Antipsychotic prescribing patterns and the treatment of extrapyramidal symptoms in older people

Prescribing Cascades with Recommendations to Prevent or Reverse Them: A Systematic Review

BACKGROUND

To reduce prescribing cascades occurring in clinical practice, healthcare providers require information on the prescribing cascades they can recognize and prevent.

OBJECTIVE

This systematic review aims to provide an overview of prescribing cascades, including dose-dependency information and recommendations that healthcare providers can use to prevent or reverse them.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed. Relevant literature was identified through searches in OVID MEDLINE, OVID Embase, OVID CINAHL, and Cochrane. Additionally, Web of Science and Scopus were consulted to analyze reference lists and citations. Publications in English were included if they analyzed the occurrence of prescribing cascades. Prescribing cascades were included if at least one study demonstrated a significant association and were excluded when the adverse drug reaction could not be confirmed in the Summary of Product Characteristics. Two reviewers independently extracted and grouped similar prescribing cascades. Descriptive summaries were provided regarding dose-dependency analyses and recommendations to prevent or reverse these prescribing cascades.

RESULTS

A total of 95 publications were included, resulting in 115 prescribing cascades with confirmed adverse drug reactions for which at least one significant association was found. For 52 of these prescribing cascades, information regarding dose dependency or recommendations to prevent or reverse prescribing cascades was found. Dose dependency was analyzed and confirmed for 12 prescribing cascades. For example, antipsychotics that may cause extrapyramidal syndrome followed by anti-parkinson drugs. Recommendations focused on dosage lowering, discontinuing medication, and medication switching. Explicit recommendations regarding alternative options were given for three prescribing cascades. One example was switching to ondansetron or granisetron when extrapyramidal syndrome is experienced using metoclopramide.

CONCLUSIONS

In total, 115 prescribing cascades were identified and an overview of 52 of them was generated for which recommendations to prevent or reverse them were provided. Nonetheless, information regarding alternative options for managing prescribing cascades was scarce.

Recognition and Management of Antipsychotic-Induced Parkinsonism in Older Adults: A Narrative Review

Background: Parkinsonism is a common side-effect of antipsychotic drugs especially in older adults, who also present with a higher frequency of neurodegenerative disorders like Idiopathic Parkinson’s disease (IPD). Distinguishing between antipsychotic-induced parkinsonism (AIP) and IPD is challenging due to clinical similarities. Up to 20% of older adults may suffer from persisting parkinsonism months after discontinuation of antipsychotics, suggesting underlying neurodegeneration. A review of the literature on AIP in older adults is presented, focusing on epidemiology, clinical aspects, and management. Methods: A literature search was undertaken on EMBASE, MEDLINE and PsycINFO, for articles on parkinsonism induced by antipsychotic drugs or other dopamine 2 receptor antagonists in subjects aged 65 or older. Results: AIP in older adults is the second most common cause of parkinsonism after IPD. Older age, female gender, exposure to high-potency first generation antipsychotics, and antipsychotic dosage are the main risk factors. The clinical presentation of AIP resembles that of IPD, but is more symmetrical, affects upper limbs more, and tends to have associated motor phenomena such as orofacial dyskinesias and akathisia. Presence of olfactory dysfunction in AIP suggests neurodegeneration. Imaging of striatal dopamine transporters is widely used in IPD diagnosis and could help to distinguish it from AIP. There is little evidence base for recommending pharmacological interventions for AIP, the best options being dose-reduction/withdrawal, or switching to a second-generation drug. Conclusions: AIP is a common occurrence in older adults and it is possible to differentiate it from IPD. Further research is needed into its pathophysiology and on its treatment.

A survey of psychotropic drug use in elderly psychiatric inpatients

Objective: The objective of the present study was to examine the use of medication in an elderly psychiatric inpatient population.

Method: This was a retrospective survey of medication prescribed to the total elderly inpatient population of a single psychiatric hospital. Data collected included basic sociodemographic information, length of stay, number of admissions, frequency of psychiatric disturbance, diagnosis and medication prescribed.

Results: A total of 340 cases were studied, 229 (67%) were female, 324 (95%) had been inpatients for more than one year, 111 (33%) suffered from dementia, while the remainder were in the functional category. In 57% more than one psychotropic drug was used. Over half (56%) of those with dementia were on neuroleptic medication.

Conclusion: Psychotropic polypharmacy was found in this population of elderly patients. Management issues emphasised include the risk of polypharmacy in this age group, the need for staff education, an active pharmacy committee and alternative methods of managing behavioural disturbance in elderly patients in particular those with dementia.

Current electroconvulsive therapy practice and research in the geriatric population

Electroconvulsive therapy (ECT) is utilized worldwide for various severe and treatment-resistant psychiatric disorders. Research studies have shown that ECT is the most effective and rapid treatment available for elderly patients with depression, bipolar disorder and psychosis. For patients who suffer from intractable catatonia and neuroleptic malignant syndrome, ECT can be life saving. For elderly patients who cannot tolerate or respond poorly to medications and who are at a high risk for drug-induced toxicity or toxic drug interactions, ECT is the safest treatment option. Organic causes are frequently associated with late-life onset of neuropsychiatric conditions, such as parkinsonism, dementia and stroke. ECT has proven to be efficacious even when these conditions are present. During the next decade, research studies should focus on the use of ECT as a synergistic therapy, to enhance other biological and psychological treatments, and prevent symptom relapse and recurrence.

Outcome of risperidone therapy in elderly patients with chronic psychosis

OBJECTIVE

This report reviews the efficacy and tolerability of risperidone therapy in elderly patients with chronic psychosis.

METHODS

A computer search was conducted for all patients who were sixty-five years or older at the time of risperidone therapy at the Cleveland VAMC. Data collected included psychiatric diagnosis, risperidone dosage/side effects, concurrent medications, comorbid medical diagnosis, and response to treatment. Treatment response was quantified on a graduated scale.

RESULTS

Twenty-six patients age sixty-five or older were included in this sample. Mean age of the group was 70.4 years. Mean risperidone dosage was 3.8 mg/day for a mean duration of 251 days. Eighteen of twenty-six patients (69%) had schizophrenia, two of twenty-six (8%) had schizoaffective disorder, two of twenty-six (8%) had bipolar disorder, and four of twenty-six (15%) had other psychotic disorders. Patients had a mean of 2.4 medical diagnoses in addition to their primary psychiatric diagnosis. Twenty-two of twenty-six patients (85%) had clinical improvement on risperidone, and twenty of twenty-six (77%) had improvement that was either marked or moderate. Risperidone therapy was very well tolerated in this elderly population with nineteen of twenty-six patients (73%) remaining on risperidone therapy at completion of this study. Medical illness did not appear to be worsened or complicated by risperidone therapy.

CONCLUSION

Risperidone appears to be an effective and well tolerated antipsychotic for elderly patients with chronic psychosis.