Review of topiramate for the treatment of epilepsy in elderly patients.

Individuals over 65 years of age experience the new onset of seizures at a prevalence rate of roughly twice that of younger adults. Differences in physiology, need of concomitant medications, and liability for cognitive deficits in this population, make the choice of anticonvulsant drugs especially important. This paper reviews topiramate (TPM), a treatment for many types of seizures, with the above risks in mind. In particular, we discuss efficacy and pharmacokinetics with emphasis on the older patient, and adverse events in both the younger and older adult. With most studies of TPM-induced cognitive deficits having been performed in younger adults and volunteers, we discuss the implications for the older adult. Even in studies of younger individuals, up to 50% discontinue TPM because of intolerable cognitive deficits. Most studies find specific declines in working memory and verbal fluency. In conclusion, we give recommendations for use of this antiepileptic drug in this population.

Trends in pharmacotherapy of Schizoaffective and bipolar affective disorders: a 5-year naturalistic study.

OBJECTIVE: The authors' goal was to determine if the actual treatment of schizoaffective and bipolar affective disorders had changed in light of recent clinical drug trials that have suggested that valproate and carbamazepine may be equivalent in efficacy to lithium. METHOD: Medication utilization rates for each 6-month period from July 1, 1989, to June 30, 1994, were compiled from the clinical database of the Palo Alto Veterans Affairs Medical Center. RESULTS: The use of valproate and valproate plus lithium was negligible in 1989. by 1994, these medication regimens accounted for 25% of the standard antimanic treatments used for bipolar affective disorder and 38% of the treatments used for schizoaffective disorder. Regimens of carbamazepine and carbamazepine plus lithium dropped from 24% of antimanic treatments in 1989 to 18% in 1994. From 1989 to 1994, there was a decline in the rate of lithium monotherapy for treatment of bipolar affective disorder (from 84% to 43%) and schizoaffective disorder (from 100% to 53%). CONCLUSIONS: In the past 5 years, valproate monotherapy has increased as a percentage of total antimanic pharmacotherapies, while lithium monotherapy has declined.

Dangerousness commitments: indices of future violence potential?

This study examines the accuracy of long-term clinical predictions of dangerousness among psychiatric inpatients and explores factors influencing the levels of such accuracy. Hospital and state criminal history records of all psychiatric patients (N = 31) for whom, during a four-year period, treatment staff pursued extended civil commitments based on dangerousness under the Postcertification for the imminently Dangerous statute (California Welfare and Institutions Code section 5300) were reviewed. A matched control group consisted of 31 patients who had been placed on 14-Day Certifications for Dangerousness to Others, but who were not subsequently placed on 180-Day Postcertifications. Sixty-one percent of patients in the postcertification group engaged in documented physically assaultive behavior during the extended one- to five-year follow-up period, compared with 26 percent of patients in the matched control group, suggesting that inclusion in the extended commitment group was indicative of greater long-term potential for assault. Differences in assaultiveness did not emerge during the first year of followup, but became clear and significant over subsequent years. Accuracy of prediction differed as a function of patient ethnic group.

Selected psychiatric symptoms associated with rate of cognitive decline in patients with Alzheimer's disease.

We examined the relation between selected psychiatric symptoms and the average rate of decline in different areas of cognition in patients with Alzheimer's disease. Measures of decline were computed by determining patients' average rates of decline on the underlying factors of the Mini-Mental State Examination (MMSE). Patients with agitation or wandering declined more rapidly on the total MMSE score than did patients without either symptom. The Following Commands factor accounted for almost all of this decline. The findings suggest a relation between the presence of certain behavioral problems in Alzheimer's disease and decline in particular cognitive areas.