Anne Bailey

Lower Incidence of Tardive Dyskinesia with Risperidone Compared with Haloperidol in Older Patients

OBJECTIVE: To compare the 9‐month cumulative incidence of tardive dyskinesia (TD) with risperidone to that with haloperidol in older patients.

Pharmacological treatment of psychosis and agitation in elderly patients with dementia: four decades of experience.

A number of studies, using different research designs and assessment instruments, have been conducted to elucidate the differential effects of drug treatments for psychosis, agitation and aggression in elderly patients with dementia. We have reviewed literature published from 1960 to 2000 on this topic; 48 studies that met our selection criteria were identified from Medline and Science Citation Index.Antipsychotic medication was generally effective for the treatment of psychosis and agitation in elderly patients with dementia. In double-blind, placebo-controlled trials in this population, mean improvement rates were 61% with antipsychotic s and 35% with placebo. Atypical antipsychotics appeared promising, but the number of well-designed studies has been small so far. Methodological limitations of the studies reviewed are discussed; future trials should ensure adequate sample size and duration and involve direct comparisons of individual medications.In conclusion, conventional antipsychotics are modestly effective for treatment of psychosis and agitation in elderly individuals with dementia, whereas newer treatments such as atypical antipsychotics appear to be at least as effective while having fewer adverse effects. Nonetheless, there is no currently available ideal pharmacotherapy, and psychosocial management is a necessary part of overall treatment. Additional large-scale, well-controlled studies are needed before conclusive statements regarding the value of treatment of psychosis and agitation with atypical antipsychotics and non-antipsychotic agents can be made.

Relationship of neuropsychological and MRI measures to age of onset of schizophrenia

Age of onset of schizophrenia (AOS) may be largely determined by neurobiological factors. We examined in a diverse sample of schizophrenia out‐patients the relationships of AOS with neuropsychological abilities and structural brain abnormalities as measured on cerebral magnetic resonance imaging (MRI). A total of 82 out‐patients meeting DSM‐III‐R criteria for schizophrenia were evaluated with a comprehensive neuropsychological battery and semi‐automated quantitatively analysed cerebral MRI. Earlier AOS correlated with poorer performance in learning and abstraction/ cognitive flexibility, and with larger volumes of caudate and lenticular nuclei, and smaller volume of thalamus on MRI. A model for predicting AOS consisting of abstraction and thalamic and caudate volumes remained significant after controlling for duration of illness, current age and daily neuroleptic dose. In conclusion, AOS may be related to specific rather than general measures of cognitive performance and structural brain abnormalities.

Patterns of Public Mental Health Service Use by Age in Patients With Schizophrenia

OBJECTIVE Authors examined the relationship between age and use of public mental health services by adults with schizophrenia in a large mental health care system. METHODS The study sample included 4,975 patients treated for schizophrenia in San Diego Countys Adult Mental Health Services (AMHS) during fiscal year 1999-2000. They compared three age-groups: 18-44 years (young adults), 45-64 (middle-aged), and 65-or-older (elderly) on 1) the number of individuals treated for schizophrenia per 10,000 people in the county, and 2) the use of six different types of public mental health services, including hospitalization, emergency psychiatric unit, crisis house, outpatient clinic, day treatment, and case management. RESULTS Elderly patients with schizophrenia were underrepresented among AMHS users with a diagnosis of schizophrenia. The use of hospitalization, emergency room, crisis house, and day treatment was highest among young-adult patients and decreased with age. Outpatient treatment use was similar for young-adult and middle-aged patients and lower for elderly patients. The only type of service use that seemed to increase with age was case management. Even after controlling for gender, ethnicity, living situation, substance use disorder, and insurance status, most of the above-mentioned age-related differences in service use persisted. CONCLUSION Among patients with schizophrenia in a public mental health system, old age was associated with significantly lower use of all mental health services except case management. Research is needed to explore reasons for this differential use of services across age-groups.

