Recent advances in geriatric psychopharmacology

Home Care for the Elderly: An Integrated Approach to Perception, Quality of Life, and Cognition

This study investigated the impact of home care, health status, and cognition. A qualitative and quantitative approach was employed through a cross-sectional study with a sample of 60 elderly individuals in need of home care in the municipality of Itatiba, São Paulo, Brazil. The analysis utilized the Discourse of the Collective Subject (DCS), EQ-5D, EQ VAS, and Mini-Mental State Examination (MMSE). The sample consisted of 40.0% male and 60.0% female individuals. The majority (61.6%) received weekly visits, mainly from community health agents, who were responsible for the majority of the care (45%). Positive considerations were highlighted, with 36.6% emphasizing the contribution to treatment continuity. The EQ VAS assessment indicated a moderately good perception of health. The EQ-5D analysis revealed significant differences between genders in personal care (p = 0.04). There were significant differences between clinical characteristics and EQ-5D dimensions, such as neoplasia and reduced mobility (p = 0.04), and arthritis/osteoarthritis/rheumatism and a limitation in common activities (p = 0.01). The presence of anxiety/depression was significant in cases of neoplasia (p = 0.006), arthritis/osteoarthritis/rheumatism (p = 0.01), and stroke (p = 0.04). The logistic regression analysis showed associations between usual activities and arthritis, osteoarthritis, rheumatism (p = 0.034), pain/malaise and arthritis, osteoarthritis, rheumatism (p = 0.038), and anxiety/depression and stroke (p= 0.028). The average MMSE scores (17.52) suggested a mild cognitive impairment, with no statistical differences between genders. Based on these results, it can be concluded that home care can provide a comprehensive approach and continuous assistance, emphasizing the importance of personalized care based on perceived and clinical differences.

Psychopharmacology in the Elderly: Why Does Age Matter?

A growing percentage of the population is aging, with a large subset of this group meeting criteria for one or more neuropsychiatric disorders. Generally, physiological changes due to aging affect most of the pharmacokinetic processes in the body, with age-related physiologic changes in cardiovascular, gastric, hepatic, and renal function leading to changes in the pharmacokinetics of medications that can affect the absorption, distribution, accumulation, and clearance and elimination of various medications. This article aims to discuss the common pharmacodynamic and pharmacokinetic changes associated with physiologic aging and their impacts on the use of psychotropic medications in the elderly.

Occurrence of Side Effects in Treatment-Resistant Depression: Role of Clinical, Socio-Demographic and Environmental Characteristics

Introduction: Treatment-resistant depression (TRD) is a disabling psychiatric condition characterized by the failure of two antidepressants (ADs). Since the occurrence of side effects (SEs) appears to be one of the main determinants of early discontinuation of pharmacological treatments contributing to a pseudo-resistance, the purpose of this study was to determine the parameters associated with the occurrence of SEs under ADs in a cohort of patients with TRD. Methods: An observational, cross-sectional, multicentre study was carried out using data from the French network of Expert Centers for TRD. For the 108 patients enrolled in the study, the statistical analyses focused on the overall occurrence and on the profile of the SEs (9 categories, 32 items). Results: SEs were influenced by age and sex and were positively associated with the intensity of anxious, depressive and suicidal symptoms, a history of childhood trauma (sexual abuse, emotional abuse and neglect), and negatively associated with self-esteem, and assessment of overall functioning. Conclusion: Using variables accessible in common practice, these results fall within the dynamic of a more tailored approach to medicine that could allow, through integrated pharmacological management, the continuation of antidepressant treatments, and therefore limit the risk of therapeutic failure.

Sleep medication use and incident dementia in a nationally representative sample of older adults in the US

BACKGROUND

Sleep difficulties are common among older adults, and clinical management of sleep difficulties commonly includes sleep medication (pharmacological and non-pharmacological). Our research examines sleep medication use and incident dementia over 8 years using nationally representative data from older adults ages 65 years and older in the United States.

METHODS

We used data collected from the National Health and Aging Trends Study (NHATS), a nationally-representative longitudinal study of Medicare beneficiaries. Routine sleep medication use (pharmacological and non-pharmacological) was defined as use "most nights" or "every night." Participants were screened for dementia with validated instruments that assessed memory, orientation, and executive function. We conduct prospective analyses to examine the relationship between routine sleep medication use and incident dementia using Cox proportional hazards modeling and estimated survival curves. Analyses controlled for age, sex, marital status, education, and chronic conditions.

RESULTS

Among respondents at baseline (n = 6373), most participants (21%) were age 70-74 years of age. Participants were 59% female and the sample comprised non-Hispanic White (71%). At baseline, 15% of our study sample reported using sleep medication routinely, which is representative of 4.6 million older adults in the US. Covariate adjusted proportional hazard models revealed that routinely using sleep medication was associated with incident dementia (HR = 1.30, 95%CI: 1.10 to 1.53, p < 0.01).

CONCLUSIONS

Our study observed, in a nationally representative study of older adults in the US across 8 years of data that 15% of older adults report routinely using sleep medication, yet routine use of sleeping medication was associated with incident dementia across the follow-up interval. Future research may examine behavioral approaches to improving sleep among older adults.

