generally better tolerated than conventional antipsychotics since most do not cause debilitating extrapyramidal symptoms. They are associated though with an array of cardiovascular adverse events that may affect morbid-mortality of schizophrenic patients. Orthostatic hypotension, electrocardiographic changes and metabolic syndrome (MS) are the main cardiovascular effects of atypical antipsychotics. They contribute to the overall disease burden associated with schizophrenia even though the benefit risk of such treatments still is highly favourable. We aim to review the main cardiovascular side effects of new atypical oral antipsychotics, the pharmacological mechanisms involved, and to which drugs they are particularly attributed.

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

Atypical antipsychotics have become a common pharmacologic option for the treatment of various psychiatric and behavioral symptoms in older adults, although these medications have been officially approved by the U.S. Food and Drug Administration for use only in schizophrenia and bipolar disorder. Despite the widespread use of these agents, there is a relative shortage of rigorously conducted trials. This review focuses on recently published randomized, blinded, controlled trials involving the use of atypical antipsychotics in elderly patients with dementia (n = 9) or schizophrenia (n = 3), with some discussion of published large, open-label studies and a few unpublished controlled trials. In general, the studies of patients with dementia reported modest efficacy of atypical antipsychotics when compared to placebo and conventional antipsychotics. In addition, an advantage in terms of motor side effects was consistently noted with atypical antipsychotics when compared to conventional antipsychotics. The studies have also shown, however, a greater risk of mortality and adverse cerebrovascular events with several of these agents than with placebo in individuals with dementia. There are insufficient data comparing atypical antipsychotics to one another. In the trials involving elderly persons with schizophrenia, atypical antipsychotics were associated with significant improvements in psychopathology; differences in efficacy among atypical antipsychotics were unclear. A careful consideration of the risk-benefit ratio of atypical antipsychotics, as well as that of available alternative treatments, is needed for each individual elderly patient. Clinical judgment, caution, and consent should be the watchwords in this area of psychopharmacology.

The efficacy and safety of quetiapine for treatment of geriatric psychosis

Quetiapine, an atypical antipsychotic, is effective for psychosis in younger patients, with limited adverse effects reported. This open-label naturalistic study was conducted to assess the 4-week efficacy and safety of quetiapine for treatment of geriatric psychosis. Clinical efficacy was evaluated using the Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression Improvement (CGI-I) instruments before and after 4 weeks of quetiapine treatment. The sample population consisted of 100 geropsychiatric inpatients with psychosis, with the therapeutic evaluation completed by 91. Eighty-one of these 91 patients (89.0%) experienced mild-to-substantial improvement, as determined from the CGI-I. Further, a mean reduction in BPRS score of 39.5% (from baseline) was also determined. The mean daily dose of quetiapine for the fourth week was 276.1 177.2mg/day (range 50-800). Higher quetiapine dosages were administered for patients with functional psychoses compared to an analogous group with organic mental disorders. The most common adverse effects were somnolence (30.0%), lower-limb weakness (28.0%) and dizziness (27.0%). Body weight and fasting triglyceride were significantly elevated after quetiapine treatment (2.2% and 8.9% from baseline, respectively). Based on the results of this study, it appears that quetiapine is an efficacious and safe treatment for geriatric inpatients with psychosis, however, there is a wide dosing range and optimal dosage is diagnosis-dependent.

Predictors of antipsychotic medication change

Atypical antipsychotics account for more than 60% of antipsychotic prescriptions written for the treatment of schizophrenia. While switching from one antipsychotic to another is a dynamic process, there has been no research on individual patient and institutional characteristics that predict antipsychotic switching. VA national administrative data were used to identify patients (n = 9660) with schizophrenia maintained on antipsychotic medication. Logistic regression was used to identify predictors of medication switching. Independent variables included information about service utilization, sociodemographic and clinical variables as well as institutional characteristics. This model was repeated for more specific switches between classes of medications and between specific medications. High levels of outpatient and inpatient service use were the most powerful predictors of switching. Sociodemographic, institutional, diagnostic, and functional measures were also predictive in some cases. Controlling for independent sociodemographic, diagnostic, and functional measures, frequency of clinical contact was the most robust predictor of switching antipsychotics.