Neuroleptic treatment of HIV-associated psychosis

The aim of this rater-blinded randomized study was to evaluate the efficacy and side effects of haloperidol and thioridazine in the treatment of new-onset psychosis in HIV-positive individuals. Participants were 13 men who had no history of psychosis prior to infection with HIV, and whose psychosis was not attributable to delirium or to non-HIV-related organic factors. Participants were evaluated at baseline after at least one month without neuroleptic treatment and then weekly for six weeks of the experimental treatment using several rating scales. The mean daily dose in chlorpromazine equivalents was 124 mg. Both neuroleptics produced modest but significant reduction in overall level of psychosis and in positive symptoms, but not in negative symptoms. All the haloperidol-treated patients developed extrapyramidal side effects and required treatment with anticholinergic medication, whereas three of the five thioridazine-treated patients had noticeable side effects. We make recommendations for the treatment of HIV-associated psychosis with neuroleptics.

Neuroleptic dose reduction in older psychotic patients

We conducted a non-randomized, rater-blind study to safely determine the lowest effective neuroleptic dosage in older psychotic patients and to evaluate the clinical, neuropsychological, and psychosocial effects of neuroleptic dosage reduction. Twenty-seven carefully selected patients with schizophrenia and related psychotic disorders over the age of 45 had their dosage tapered by 25% each month to determine their lowest effective dosage. These patients were compared with patients similar in age, gender, and education who were currently off neuroleptics (n = 19) or maintained on neuroleptics (n = 22). All groups were followed for 11 months. Over the follow-up period, 29% of patients in the taper group, 8% of neuroleptic-free patients, and 0% of patients in the maintenance group experienced some increase in psychopathology, although there was no significant change in mean PANSS score in any group, and no patient required hospitalization. Patients in the taper group were maintained on approximately 60% of their original neuroleptic dosage after restabilization. Extrapyramidal symptoms continued to improve over time in the taper group. Neuropsychological testing did not change significantly over time except for those in the taper group who experienced a decrease in memory-retention on the Hopkins Verbal Learning Test and a significant improvement in digit vigilance and Stroop Interference Index. Carefully selected middle-aged and elderly psychotic patients can have their neuroleptic medications reduced without a significant change in psychopathology. Extrapyramidal symptoms may continue to improve gradually over time. The impact on cognition functioning needs further investigation.

Validating specific psychopathology scales in older outpatients with schizophrenia.

To our knowledge, there have been no published studies validating commonly used psychopathology rating scales in older outpatients with schizophrenia. We studied specific psychopathology rating scales (three subscales of the Brief Psychiatric; Rating Scale: positive symptoms, negative symptoms, and depression subscales; the Scale for the Assessment of Positive Symptoms; the Scale for the Assessment of Negative Symptoms; and the Hamilton Depression Rating Scale) in 101 older (age > 45 years) DSM- III-R-diagnosed schizophrenia outpatients. We found high interrater reliability (intra-class correlation coefficient >.77) on these scales. Using principal components analysis, we demonstrated satisfactory construct validity, suggesting three factors—positive symptoms, negative symptoms, and depressive symptoms.

Validity of specific subscales of the positive and negative symptom scales in older schizophrenia outpatients

We investigated the construct validity of subscales of the Scale for the Assessment of Positive Symptoms (SAPS) and the Scale for the Assessment of Negative Symptoms (SANS) along with other measures of psychopathology in 109 schizophrenia outpatients aged 45-84 years. Scores on subscales of the SAPS, SANS and Brief Psychiatric Rating Scale (BPRS) and on the Hamilton Depression Scale (HAM-D) were subjected to a principal components analysis and orthogonal rotation followed by an extension analysis. In both analyses, three of four SAPS subscales had their highest loading on the positive symptom factor and four of five SANS subscales had their highest factor loading on the negative symptom factor. The SAPS bizarre behavior subscale, however, had a much higher loading on the depressive symptom factor than on the positive symptom factor, and the SANS avolition-apathy subscale had moderate loadings on both the negative symptom factor and the depressive symptom factor. The use of SAPS and SANS subscales to represent two constructs was largely (but not entirely) validated among middle-aged and elderly schizophrenia outpatients. The SAPS bizarre behavior subscale and, to a lesser extent, the SANS avolition-apathy subscale appear to represent in this older population a separate construct which may be related to depressive symptoms.