Association Between Side Effects and Blood microRNA Expression Levels and Their Targeted Pathways in Patients With Major Depressive Disorder Treated by a Selective Serotonin Reuptake Inhibitor, Escitalopram: A CAN-BIND-1 Report

INTRODUCTION

Antidepressant drugs are effective therapies for major depressive disorder; however, they are frequently associated with side effects. Although there is some evidence for a relationship between genetic variation and side effects, little is known regarding the role of dynamic molecular factors as moderators of side effects. The aim of this study was to assess microRNA (miRNA) changes associated with side effects during escitalopram treatment and their downstream effects on target gene expression.

METHODS

A total 160 patients with major depressive disorder from the CAN-BIND-1 cohort were included. Side effects were assessed with the Toronto Side Effect Scale after 2 weeks of treatment with escitalopram. We assessed the relationship between side effects and changes in peripheral expression of miRNAs between baseline and week 2. For miRNA whose expression changed, we used target prediction algorithms to identify putative messenger RNA (mRNA) targets and assessed their expression.

RESULTS

Nausea was experienced by 42.5% of patients. We identified 45 miRNAs whose expression changed on initiation of escitalopram treatment, of which 10 displayed a negative association with intensity of nausea (miR15b-5p, miR17-5p, miR20a-5p, miR20b-5p, miR103a-3p, miR103b, miR106a-5p, miR182-5p, miR185-5p, and miR660-5p). Additionally, we found negative associations between 4 microRNAs (miR20a-5p, miR106a-5p, miR185-5p, miR660-5p) and mRNA targets. The expression of the miR185-5p target, CAMK2δ was significantly decreased [log 2 mean = -0.048 (0.233)] between weeks 0 and 2 (P = .01)].

CONCLUSIONS

We identified an overexpression of miR185-5p during escitalopram treatment of major depressive disorder, which was negatively associated with intensity of nausea, and identified a potential mRNA target that may mediate this effect.

Clozapine use in old age psychiatry

Clozapine is one of the most effective drugs available to psychiatrists for treating psychosis. It is currently licensed for use in treatment-resistant schizophrenia and psychosis in Parkinson's disease, but its use in old age psychiatry is very uncommon. With the ageing population, and the increased incidence of psychosis in older patients, it is important to consider whether this is a drug that is not being used to its full advantage.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change.

Use of benzodiazepines and association with falls in older people admitted to hospital: a prospective cohort study

BACKGROUND

Hypnosedatives are commonly prescribed for anxiety and sleep problems. Changes in pharmacokinetics and pharmacodynamics of benzodiazepines (BZDs) during ageing may increase their potential to cause adverse outcomes.

OBJECTIVE

This study aimed to investigate the use of BZDs in acute care settings and explore their association with falls.

METHODS

A prospective cohort study was undertaken of patients aged over 70 years consecutively admitted to 11 acute care hospitals in Australia. Data were collected using the interRAI Acute Care assessment tool. Falls were recorded prospectively (in hospital) and retrospectively (in the 90 days prior to admission).

RESULTS

Of 1,412 patients, 146 (10.3 %) were taking BZDs at admission and 155 (11.3 %) at discharge. Incidence rates of in-hospital fallers for users and non-users of BZDs were not statistically different [incidence rate ratio 1.03, 95 % confidence interval (CI) 0.58-1.82]. There was also no significant association between benzodiazepine use at admission and history of falls in the previous 90 days compared with non-users. However, patients on diazepam were significantly more likely to have a history of falls than all other benzodiazepine users (70.8 vs. 36.1 %; p = 0.002), particularly when compared with oxazepam users (70.8 vs. 25.0 %; p < 0.001). Adjusting for confounders, use of diazepam at admission was positively associated with a history of falls compared with all other benzodiazepine users (odds ratio 3.0; 95 % CI 1.1-8.5; p = 0.036).

CONCLUSIONS

Different BZDs may vary in their propensity to predispose to falls, with diazepam having the strongest association. The selection of particular BZDs for older patients should be carefully evaluated.

SSRIs increase risk of blood transfusion in patients admitted for hip surgery

Background

Recent studies have shown that an increased bleeding tendency can be caused by Selective Serotonin Reuptake Inhibitors (SSRI) use. We aimed to investigate the occurrence and risk of blood transfusion in SSRI users compared to non-SSRI users in a cohort of patients admitted for hip-surgery.

Methods

We conducted a retrospective cohort study of patients who underwent planned or emergency hip surgery from 1996 to 2011 in the Academic Medical Center in Amsterdam. Primary outcome measure was risk of blood transfusion. Secondary outcome measures were pre- and postoperative hemoglobin level. Multivariate logistic regression was used to adjust for potential confounders.

Results

One-hundred and fourteen SSRI users were compared to 1773 non-SSRI users. Risk of blood transfusion during admission was increased for SSRI users in multivariate analyses (OR 1.7 [95% CI 1.1–2.5]). Also, pre-operative hemoglobin levels were lower in SSRI users (7.8±1.0 mmol/L) compared to non-SSRI users (8.0±1.0 mmol/L) (p = 0.042)), as were postoperative hemoglobin levels (6.2±1.0 mmol/L vs. 6.4±1.0 mmol/L respectively) (p = 0.017)).

Conclusions

SSRI users undergoing hip surgery have an increased risk for blood transfusion during admission, potentially explained by a lower hemoglobin level before surgery. SSRI use should be considered as a potential risk indicator for increased blood loss in patients admitted for hip surgery. These results need to be confirmed in a prospective study.