A comparison of extrapyramidal symptoms in older outpatients treated with quetiapine or risperidone

OBJECTIVE

To compare the tolerability of quetiapine with risperidone in older outpatients.

RESEARCH DESIGN AND METHODS

Post hoc analysis of a subset of older patients (aged 60-80; n = 92) from a randomized, 4-month, multicenter, open-label trial comparing quetiapine and risperidone in an outpatient setting. Participants had various neuropsychiatric disorders associated with psychosis as defined by criteria from the Diagnostic and Statistical Manual of Mental Disorders (4th edn).

MAIN OUTCOME MEASURES

The main outcome measure was an extrapyramidal symptoms (EPS) checklist, used to assess motor symptoms, including parkinsonism, at baseline and after treatment. The Positive and Negative Syndrome Scale (PANSS) and the Clinical Global Impression scale were used to assess therapeutic efficacy.

RESULTS

Substantial EPS (defined as EPS requiring a dosage adjustment or use of medication to reduce EPS) occurred less often with quetiapine (median dosage, 200 mg/day) than with risperidone (median dosage, 3 mg/day); odds ratio, 0.31 (P < 0.03). Quetiapine was also less likely than risperidone to cause akathisia or hypertonia. Both compounds produced comparable reductions in PANSS scores.

CONCLUSIONS

Interpretation of findings in this report is limited by the open-label design of the study and the post hoc nature of this analysis. However, the results suggest that quetiapine, when given within the recommended dosage range, has a benign EPS profile, with potentially greater tolerability and comparable efficacy to risperidone in older outpatients with psychotic disorders.

The psychiatric management of end-of-life pain and associated psychiatric comorbidity

Involvement by psychiatrists in the care of patients who are terminally ill has been limited historically; however, psychiatrists increasingly are participating in the care of these people who are facing the most challenging times of their lives. Pain management is considered to be an area of subspecialization for psychiatrists beyond their traditional role of being psychopharmacologists and psychotherapists. Biologically focused psychiatrists are able to address neuropsychiatric disorders, including pain and depression in the medically ill, and actively improve the quality of life for dying patients and their family members. This article provides a review of the recent literature that has addressed the involvement of psychiatrists in end-of-life care. Beginning with an example of the scientific aspects of cancer-related treatment from a patient's perspective, and into the major treatment considerations, this article addresses pain, its recognition, and management challenges when the end of life approaches. The prompt recognition of frequently overlooked and underestimated concomitant depressions, delirium, dementia, and other mental disorders is important for mental health specialists. The importance of psychiatric care for patients who are terminally ill and the role of psychiatrists in the phase of care also are discussed.

The efficacy and safety of olanzapine for the treatment of geriatric psychosis

Elderly psychiatric patients often present with psychotic symptoms that need antipsychotic treatment. Olanzapine is one of the atypical antipsychotics with efficacy for psychotic symptoms and a safer side-effect profile than typical antipsychotics. This study was conducted to assess the efficacy and safety of olanzapine for treatment of geriatric psychosis. The sample population comprised 94 acute-ward patients who were 65 years of age or older. Clinical assessment was conducted at baseline and also at 4 weeks after commencement of olanzapine treatment, with use of the Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression Improvement (CGI-I) instruments. A 4-week therapeutic evaluation was completed for 80 patients, 73 of whom (91.3%) experienced mild to substantial improvement as determined from the CGI-I. A mean 52.6% reduction from baseline was also determined from the BPRS. The mean daily dosage of olanzapine in the fourth week was 10.1 +/- 5.3 mg/d (range, 2.5-20.0). Higher olanzapine dosages were administered for patients with functional psychoses than for an analogous group with organic mental disorders. Adverse effects were monitored for all 94 patients, the most common of which were somnolence (18.1%), dizziness (18.1%), and weakness of legs or bradykinesia (16.0%). Body weight and fasting triglyceride and sugar levels were significantly elevated after olanzapine treatment (2.2, 39.9, and 8.9% from baseline, respectively). It seems reasonable to suggest that olanzapine is efficacious for geriatric patients with psychosis and that the dosage should be diagnosis-dependent.