Risperidone: treatment response in adult and geriatric patients.

OBJECTIVE: To compare the efficacy and side effects of risperidone in younger adult and geriatric patients. METHODS: Open retrospective study of 102 consecutive intakes, prescribed risperidone, by a mental health team. All patients were non-hospitalized community residents. Prior to initiation of risperidone, and at termination of study period, Clinical Global Impression (CGI) scores were used to track progress. Variables monitored were: concurrent use of other antipsychotics, compliance, side effects, and maintenance dosage. RESULTS: The most common DSM-IV diagnoses were schizophrenia in the younger adult group and late onset delusional disorders in the geriatric group. Compliance was good for both groups. The geriatric group demonstrated a greater treatment response which was reached at a significantly lower dosage. There was no statistically significant difference in the occurrence of side effects. Examination of response by diagnostic category indicated that geriatric patients with late onset delusional disorder showed the best response while adults with either schizophrenia or affective syndromes also showed positive response. CONCLUSIONS: Risperidone, at lower than recommended doses, shows promise in the treatment of late onset delusional disorders and behavior syndrome of dementia. The side effect profile was benign, as was suggested by experience in treating schizophrenia. Scientifically more rigorous prospective studies for the indications and efficacy of risperidone in late onset psychotic disorders and psychoses and behavior syndromes associated with dementing illness are overdue.

The relationship of endogenous cortisol to psychiatric disorder: a review.

OBJECTIVES: To focus on hypothalamic-pituitary-adrenal (HPA) axis activity, especially endogenous hypercortisolemia, to study its role in the maintenance of psychiatric illness, and to entertain the probability that the elderly are vulnerable. METHOD: Case presentation, clinical and research literature review, and theoretical discussion. RESULTS: Clinical and research evidence overwhelmingly suggest that hypercortisolemia is toxic to the hippocampus. Some research supports the position that it can be a treatable perpetuating factor in a subset of affective disorders and psychoses. Pharmacological treatments to correct hypercortisolemia have been used by endocrinologists. Hypercortisolemic treatment-resistant and nontreatment-resistant psychoses and affective disorders have been successfully treated by a small number of researchers who remain interested in this subject. Data pertaining to geriatric psychoses may be germane but are sparse. CONCLUSIONS: It behooves us to research diagnostic methods pertaining to psychoses and affective disorders associated with hypercortisolemic states. Very little research is available, but we must be alert to the possibility that the elderly are more susceptible to cortisol endotoxicosis than the younger adult population. Without accurate diagnosis, we cannot take advantage of existing antiglucocorticoid strategies.

Aggression in the demented patient: a double-blind study of loxapine versus haloperidol.

Aggression is common in dementia, with devastating social consequences. While high or low potency neuroleptics are the usual treatment of choice, they have been shown to yield inconsistent behavioral improvement and significant iatrogenic disability. This double-blind study was undertaken with aggressive demented patients to assess the efficacy and safety of a mid-potency neuroleptic, loxapine, in comparison to the more commonly prescribed high potency drug, haloperidol. Using an optimizing dosage regime, the outcome variables studied were aggression frequency and the number and nature of emergent side effects. Results demonstrated no significant difference regarding efficacy, but significantly fewer side effects with loxapine administration. The clinical and theoretical implications of these findings are discussed.

Diagnostic confusion in treatment-refractory psychotic patients.

BACKGROUND: Two surveys of diagnostic practices in the United States suggest that many clinicians base their diagnoses on presenting symptoms and pay little attention to course and exclusionary criteria. Failure to correctly diagnose patients may result in inappropriate therapy and poor treatment response. The purpose of the present study was to investigate diagnostic practices. METHODS: We made detailed assessments of 50 consecutively admitted treatment-refractory psychotic patients and carefully applied DSM-III-R criteria. RESULTS: Referral diagnoses were changed in 23 of the 50 patients. Diagnoses of schizophrenia and schizoaffective disorder were made far less frequently and mood disorders (bipolar disorder and major depression) were diagnosed far more frequently by our group than by referring psychiatrists. Patients whose diagnosis was changed were more likely to be given mood-stabilizing medication and tended to show more improvement than patients whose diagnosis was not changed. CONCLUSIONS: These findings raise the possibility that patients may not respond to treatment because incorrect diagnoses result in inappropriate treatment.

Agitation in the demented elderly: a role for benzodiazepines?

"Agitation" is a term that is used to describe a wide range of dysfunctional behaviours in geriatric populations. The term is so widely used that in many cases it loses clinical meaning and therefore a more restricted use of the term is suggested. When patients with agitation are identified it is important to look for underlying treatable pathology which is often present. Controversy surrounding the most appropriate medications is reviewed with particular reference to both neuroleptics and benzodiazepines. A randomized double-blind comparison of lorazepam and alprazolam in demented patients with agitation was carried out. While both drugs were efficacious for some patients, there were significantly more serious side-effects with lorazepam. It appears that there is a role for benzodiazepines such as alprazolam in the management of the agitated demented patient.

