Duration of neuroleptic treatment and prevalence of tardive dyskinesia in late life

Comparing the risk of tardive dyskinesia in older adults with first-generation and second-generation antipsychotics: a systematic review and meta-analysis

OBJECTIVE

The advent of second-generation antipsychotics (SGAs) in the 1990s brought optimism that neuroleptic-induced tardive dyskinesia (TD) may become relegated to history. Whether or not this is the case remains inconclusive, and this review aims to compare the risk of TD in older adults treated with first-generation antipsychotics (FGAs) versus SGAs.

METHODS

Relevant papers were sourced via a range of electronic databases, with a date range from 1957 to January 2015. Included studies used both a validated rating scale and research diagnostic criteria to report on the prevalence or incidence of TD in older adults exposed to antipsychotic medications.

RESULTS

For FGAs, the prevalence estimate was 53% (95% confidence interval [CI] [39.0, 68.4]) for mild TD and 38% (95% CI [25.9, 50.3]) for probable TD. Incidence estimates for probable TD with FGAs were 23% (95% CI [15.3, 30.6]) at 1 year, 42% (95% CI [24.8, 58.4]) at 2 years and 57% (95% CI [45.3, 69.1]) at 3 years. For SGAs, the incidence estimates at 1 year were 7% (95% CI [4.4, 10.2]) for probable TD and 3% (95% CI [1.5, 4.2]) for persistent TD.

CONCLUSIONS

The risk of probable TD is more than three times lower in older adults receiving SGAs in comparison with FGAs after 1 year of treatment (23% vs 7%). The risk of persistent TD at 1 year with SGAs is particularly low. Evidence is lacking in regard to the longer-term risk of TD with SGAs, although the rates associated with the prolonged use of FGAs are high. Caution is therefore still required, particularly with the protracted use of both FGAs and SGAs.

Antipsychotic Medication Use in the Elderly Patient

The use of antipsychotic medications in the elderly can be very complex and is ever changing. Consideration must be given to not only the physiologic and functional changes normally associated with age but also to the latest data on safety and adverse outcomes associated with using these agents. Because of new and changing information, this article will review the effects of aging, side effects of antipsychotic medications, and the current issues surrounding their use in elderly patients for those clinicians who are not specialists in this area of practice.

Implications of the CATIE trial on treatment: extrapyramidal symptoms

Development of extrapyramidal symptoms (EPS), particularly tardive dyskinesia (TD), has long been a troubling side effect for patients taking antipsychotics. Atypical antipsychotics have been hailed as an improvement over conventional antipsychotics, offering similar efficacy with more favorable EPS profiles. In the recent Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, which compared the conventional antipsychotic perphenazine with atypical antipsychotics olanzapine, quetiapine, risperidone, and ziprasidone in patients with schizophrenia, no significant differences in time to treatment discontinuation due to intolerability were observed between treatment groups. However, perphenazine was associated with a higher rate of patients experiencing EPS as well as a significantly higher rate of discontinuation due to EPS, despite the fact that patients with TD at baseline were excluded from the perphenazine group. Unfortunately, due to short treatment duration, the CATIE study did not have the assay sensitivity to detect differences in TD risk among any of the drugs. Thus, the atypical antipsychotics remain the first line of treatment for most patients, with specific drug selection based on benefit-risk profiles that best fit the individual patient's needs. Frequent monitoring, while noting a patient's subjective experience, remains the best strategy for choosing therapy to maximize symptom relief and minimize the impact of EPS and other side effects over the long- term. This article explores the reported results of the CATIE trial regarding EPS and emphasizes the differentiation of the atypicals from perphenazine on EPS and how these results should be incorporated into daily practice for the clinician.

Tardive Dyskinesia: analysis of outpatients with schizophrenia from Africa and the Middle East, Asia, Central and Eastern Europe, and Latin America

The point prevalence of Tardive Dyskinesia (TD) in schizophrenia outpatients (n=6981) participating in a study of health outcomes was 8.9%. Duration of diagnosis, age, and prior use of typical antipsychotics were diagnostic indicators of TD in this population, with male sex further increasing risk. This study provides new data in a non-Western population with a unique regional geography comparison.

The early stage of vascular dementia: significance of a complete therapeutic program

THEORY

Mild manifestations of vascular dementia are relatively widespread among the old-age population. Drug therapy for this disorder is insufficiently effective at present, making it necessary to improve the treatment of such patients by means of an adequate psychotherapeutic and rehabilitation program.