Side effects of antidepressants during long-term use in a naturalistic setting

Side effects of antidepressants are usually underreported in clinical trials and large scale naturalistic studies are restricted to six months of use. We examined the prevalence and nature of patient-perceived side effects and their determinants during long-term antidepressant use in a naturalistic setting. Subjects, aged 19 to 67 years, in the Netherlands Study of Depression and Anxiety were recruited from primary care and specialized mental health care covered 927 cases of single antidepressant use. In 64% of cases, on average, 2.9 side effects were reported. The number of side effects was higher when subjects had higher depression severity (OR=1.28; p=0.002), three or more psychiatric diagnoses (OR=1.97; p=0.02), higher dose (OR=1.44; p=0.006) and was lower when subjects were older (OR=0.83; p=0.02) and had longer duration of use (OR=0.94; p=0.04). Tricyclic antidepressants were associated with more side effects (OR=2.52; p=0.003) and, particularly, more anticholinergic effects, like dry mouth and constipation, as compared to selective serotonin reuptake inhibitors. Venlafaxine showed more profuse sweating (OR=1.79; p=0.007), whereas mirtazapine showed more weight gain and less sexual dysfunction (OR=0.36; p=0.03), as compared to selective serotonin reuptake inhibitors. Weight gain was associated with female gender (OR=1.76; p=0.004) and duration of use (OR=1.06; p=0.03). We show that antidepressant side effect, known from short-term studies, persist during long-term use and are associated with depression severity and antidepressant dose. A novel finding was that venlafaxine is associated with more profuse sweating and that weight gain appeared more specific in female users. Clinicians should be aware that, during long-term antidepressant use, side effects are common and persistent.

Therapy of depression in dementia

This is a comprehensive review of the existing diagnostic and treatment approaches to depression in Alzheimer's disease and related dementias. The existing evidence for the efficacy of pharmacological and nonpharmacological treatments are reviewed with an emphasis on the paucity of existing data and the need for more definitive controlled studies. In addition, data on the efficacy of such novel experimental treatments, such as various brain stimulation techniques (e.g., vagal nerve stimulation) are discussed. Alternative and psychosocial treatments are also reviewed.

One-time counselling decreases the use of benzodiazepines and related drugs among community-dwelling older persons

BACKGROUND

evidence about possibilities to help older persons to withdraw the long-term use of benzodiazepines (BZD) is scarce. Effective and practicable methods are needed.

OBJECTIVE

the study aimed to assess the persistence of one-time counselling by a geriatrician to reduce psychotropic drugs, especially BZD and related drugs (RD).

DESIGN

a prospective randomised controlled trial with a 12-month follow-up was conducted.

SUBJECTS

five hundred ninety-one community-dwelling people aged 65 or older participated in the study.

METHODS

instructions to withdraw, reduce or change psychotropic drugs were given to the intervention group. A 1-h lecture about these drugs and their adverse effects was given later on. No changes in the drug therapy were suggested for the controls.

RESULTS

the number of regular users of BZD and RD decreased by 35% (12/34) (odds ratios (OR) = 0.61, 95% confidence interval (95% CI) 0.44-0.86) in the intervention group while it increased by 4% (2/46) (OR = 1.05, 95% CI 0.81-1.36) in the controls (P = 0.012). No significant changes in the users of other types of psychotropics were found.

CONCLUSION

one-time counselling of psychotropics and other fall-risk-increasing drugs by a geriatrician followed with a 1-h lecture about adverse effects of these drugs had positive effects in decreasing the number of regular users of BZD and RD, and these effects persisted for the total 12-month intervention period.

Evidence-based guidelines for treating bipolar disorder: revised second edition--recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and target of treatment for bipolar disorder. The second version, like the first, is based explicitly on the available evidence and presented, like previous Clinical Practice guidelines, as recommendations to aid clinical decision making for practitioners: they may also serve as a source of information for patients and carers. The recommendations are presented together with a more detailed but selective qualitative review of the available evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. The strength of supporting evidence was rated. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in treatment of episodes, relapse prevention and stopping treatment.

Review of lithium effects on brain and blood

Clinicians have long used lithium to treat manic depression. They have also observed that lithium causes granulocytosis and lymphopenia while it enhances immunological activities of monocytes and lymphocytes. In fact, clinicians have long used lithium to treat granulocytopenia resulting from radiation and chemotherapy, to boost immunoglobulins after vaccination, and to enhance natural killer activity. Recent studies revealed a mechanism that ties together these disparate effects of lithium. Lithium acts through multiple pathways to inhibit glycogen synthetase kinase-3beta (GSK3 beta). This enzyme phosphorylates and inhibits nuclear factors that turn on cell growth and protection programs, including the nuclear factor of activated T cells (NFAT) and WNT/beta-catenin. In animals, lithium upregulates neurotrophins, including brain-derived neurotrophic factor (BDNF), nerve growth factor, neurotrophin-3 (NT3), as well as receptors to these growth factors in brain. Lithium also stimulates proliferation of stem cells, including bone marrow and neural stem cells in the subventricular zone, striatum, and forebrain. The stimulation of endogenous neural stem cells may explain why lithium increases brain cell density and volume in patients with bipolar disorders. Lithium also increases brain concentrations of the neuronal markers n-acetyl-aspartate and myoinositol. Lithium also remarkably protects neurons against glutamate, seizures, and apoptosis due to a wide variety of neurotoxins. The effective dose range for lithium is 0.6-1.0 mM in serum and >1.5 mM may be toxic. Serum lithium levels of 1.5-2.0 mM may have mild and reversible toxic effects on kidney, liver, heart, and glands. Serum levels of >2 mM may be associated with neurological symptoms, including cerebellar dysfunction. Prolonged lithium intoxication >2 mM can cause permanent brain damage. Lithium has low mutagenic and carcinogenic risk. Lithium is still the most effective therapy for depression. It "cures" a third of the patients with manic depression, improves the lives of about a third, and is ineffective in about a third. Recent studies suggest that some anticonvulsants (i.e., valproate, carbamapazine, and lamotrigene) may be useful in patients that do not respond to lithium. Lithium has been reported to be beneficial in animal models of brain injury, stroke, Alzheimer's, Huntington's, and Parkinson's diseases, amyotrophic lateral sclerosis (ALS), spinal cord injury, and other conditions. Clinical trials assessing the effects of lithium are under way. A recent clinical trial suggests that lithium stops the progression of ALS.