Randomized double-blind, placebo-controlled clinical trial of a selective 5-lipoxygenase inhibitor (AA-861) for the prevention of seasonal allergic rhinitis.

In a randomized, double-blind, parallel group trial conducted in eight European centres, the 5-lipoxygenase inhibitor AA-861 was administered orally, starting 2 weeks before the pollen season and continuing for 8 weeks; after the start of the season escape medication was permitted if necessary. Patients were enrolled who had a previous history of pollen allergy, confirmed by skin prick tests and/or relevant allergen-specific immunoglobulin E to pollen. Daily symptoms scores were recorded on diary cards and assessments were made by the investigator during the study period. Better global improvement ratings were achieved using AA-861, as assessed both by the investigators and the patients. The total nasal symptoms scores and activities of daily living were also improved compared to placebo. No significant adverse reactions were encountered.

Treatment of depression in the elderly: a Canadian view.

1. Between 10 and 15% of people over the age of 65 have a potentially treatable depression. 2. The commonest antidepressants used in Canada, the tertiary-amine tricyclics, are potentially problematic when used with geriatric patients. 3. It is current practice in geriatric psychiatry to use secondary-amine tricyclics as "first choice" drugs for elderly depressed patients. 4. Electroconvulsive therapy can be effectively used to deal with severely depressed elderly patients, particularly if there are also features of dementia. 5. Although "better drugs" are needed for the elderly, people over the age of 65 are typically excluded from treatment outcome research.

Comparative plasma levels of doxepin and desipramine in the elderly.

Although tricyclic antidepressants remain a principal mode of treatment of depression in the elderly, concomitant medical illness in this subgroup creates particular concern regarding the safety of these drugs. Doxepin has gained favour for use in the geriatric population due to claims of low cardiovascular side effects. This perceived safety has been questioned, however, since few investigators have actually reviewed plasma levels. A recent finding of interest revealed that two patients on 150 mg of doxepin daily with assured compliance had undetectable levels of doxepin or desmethyldoxepin in their plasma. A prospective study was consequently undertaken to compare oral doses and plasma levels of doxepin with desipramine as a standard reference compound. Data was collected for 19 females (12 on doxepin, seven on desipramine) and 12 males (five on doxepin, seven on desipramine) with a mean age of 76. Eight patients on doxepin showed undetectable plasma levels as compared with none on desipramine. This is a highly significant difference. Although the therapeutic plasma range for doxepin remains controversial, it is unlikely that patients can respond to levels of zero. The authors recommend routine monitoring of doxepin levels in the elderly and question poor bioavailability or absorption of this tricyclic antidepressant in some patients.

Assessment of suicide risk by computer-delivered self-rating questionnaire: preliminary findings.

A prospective study of 167 consecutive patients admitted to a general hospital following an episode of deliberate self-harm was carried out; 102 patients were interviewed by computer and then by a psychiatrist who was blind to the results of the computer interview. The computer interview consisted of a self-rating modification of the Hamilton Rating Scale for Depression and a novel questionnaire developed to assess suicidal ideation. This article explores the preliminary findings in these patients and suggests that not only is the computer interview acceptable to the majority of patients but the data suggest, in line with previous studies, that the patients are prepared to confide information to the computer that they may be unwilling to tell the clinician. Further the data also suggest a significant pathoplastic effect of the personality of the patient on the perception of the psychopathology by the clinician. The computer appeared to be a better predictor of suicidality than the interview by the clinician.

The use and misuse of psychotropic prescribing for elderly psychiatric patients.

The presenting problems and pre-admission diagnoses of 100 consecutive admissions to a geriatric psychiatry inpatient assessment unit were assessed in a retrospective survey and the use of psychotropic medication examined. Although post-admission diagnoses showed a high proportion of depressive illness amongst the patients, depression was infrequently diagnosed prior to admission and antidepressants infrequently used. The majority of these elderly patients were referred with a diagnosis of dementia and 'behaviour problems'. These were treated prior to admission with neuroleptics or benzodiazepines in line with prescribing habits in this population reported elsewhere in North America. Attention is drawn to the significant incidence of major depression in these patients and the excellent response to treatment, both with chemotherapy or with electrotherapy. Attention is also drawn to the pre-admission prescribing of psychotropic drugs which are likely to lead to problems when used in the elderly and likely to result in significant iatrogenic disorders.

ECT in the treatment of mixed depression and dementia.

Recent work has demonstrated the coexistence of depressive illness in some patients with dementing disorders. Two cases of mixed depression and dementia showed behavioural and mood improvement after treatment with ECT, but without improvement in cognition. The role of ECT in the treatment of affective symptoms in dementia is discussed.