AIMS

To assess the role of psychotherapeutic and rehabilitation measures in improving outcome in the early stage of vascular dementia.

METHODS

The test and control cohorts (each n = 95) were matched for characteristics found to be significant for outcome of treatment (the relevant predictors were found using Multiple Regression Analysis). The cohorts differed in the amount of the psychotherapy and rehabilitation received. To assess the effects of treatment the SCAG scale and a special scale for evaluating the level of activity in the household were used.

RESULTS

In the test cohort the patients' condition improved significantly compared with the controls. Even in case of only slight therapeutic reduction of psychopathologic symptoms the systematic use of psychotherapeutic and rehabilitation methods favoured preserving a certain level of activity in the household and for some patients even improving it.

CONCLUSIONS

The results of therapy at the early stage of vascular dementia to a great extent depend on carrying out a full-scale psychotherapeutic and rehabilitation program. The positive significance of the latter is connected not only with improvement of clinical indices but also with direct optimizing the every day life activity level.

The effect of age on the pharmacological management of ambulatory patients treated with depot neuroleptic medications for schizophrenia and related psychotic disorders

BACKGROUND

Cross-sectional studies indicate that, in comparison to younger patients, older schizophrenic patients have a higher risk for neuroleptic-induced Parkinsonism and tardive dyskinesia (TD). It has been suggested, therefore, that older patients with schizophrenia could be maintained on reduced doses of conventional neuroleptics.

METHOD

We examined the effect of age on psychopharmacological management in a naturalistic study of a group of 165 patients with a clinical diagnosis of schizophrenia or a related psychotic disorder (age range = 21-84 years; subjects > or = 1;45 years n = 86) treated with either haloperidol decanoate or fluphenazine decanoate.

RESULTS

Increasing age was not correlated with total daily dose of neuroleptics or anticholinergic medication. However, a modest negative correlation of age with daily neuroleptic dose was found in patients aged 45 years and older.

CONCLUSION

The results of this study highlight the need for prospective assessments of depot neuroleptic dose requirements in older patients suffering from primary psychotic disorders.

Association between three functional polymorphisms of dopamine D2 receptor gene and tardive dyskinesia in schizophrenia

The dopamine D2 receptor (DRD2) gene is considered one of the candidate genes contributing to the development of tardive dyskinesia (TD). In the present study, we investigated the genetic association between three functional polymorphisms (Ser311Cys, -141C Ins/Del and TaqI A) in the DRD2 gene and TD (200 patients with schizophrenia: 44 with TD and 156 without TD). No significant difference in the allelic and genotypic distribution between patients with TD and those without TD was observed. However, we found a slightly significant association between the -141C Ins/Del polymorphism and the total Abnormal Involuntary Movement Scale (AIMS) score (P = 0.037). The significant association between the -141C Ins/Del polymorphism and the total AIMS score did not remain after the regression analysis was taken into account (P = 0.14). Our results suggest that that three functional polymorphisms in DRD2 may not play a major role in the occurrence of TD.

Mood Disorders in Neurologic Illness

Patients with neurologic illness frequently develop secondary mood disorders that are broadly categorized as unipolar or bipolar. Accurate diagnosis is essential because the treatment of unipolar disorders is markedly different from that of bipolar disorders. Aggressive treatment of mood disorders improves quality of life, reduces morbidity and mortality, and may prevent worsening of both psychiatric and neurologic disease. Antidepressants and psychotherapy are both effective for patients suffering from depressive disorders. Choice of antidepressant depends on the patient's particular symptom complex; medication side effects, which may exacerbate the underlying neurologic condition; potential interactions with other drugs; and costs. Bipolar disorder associated with neurologic illness typically requires treatment with mood stabilizers such as lithium, divalproex sodium, carbamazepine, or verapamil. Although psychotherapy in combination with pharmacologic therapy improves the outcome in bipolar illness, psychotherapy alone is not effective for this condition. Electroconvulsive therapy is an effective treatment for both depression and mania. It may have particular usefulness in Parkinson's disease, for which it has been shown to improve the movement disorder itself. Treatment of bipolar disorder, psychotic depression, or refractory depression is complicated and should be referred to a psychiatrist.