Psicofármacos en el anciano

Based on the following realities, general knowledge on the management of psychodrugs in the elderly population is necessary for any physician: high prescription of psychodrug in this population, up to 25% of the elderly may require this treatment at any time, and good therapeutic response. To achieve good compliance to the psychiatric treatment by the elderly patient, the pharmacokinetic characteristics and interactions in this population must be well known to avoid the appearance of significant side effects. These side effects may induce the patient to drop out of the treatment or to even have at risk side effects. A review on the pharmacodynamic and pharmacokinetic characteristics related with psychodrugs in the elderly is done in this article. Based on this, the three large groups of anxiolytic, antidepressive and antipsychotic psychodrugs are reviewed.

Managing Bipolar Disorder in the Elderly

Clinical research in geriatric psychopharmacology has been a relatively neglected focus compared with the wealth of information on younger populations, and there is a dearth of published, controlled trials. Similarly, these are limited data in the area of geriatric bipolar disorder. Although there is an absence of rigorous, evidence-based information, preliminary data on older adults with bipolar disorder suggest some promising treatment options and important differences in older versus younger patients with bipolar illness. Lithium, while widely utilised in younger populations, is often poorly tolerated in the elderly. Clinical evidence regarding use of antiepileptic compounds in late-life bipolar disorder is generally compiled from bipolar disorder studies in mixed populations, studies in older adults with seizure disorders, and studies on dementia and psychotic conditions other than bipolar disorder. Valproate semisodium and carbamazepine are widely prescribed compounds in older adults with bipolar disorder. However, the popularity of these compounds has occurred in context of an absence of evidence-based data. The atypical antipsychotics have expanded the treatment armamentarium for bipolar disorder in mixed populations and may offer particular promise in management of bipolar illness in older populations as well. Olanzapine, risperidone, quetiapine, ziprasidone and aripiprazole are atypical antipsychotics that have been approved by the US FDA for the treatment of bipolar disorder; however, there are no published, controlled trials with atypical antipsychotics specific to mania in geriatric patients. Preliminary reports on the use of clozapine, risperidone, olanzapine and quetiapine suggest a role for the use of these agents in late-life bipolar disorder. Information with ziprasidone and aripiprazole specific to geriatric bipolar disorder is still lacking.

Prevalence, correlates, and associated outcomes of potentially inappropriate psychotropic use in the community-dwelling elderly

BACKGROUND

Previous applications of the Beers criteria have shown significant prescribing of potentially inappropriate psychotropic agents for the community-dwelling elderly. However, there is limited information at the national level on potentially inappropriate psychotropic use, the characteristics of elderly persons at risk, and the impact of this inappropriate use on health care outcomes.

OBJECTIVE

This study addressed the prevalence, correlates, and associated outcomes of potentially inappropriate psychotropic use among community-dwelling elderly persons in the United States who were receiving psychotropic medications.

METHODS

Data from the 1996 Medical Expenditure Panel Survey (MEPS) were employed to examine the use of psychotropic medications that generally should be avoided in the elderly and those that should be avoided in elderly patients with certain preexisting conditions, as defined by the Beers criteria. The MEPS sampling weights were used to derive national estimates. Cross-sectional data were analyzed by multivariate analyses to examine the correlates and associated health care outcomes (health care utilization, economic, and humanistic) of potentially inappropriate psychotropic use in the elderly.

RESULTS

An estimated 2.30 million community-dwelling elderly persons received potentially inappropriate psychotropic medications in 1996. This represented 7.14% of all community-dwelling elderly persons and 37.86% of all community-dwelling elderly persons using psychotropic agents; 32.94% of those taking psychotropic drugs received agents that were generally inappropriate, and 10.21% received agents that were inappropriate in the presence of specific conditions. The rates of potentially inappropriate psychotropic use in those receiving antidepressant, antianxiety, and sedative/hypnotic agents were 50.93%, 31.84%, and 23.49%, respectively. Multivariate analyses showed that correlates of potentially inappropriate psychotropic use in the elderly were age <75 years and use of multiple psychotropic agents. After controlling for predisposing, enabling, and need factors, no association was found between the use of potentially inappropriate psychotropic medications and differences in health care utilization, economic, or humanistic outcomes.

CONCLUSIONS

The study findings suggest that although the use of potentially inappropriate psychotropic medications is common among the community-dwelling elderly who are prescribed psychotropic agents, the unfavorable risk-benefit ratio of these inappropriate medications does not appear to influence broad measures of health care utilization, costs, or quality of life in this population.

