Adverse Effects of Atypical Antipsychotics in the Elderly

The safety of clozapine in the elderly

BACKGROUND

Clozapine was the first atypical 'broad spectrum' antipsychotic drug to be marketed and the first agent approved for the treatment of schizophrenia refractory to other medications. It is also effective for the treatment of aggressive behaviour in schizophrenic and demented patients and in the management of psychosis and aggression in Parkinson's disease and Lewy body dementia.

OBJECTIVE

The aim of this review is to study the safety of clozapine for use in elderly patients.

METHODS

An extensive Medline search was made. Some studies that were referenced in reports from our pharmacovigilance centre and from regulatory agencies such as the FDA, EMEA and WHO were included.

CONCLUSIONS

Clozapine treatment in the elderly requires a careful geriatric assessment. However, its use is strongly limited by the possibility of onset of severe adverse effects such as potentially fatal agranulocytosis, myocarditis and others such as seizures, weight gain and metabolic adverse effects.

Antipsychotics and oropharyngeal dysphagia in hospitalized older patients

In the inpatient setting, dysphagia is a common, morbid, and costly condition. Antipsychotic medications in older patients have been associated with dysphagia. The purpose of this study was to determine if hospitalized patients who were exposed to antipsychotic medications had worse swallowing function than those who were not exposed. Retrospectively, all patients referred for swallowing difficulty who underwent a videofluoroscopic swallowing study during the course of their hospital care were considered eligible. We excluded patients younger than 50 years and those with a history of dysphagia, a medical cause for dysphagia, or chronic antipsychotic medication usage. Patients exposed to antipsychotics (n = 17) were matched at a 3:1 ratio to patients without exposure (n = 51) for age, comorbidity, and anticholinergic risk. Videofluoroscopic swallowing study was scored according to the Dysphagia Severity Rating Scale (range, 0-6; 6 = worst). Patients who were given antipsychotic medications scored significantly worse on the Dysphagia Severity Rating Scale compared with matched controls (4.1 +/- 1.0 vs 3.0 +/- 1.4; P < 0.01). Using the medication and dosage, the antipsychotic exposure was quantified by converting to chlorpromazine equivalency units. Higher doses of antipsychotic medication were associated with worse swallowing function (P = 0.04). Thus, the potential impact on swallow functions should be considered when prescribing antipsychotic medications in older patients.

Psychotropic prescribing in long-term care facilities: impact of medication reviews and educational interventions

The objective of this literature review was to evaluate the evidence pertaining to the impact of medication reviews and/or educational interventions on psychotropic drug use in long-term care facilities. A computerized search was conducted using MEDLINE, Cochrane Central Register of Control Trials, CINAHL, EMBASE, International Pharmaceutical Abstracts and PsycINFO, from January 1980 to April 2007. Controlled studies or randomized controlled studies were included for review. The authors identified 26 studies evaluating the impact of medication reviews and/or educational interventions on psychotropic drug use in long-term care facilities. Eleven studies met the inclusion criteria for this review and the data from six of these studies were included in a meta-analysis. The pooled odds ratio (OR) from five studies on hypnotic prescribing showed a decrease in use postintervention (OR = 0.57, 95% confidence intervals [CI] = 0.41-0.79). The pooled OR from five studies on prevalence of antipsychotic prescribing postintervention was not significant (OR = 0.81, 95% CI = 0.63-1.04). Medication reviews and/or educational interventions are effective at reducing psychotropic drug prescribing. However, research on the benefits of these interventions in reducing psychotropic drug use on total health care costs and resident health outcomes is lacking.

Clinical characterization of late- and very late-onset first psychotic episode in psychiatric inpatients

OBJECTIVES

The goals of this study were to investigate the prevalence and initial symptoms of the late-onset schizophrenia (LOS: >40 years) and very-late-onset schizophrenia-like psychosis (VLOSLP: >60 years) nosological groups proposed by the International Late-Onset Schizophrenia Group.

DESIGN

This was a retrospective, cross-sectional, chart review study.

SETTING

The study was conducted at Centre Hospitalier Robert-Giffard (CHRG), Quebec City, Canada.

PATIENTS

The medical records of inpatients from the CHRG who presented with psychotic symptoms were analyzed.

MEASUREMENTS

Positive and negative symptoms were scored using the SAPS and SANS. Groups' symptoms were compared using chi(2), Fisher's exact tests, t tests, and exact Mann-Whitney tests. An exact conditional logistic regression analysis was performed to determine which clinical characteristics were the most predictive of the groups' classification.

RESULTS

Among the 1,767 unique, first-admission medical records reviewed, 23 (1.3%) inpatients developed their first psychotic symptoms at the age of 40-59 years old (LOS), and 13 (0.7%) at the age of 60 years and above (VLOSLP). LOS patients were more apathetic and presented more abnormal psychomotor activity than the VLOSLP. Persecutory delusions, auditory hallucinations, inappropriate social behavior, formal thought disorders and anhedonia were frequent in the two groups. A logistic regression model including psychomotor abnormalities was statistically relevant to predict the belonging to LOS group.

CONCLUSION

LOS and VLOSLP are rare. Abnormal psychomotor activity can properly differentiate VLOSLP and LOS. The nosological model proposed by the International Late-Onset Schizophrenia Group is at least partially supported by the present data.

CNS-active drugs in aging population at high risk of cerebrovascular events: evidence from preclinical and clinical studies

The recovery process following cerebral insults such as stroke is affected by aging and pharmacotherapy. The use of medication including CNS-active drugs has increased in the elderly during recent years. However, surprisingly little is known about how safe they are with respect to severity of sensorimotor and cognitive impairments or recovery of function following possible cerebrovascular accidents. This review examines the experimental and clinical literature, primarily from 1995 onwards, concerning medication in relation to cerebrovascular events and functional recovery. Special attention is directed to polypharmacy and to new CNS-active drugs, which the elderly are already taking or are prescribed to treat emerging, stroke-induced psychiatric symptoms. The neurobiological mechanisms affected by these drugs are discussed.