Tardive dyskinesia in a chronically institutionalized population of elderly schizophrenic patients: prevalence and association with cognitive impairment

BACKGROUND

Chronically hospitalized geriatric inpatients with schizophrenia are at particular risk for both tardive dyskinesia (TD) and cognitive impairment but have been insufficiently studied in this regard. Similarly, the relationship between TD and cognitive impairment has not be adequately addressed in this population.

OBJECTIVES

(1) To determine the prevalence of TD in a cohort of chronically institutionalized schizophrenic geriatric inpatients. (2) To examine the relationship between the manifestations of TD in various body regions and several potentially related variables including current pharmacological regimen, age, age at first hospitalization and cognitive status.

METHOD

TD was assessed by the Modified Simpson Dyskinesia Scale and cognitive status by the Mini-Mental State Examination (MMSE). The relationship between manifestations of TD and other variables was examined by t-tests, ANOVA, MANOVA and correlational analysis.

RESULTS

The prevalence of TD was 60%. Prevalence increased with age but was not related to current antipsychotic or anticholinergic regimen. Mean MMSE score did not differ between groups of patients with and without TD as defined by the criteria of Schooler and Kane (1982); however, the mean MMSE score was significantly (p < 0.0004) lower in subjects with orofacial TD as defined by Waddington and Youssef (1996), and the difference was not entirely accounted for by the older age of the latter group.

CONCLUSIONS

TD and cognitive impairment both increase with age. However, TD alone does not account for the severity of cognitive impairment in this population. The present study provides further support for the hypothesis that the correlation between TD and cognitive impairment holds primarily for the orofacial manifestations of TD.

Drug-induced movement disorders

Drug-induced movement disorders are often unrecognized, especially when not due to dopamine receptor blockers. This review discusses acute, subacute, and chronic syndromes. Pathophysiology relates almost always to dopaminergic transmission. Patient-dependent vulnerability and drug-dependent sensitivity are contributing factors. Young patients are more prone to acute reactions, and tardive or chronic conditions are more frequent in the elderly. Subclinical Parkinsonism can be unmasked by medication exposure. Treatment of tardive dyskinesia remains a challenging task for the clinician, but novel antipsychotics and dopamine depleting agents can be beneficial.

Craniofacial and TMJ effects after glutamate and TRH microsphere implantation in proximity to trigeminal motoneurons of growing rats

The sequelae of sustained, in vivo delivery of two important neurotransmitter substances, glutamate and thyrotropin-releasing hormone (TRH), upon craniofacial growth and development have previously not been investigated. Our purpose was to document and compare the relative effects of glutamate and TRH microspheres stereotactically placed in proximity to trigeminal motoneurons within the trigeminal motor nucleus. The following null hypotheses were tested: (1) TRH microspheres in proximity to trigeminal motoneurons have no significant effect upon the craniofacial skeleton, and (2) there are no significant differences between the relative effects of chronic, long-term delivery of glutamate and TRH upon the neuromusculoskeletal system of growing rats. Forty male Sprague-Dawley rats were divided into 4 experimental groups (glutamate microspheres, TRH microspheres, blank microspheres, sham surgeries) and underwent stereotactic neurosurgery at 35 days; 5 rats of each group were killed at 14 and 21 days for data collection. Histology revealed that implants were clustered in the pontine reticular formation, close to the ventrolateral tegmental nucleus. Both glutamate and TRH rats had implant-side deviation of their facial skeleton and snout regions; 4 x 2 ANOVA and post hoc t-tests revealed significant (P < or = 0.05, 0.01) differences between groups and sides for motoneuron count, muscle weight, and osteometric data. TRH rats also demonstrated larger implant-side TMJ discs and mandibular fossae in comparison with the other groups. The stated null hypotheses were therefore rejected.

Pharmacodynamic and pharmacokinetic considerations in geriatric psychopharmacology

Age-associated decreases in metabolism and elimination of drugs are sufficient to give one pause before prescribing drugs in the elderly particularly if multiple drugs are to be used. When one factors in concomitant drugs that may inhibit P450-mediated metabolism of other more toxic drugs, genetic deficiency of P450 enzymes, and medical illnesses such as liver and renal failure that will lead to further elevation of drug levels and delay in drug clearance, the likelihood of adverse events when multiple drugs are used in the elderly becomes truly dizzying. In consideration of the pharmacologic principles discussed, when prescribing drugs in the elderly, one might add to the often heard recommendation, "Start low and go slow," a third admonition, "Keep it as simple as possible!"