Evidence-based guidelines for treating bipolar disorder: recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and target of treatment for bipolar disorder. They are based explicitly on the available evidence and presented, similar to previous Clinical Practice guidelines, as recommendations to aid clinical decision-making for practitioners. They may also serve as a source of information for patients and carers. The recommendations are presented together with a more detailed review of the available evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. The strength of supporting evidence was rated. The guidelines cover the diagnosis of bipolar disorder, clinical management and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment.

Psychotropic prescription use by community-dwelling elderly in the United States

OBJECTIVES

To examine psychotropic prescription use in community-dwelling elderly in the United States and its association with predisposing, enabling, and need factors.

DESIGN

Retrospective analysis of the 1996 Medical Expenditure Survey (MEPS).

SETTING

A national representative sample survey of the United States non-institutionalized population.

PARTICIPANTS

Community-dwelling persons aged 65 and older participating in the MEPS.

MEASUREMENTS

Psychotropic prescription use patterns and factors associated with the use of psychotropics in general as well as of individual classes, specifically antidepressants, antianxiety agents, and sedative/hypnotics.

RESULTS

According to the MEPS, more than 6 million (19%) community-dwelling elderly persons used psychotropic medications in 1996. Nearly 3 million (9.1%) elderly were taking antidepressants, almost 2.5 million (7.5%) antianxiety agents, and 1.5 million (4.8%) sedative/hypnotics. Several correlates of psychotropic prescription use were identified. Enabling (e.g., prescription insurance) and need (e.g., health status) factors were found to be consistently associated with the use of antidepressant, antianxiety, and sedative/hypnotic agents. Predisposing factors such as sex, race, region, and education varied with the type of psychotropic drug class examined.

CONCLUSION

Nearly one in five community-dwelling elderly persons used psychotropic medications, primarily antidepressants followed by antianxiety agents. Enabling and need factors were consistently associated with psychotropic classes examined, whereas most predisposing factors varied with the type of psychotropic drug class.

Pharmacokinetic and safety assessments of concurrent administration of risperidone and donepezil

Treatment of Alzheimer's disease sometimes uses combinations of drugs because dementia is frequently associated with behavioral symptoms. Risperidone and donepezil are both metabolized through cytochrome P450 2D6 and 3A4, raising the possibility of drug interactions with combination therapy. The objective of this study was to determine whether significant drug interactions occur with concomitant administration of donepezil and risperidone. In an open-label, three-way crossover study, 24 healthy men were randomly assigned to receive 0.5 mg of risperidone twice daily, 5 mg of donepezil once daily, or both drugs for 14 consecutive days, followed by a 21-day washout period. The treatment ratios of AUC and associated 90% confidence intervals (CIs) for risperidone active moiety, defined as risperidone plus 9-hydroxyrisperidone (ratio = 110.2%; 90% CI = 103.7-117.2), and for donepezil (ratio = 97.1%; 90% CI = 90.0-103.6) were within the 80% to 125% of bioequivalence range. The treatment ratios of Cmax and associated 90% CIs for risperidone active moiety (ratio = 114.6%; 90% CI = 107.0-122.8) and for donepezil (ratio = 96.1%; 90% CI = 90.0-102.6) were also within the bioequivalence range. Therefore, no significant pharmacokinetic differences occurred in either risperidone active moiety or donepezil when given alone or in combination. Adverse events (predominantly headache, nervousness, and somnolence) were minor and comparable for all treatment groups. The results indicate that no clinically meaningful drug interactions occurred between risperidone 1 mg daily and donepezil 5 mg daily at steady state, and therefore no dosage adjustment is required when both drugs are combined with the dosage regimen studied. Additional investigations are warranted to determine the potential for interactions in elderly patients with dementia who may eliminate risperidone and donepezil more slowly and thus be more vulnerable to clinical drug interactions than the young healthy subjects examined in this study.

Pharmacokinetic and safety assessments of galantamine and risperidone after the two drugs are administered alone and together

To explore the steady-state pharmacokinetic profile after coadministration of galantamine and risperidone, an open-label, randomized, single-center, two-way crossover drug-drug interaction study was conducted in 16 healthy elderly subjects, ages 60 years and older. The results showed that risperidone, when administered with galantamine, did not change the bioavailability of galantamine at steady state. In addition, systemic exposure of risperidone active moiety (risperidone plus 9-hydroxyrisperidone), the most clinically relevant component of risperidone treatment, was not affected by galantamine coadministration, while systemic exposure was increased by approximately 10% for risperidone and decreased by about 10% for 9-hydroxyrisperidone (active metabolite of risperidone). Galantamine and risperidone were both safe and well tolerated administered either alone or together. Thus, no dose adjustment for either risperidone orgalantamine is necessary when these two drugs are administered together in the dose range evaluated.

Prescribing of psychotropics in the elderly: why is it so often inappropriate?

Psychotropic medications are an important treatment approach to mental health disorders; such disorders are common in the elderly population. Elderly patients are more likely to experience adverse effects from these agents than their younger counterparts due to age-related changes in pharmacodynamic and pharmacokinetic parameters. Because of these factors, inappropriate use of psychotropic medications in elderly patients has become a focus of concern. In general an agent is considered inappropriate if the risk associated with its use exceeds its benefit. Implicit and explicit criteria for inappropriate use of medications in the elderly have been created and include psychotropic agents. These criteria vary in their make-up but the explicit criteria tend to agree that amitriptyline, doxepin, and benzodiazepines that have long half-lives are not appropriate. Although explicit inappropriate medication criteria have been in existence since 1991, elderly patients continue to receive inappropriate psychotropic medications. A wide array of factors may be responsible for this practice. Provider-related causes include deficits in knowledge, confusion due to the lack of a consensus on the inappropriate psychotropic criteria, difficulties in addressing an inappropriate medication started by a previous provider, multiple prescribers and pharmacies involved in the care of a patient, negative perceptions regarding aging, and cost issues. Patients may contribute to the problem by demanding an inappropriate medication. Finally, the healthcare setting may inadvertently contribute to inappropriate prescribing by such policies as restrictive formularies or lack of reimbursement for pharmacists' clinical services. Successful approaches to optimising prescribing have been either educational or administrative. Educational approaches (e.g. one-on-one sessions, academic detailing) seek to influence decision making, while administrative approaches attempt to enforce policies to curtail the undesired practice. The US Omnibus Budget Reconciliation Act of 1987, which improved psychotropic medication use in long-term care, is an excellent example of administrative intervention. More research specifically focused on the causes of inappropriate psychotropic medication use and methods to avoid this practice is needed before targeted recommendations can be made.

Clinical and economic factors in the treatment of behavioural and psychological symptoms of dementia

The prevalence of behavioural and psychological symptoms of dementia (BPSD) exceeds 50%. They cause distress to patients and caregivers, increase resource utilisation of various kinds, and form a high risk for accelerated psychiatric care through institutionalisation. Although evidence for current pharmacological treatment is not strong and the construct of BPSD is still not very clear, future aspects of treatment of BPSD may be positive. If we look at overall success rates of the antipsychotics, the traditional antipsychotics have the highest combined success rate of 63.1%, whereas the novel antipsychotics have an overall success rate of 56.1%. Haloperidol is the drug with the highest success rate of 65.4%, although this drug is associated with parkinsonian adverse drug reactions. Newer antipsychotics show promise in treating BPSD, but more convincing evidence (e.g. from randomised clinical trials) is required. We provide an overview of the clinical, epidemiological and economic aspects of BPSD and a review of the available literature on their pharmacological treatment. Although only 1 pharmacoeconomic study has been conducted on BPSD, it seems likely that these manifestations drastically increase the burden of dementia.

Use of drugs by Old Age Psychiatrists in the treatment of psychotic and behavioural symptoms in patients with dementia

The objective was to elicit the prescribing practises of Old Age Psychiatrists in the UK in the treatment of psychotic and behavioural symptoms in patients with dementia. A structured questionnaire was sent to all Old Age Psychiatrists in the United Kingdom. Respondents were questioned regarding their use of both typical and atypical antipsychotics and the most common dosages prescribed. Information was sought about usage of depot medication and dosages; use of alternative or adjunctive medications to antipsychotics and use of parenteral medication for acute management of agitation. The most commonly used antipsychotic to treat psychotic symptoms was haloperidol, and thioridazine to treat behavioural symptoms. A wide range of dosages was used. Use of depot medication was common, with flupenthixol decanoate being the most frequently used. Most respondents use at least one of the atypical antipsychotics, risperidone being most popular. Use of other psychotropic medication used as alternatives to antipsychotics or adjunctives in the treatment of behavioural symptoms was common, the most popular being trazodone. Of the respondents, 62.7% use parenteral medication for the acute management of agitation, the most popular drug being haloperidol. The typical antipsychotics are still the most commonly used despite the reputed better safety profile of the atypicals. There was wide variation in the dosages prescribed. Use of psychotropics other than phenothiazines was common. More research is needed into the use of psychotropic medication for dementia and there is need for consensus in this area. Forming an expert group may be the best way to create uniformity of prescription.

Quantitative electroencephalographic changes induced by odor detection and identification tasks: age related effects

There are no previous studies which have compared quantitative electroencephalographic (QEEG) activity in young adult and normal elderly participants during olfactory tasks. This may be important if QEEG is to have a role in distinguishing between normal and pathological aging associated with this sensory system. Seventeen healthy elderly subjects (mean age 79.00+/-3.54 years) and 16 young adult controls (mean age 22.60+/-2.00 years) participated in the study. As reported in previous studies, beta1 and 2 activity was significantly greater in elderly subjects compared to young adults, thus confirming the reliability and validity of this study's quantitative electroencephalographic (QEEG) methodology. More alpha activity was evident in young adults compared with the elderly, whilst &theta; activity was distributed differently in the two age groups. These findings support previous literature suggesting EEG bandwidth activity reflect greater attentional capacity in young adults and EEG desynchronization in older people. Elderly subjects who identified two or fewer odors were found to have more beta activity in the olfaction condition compared to resting eyes closed, which may reflect cognitive impairment. These findings stress the importance of distinguishing subgroups of healthy elderly adults when examining the electroencephalographic profile.

Recommendations for the management of behavioral and psychological symptoms of dementia

BACKGROUND

The behavioral and psychological symptoms of dementia (BPSD) are common, serious problems that impair the quality of life for both patient and caregiver. In order to provide recommendations based upon the best available evidence, a qualitative literature review was performed.

METHODS

A search of the English language medical literature published between 1966 and 2000 was performed. The quality of the studies was assessed by considering the subjects, trial design, analysis and results. Final recommendations were based upon the quality of available evidence.

RESULTS

The management of BPSD begins with a thorough assessment to search for underlying causes of behaviour change. Concomitant medical illness should be treated and sensory impairment ameliorated. Nonpharmacological approaches should be instituted prior to medication use. These interventions include music, light, changes in level of stimulation and specific behavioral techniques. Antipsychotics are the best studied pharmacological intervention for agitation and aggression and have demonstrated modest but consistent efficacy. Antidepressants such as trazodone and selective serotonin re-uptake inhibitors, as well as anticonvulsants such as carbamazepine and valproic acid have also demonstrated efficacy. Benzodiazepines can be used for short-term treatment as p.r.n. agents when necessary. Pharmacotherapy must be monitored closely for both effectiveness and side effects, with consideration of medication withdrawal when appropriate.

CONCLUSION

The management of BPSD can significantly improve the quality of life for the patient and caregiver. Their assessment and management are essential components of the treatment of dementia.

Managing depression and anxiety in the elderly patient

Depression in the elderly is under-recognised and under-treated, even more than in younger patients. Late-life depression is a chronic and disabling illness, but there is a common misconception that it is a normal feature of ageing. It can also be difficult to differentiate depression from coexisting anxiety and cognitive disorders. Antidepressants are as effective in acute treatment in older, as in younger, depressed adults. Maintenance antidepressant therapy also appears as effective in older patients. It may, however, be difficult to attain therapeutic levels of tricylic antidepressants (TCAs) in the elderly because of side effects. The selective serotonin re-uptake inhibitors (SSRIs) have more favourable safety and tolerability profiles, making them a suitable treatment option for older patients, who are more vulnerable to adverse effects. In selecting an SSRI for treating late-life depression, its pharmacokinetic profile and effects on coexisting illnesses that are prevalent in the elderly, such as anxiety, dementia and cardiovascular disease, also need to be considered.

A risk-benefit assessment of risperidone for the treatment of behavioural and psychological symptoms in dementia

The importance of behavioural and psychological symptoms in dementia (BPSD) is increasingly being recognised. Symptoms such as verbal and physical aggression, agitation, sleep disturbances and wandering are common, cause great distress to caregivers and are likely to lead to institutionalisation of patients. At present, these symptoms are also more amenable to treatment compared with the progressive intellectual decline caused by dementing illnesses. The care of individuals with BPSD involves a broad range of psychosocial treatments for the patient and his or her family. If pharmacotherapy is deemed necessary to manage BPSD, a careful balance must be struck between the benefits of symptom control and the inherent risks associated with most psychotropic agents in the elderly. Elderly patients in general, and patients with dementia in particular, are more sensitive to medication adverse effects, including anticholinergic effects, orthostatic hypotension, sedation, parkinsonism, tardive dyskinesia and cognitive impairment than younger patients with dementia or individuals without dementia. To date, treatment of symptoms of aggression and psychosis has relied on the empirical use of antidepressants, anxiolytics, typical antipsychotics (neuroleptics) and other agents. Treatment-limiting adverse effects are frequently reported with all of these agents. However, it is the typical antipsychotics and the atypical antipsychotic clozapine that are associated with the greatest risk of adverse effects in the elderly. The present review highlights the issues that limit the use of older psychotropic agents in the elderly, and presents an assessment of the available evidence concerning the efficacy, safety and tolerability of the atypical antipsychotic risperidone, in the treatment of BPSD in elderly patients with dementia. The extensive clinical development programme for risperidone has shown the drug to be effective and well tolerated in many fragile patients. As a result of its efficacy and safety profile, risperidone can be used for the treatment of behavioural and psychological symptoms in patients with dementia. Risperidone therefore represents a significant addition to the armamentarium for BPSD. While efforts continue in the development of treatment for the cognitive decline associated with dementia, treatment is now available for the noncognitive symptoms. By treating the latter, risperidone has the potential to be of substantial benefit to patients with dementia, their carers and the costs of healthcare.

Pharmacokinetics of radiotracers in human plasma during positron emission tomography

Many radiopharmaceuticals for positron emission tomography (PET) are substantially metabolized in peripheral organs. Pharmacological treatments intended to alter cerebral metabolism might also alter radiotracer metabolism, consequently altering the cerebral uptake. First-order rate constants for the metabolism of PET tracers can be calculated by a linear graphical method from the precursor and metabolite concentrations measured in plasma extracts fractionated by HPLC. We tested the effects of specific pharmacological challenges on the plasma kinetics of six tracers used for PET studies of neurotransmission. The rate of O-methylation of circulating [(18)F]fluorodopa, a tracer of dopa decarboxylase activity in brain, was unaffected by pretreatment with amantadine, an antagonist of glutamate receptors. [(11)C]Deprenyl, a tracer of monoamine oxidase activity, was rapidly metabolized to [(11)C]methamphetamine and polar metabolites in healthy volunteers. The net rate constant of this metabolism was three times higher in a group of subjects under treatment for epilepsy, consistent with induction of hepatic microsomal enzymes by antiepileptic drugs. [(11)C]Sch 23390, a ligand for dopamine D1 receptors, was rapidly metabolized to polar metabolites. The net rate constant of metabolism was unaffected by pretreatment with lorazepam. [(11)C]-(S)-Nicotine, a ligand for nicotinic receptors, was rapidly metabolized to [(11)C]-(S)-cotenine, which is less polar than the parent compound. Pretreatment with mazindol, a dopamine uptake inhibitor, was without effect on peripheral metabolism of [(11)C]-(S)-nicotine. [(11)C]WIN 35,428, a tropane derivative which labels dopamine uptake sites, was metabolized to a nonpolar metabolite, but so slowly that the rate constant of this process could not be calculated. [(11)C]Raclopride, a ligand for dopamine D2 receptors, was first metabolized to a nonpolar metabolite, which then yielded two hydrophilic metabolites. The initial metabolic step was substantially blocked by pretreatment with amphetamine, possibly indicative of competitive inhibition of microsomal oxidation. Together, these results indicate that the linear graphic method is useful for estimating the kinetics of the plasma metabolism of many widely used PET tracers. Drug-drug interactions were revealed in subjects treated with specific pharmacological agents prior to tracer administration.

The nature and management of mania in old age

Mania in old age represents a syndrome involving affective vulnerability in association with neurologic lesions that affect specific areas of the brain. Most patients suffering from mania in late life have converted to bipolarity later in life after many years and often repeated episodes of depression or else have developed mania in association with specific neurologic insults, particularly cerebrovascular disease (vascular mania). The outcome is generally worse in mania than in depression with higher prevalence of cognitive dysfunction, persistent symptoms, and greater mortality. The management of elderly bipolar patients with mood stabilizers reflects the experience with a mixed age population primarily involving the use of lithium carbonate and valproate in appropriately adjusted dosages and serum levels, with valproate having an edge on better tolerability. The use of neuroleptics is often unavoidable in initial stabilization, and electroconvulsive therapy can be life-saving in severely overactive or refractory patients.

Psychotropic prescribing for the elderly in office-based practice

This study employed data from the National Ambulatory Medical Care Survey (NAMCS) 1995 to (1) determine the prevalence of the prescribing of psychotropic drugs for elderly patients by office-based physicians in the United States; (2) estimate the prevalence of the prescribing of potentially inappropriate psychotropic drugs in this patient population; and (3) identify any factors that predict such prescribing. For the purposes of this study, previously developed consensus criteria were adopted defining inappropriate psychotropic drugs as those that should be avoided in the elderly. According to the NAMCS data, psychotropic medications were prescribed in an estimated 12.02 million visits by elderly patients (95% confidence interval [CI], 11.07-12.97 million). The psychotropic medications most frequently prescribed for elderly patients by office-based physicians were antidepressants and antianxiety agents. The occurrence of visits at which psychotropic medications were prescribed was greater in patients who were over 84 years of age, female, white, or from the western United States. Primary care physicians prescribed the majority of these psychotropic drugs, and most visits to psychiatrists by elderly patients resulted in the prescribing of psychotropic drugs. Office-based physicians prescribed at least one potentially inappropriate psychotropic medication in 2.03 million visits by the elderly (95% CI, 1.70-2.36 million), or 16.87% of visits by the elderly involving prescriptions for psychotropic drugs. The most frequently prescribed potentially inappropriate psychotropic drugs were amitriptyline and long-acting benzodiazepines such as diazepam, chlordiazepoxide, and flurazepam. Logistic regression analyses revealed that inappropriate prescribing of psychotropic drugs for elderly patients was associated with particular patient characteristics (visit due to an injury), drug characteristics (number of medications prescribed and the drug being an antidepressant or antianxiety agent), and physician characteristics (psychiatric specialty and location in the South or Northeast). The patterns of psychotropic prescribing found in the ambulatory setting raise concerns about the quality of care being received by elderly patients with psychiatric illnesses.

A double-blind comparison of the efficacy and safely of paroxetine and imipramine in the treatment of depression with dementia

OBJECTIVES

To compare the efficacy of paroxetine and imipramine prospectively in patients with coexisting depression and dementia.

METHODS

An 8-week, double-blind, parallel group trial comparing paroxetine 20-40 mg/day with imipramine 50-100 mg/day in 198 patients aged 60 years or over with a Montgomery-Asberg Depression Rating Scale (MADRS) score > or = 20 and a Folstein mini-mental state evaluation score of 17-23 points after a 3- to 7-day placebo run-in period.

RESULTS

Both paroxetine and imipramine reduced the MADRS and the Clinical Global Impression (CGI) severity-of-illness and global improvement scores at weeks 2, 4, 8 and at endpoint, with no significant differences between treatment groups at any timepoint (MADRS, p > or = 0.368; cgi, p > or = 0.286). There was a statistically significant difference in favour of paroxetine at both the week 4 and week 8 timepoints (analysis of variance, p < or = 0.049) in the Cornell scale for depression in dementia: at endpoint there was no significant difference between treatments (p = 0.103). Treatment-emergent adverse experiences were reported by 51.5% (51/99) of patients treated with paroxetine and 50.5% (50/99) of patients treated with imipramine. Anticholinergic adverse experiences (paroxetine 6.1%; imipramine 13.1%) and serious non-fatal adverse experiences (paroxetine 4.0%; imipramine 8.1%) were reported by more patients in the imipramine group than in the paroxetine group.

CONCLUSIONS

Paroxetine and imipramine were both effective in the treatment of depression in elderly subjects with co-existing dementia, and no significant differences were detected between the groups. There were trends suggesting that paroxetine was better tolerated than imipramine in terms of anticholinergic adverse experiences and serious non-fatal adverse experiences.