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Ljubic N, Ueberberg B, Grunze H, Assion HJ. Treatment of bipolar disorders in older adults: a review. Ann Gen Psychiatry 2021; 20:45. [PMID: 34548077 PMCID: PMC8456640 DOI: 10.1186/s12991-021-00367-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/04/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Old age bipolar disorder has been an orphan of psychiatric research for a long time despite the fact that bipolar disorder (BD)-I and II together may affect 0.5-1.0% of the elderly. It is also unclear whether aetiology, course of illness and treatment should differ in patients with a first manifestation in older age and patients suffering from a recurrence of a BD known for decades. This narrative review will summarize the current state of knowledge about the epidemiology, clinical features, and treatment of BD in the elderly. METHODS We conducted a Medline literature search from 1970 to 2021 using MeSH terms "Bipolar Disorder" × "Aged" or "Geriatric" or "Elderly". Search results were complemented by additional literature retrieved from examining cross references and by hand search in text books. Varying cut-off ages have been applied to differentiate old age from adult age BD. Within old age BD, there is a reasonable agreement of distinct entities, early and late-onset BD. They differ to some extent in clinical symptoms, course of illness, and some co-morbidities. Point prevalence of BD in older adults appears slightly lower than in working-age adults, with polarity of episodes shifting towards depression. Psychopharmacological treatment needs to take into account the special aspects of somatic gerontology and the age-related change of pharmacokinetic and pharmacodynamic characteristics. The evidence for commonly used treatments such as lithium, mood-stabilizing antiepileptics, antipsychotics, and antidepressants remains sparse. Preliminary results support a role of ECT as well as psychotherapy and psychosocial interventions in old age BD. CONCLUSIONS There is an obvious need of further research for all treatment modalities of BD in old age. The focus should be pharmacological and psychosocial approaches, as well as their combination, and the role of physical treatment modalities such as ECT.
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Affiliation(s)
- Nemanja Ljubic
- Bereich Forschung & Wissenschaft, LWL-Klinik, Marsbruchstr. 179, 44287, Dortmund, Germany
| | - Bianca Ueberberg
- Bereich Forschung & Wissenschaft, LWL-Klinik, Marsbruchstr. 179, 44287, Dortmund, Germany
| | - Heinz Grunze
- Psychiatrie Schwäbisch Hall, Ringstraße. 1, 74523, Schwäbisch Hall, Germany.
- Paracelsus Medical University, Ernst-Nathan Straße 1, 90419, Nuremberg, Germany.
| | - Hans-Jörg Assion
- Bereich Forschung & Wissenschaft, LWL-Klinik, Marsbruchstr. 179, 44287, Dortmund, Germany
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Harris SS, Urs NM. Targeting β-Arrestins in the Treatment of Psychiatric and Neurological Disorders. CNS Drugs 2021; 35:253-264. [PMID: 33651366 DOI: 10.1007/s40263-021-00796-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 12/23/2022]
Abstract
Therapies for psychiatric and neurological disorders have been in the development and refinement process for the past 5 decades. Yet, most of these therapies lack optimal therapeutic efficacy and have multiple debilitating side effects. Recent advances in understanding the pathophysiological processes of psychiatric and neurological disorders have revealed an important role for β-arrestins, which are important regulators of G-protein-coupled receptor (GPCR) function, including desensitization and intracellular signaling. These findings have pushed β-arrestins to the forefront as potential therapeutic targets. Here, we highlight current knowledge on β-arrestin functions in certain psychiatric and neurological disorders (schizophrenia, Parkinson's disease, and substance abuse disorders), and how this has been leveraged to develop new therapeutic strategies. Furthermore, we discuss the obstacles impacting the field of β-arrestin-based therapeutic development and future approaches that might help advance strategies to develop optimal β-arrestin-based therapies.
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Affiliation(s)
- Sharonda S Harris
- Department of Pharmacology and Therapeutics, University of Florida, 1200 Newell Dr, ARB-R5-140, Gainesville, FL, 32610, USA
| | - Nikhil M Urs
- Department of Pharmacology and Therapeutics, University of Florida, 1200 Newell Dr, ARB-R5-140, Gainesville, FL, 32610, USA.
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3
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Frei K. Tardive dyskinesia: Who gets it and why. Parkinsonism Relat Disord 2019; 59:151-154. [DOI: 10.1016/j.parkreldis.2018.11.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/12/2018] [Accepted: 11/14/2018] [Indexed: 01/13/2023]
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Miura I, Zhang JP, Nitta M, Lencz T, Kane JM, Malhotra AK, Yabe H, Correll CU. BDNF Val66Met polymorphism and antipsychotic-induced tardive dyskinesia occurrence and severity: a meta-analysis. Schizophr Res 2014; 152:365-72. [PMID: 24411528 PMCID: PMC4010225 DOI: 10.1016/j.schres.2013.12.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 12/13/2013] [Accepted: 12/18/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Tardive dyskinesia (TD) is a serious long-term consequence of antipsychotic treatment. Since brain-derived neurotrophic factor (BDNF) has potent neurotrophic activity, genetic alterations in the BDNF gene may affect antipsychotic-induced TD. METHODS Searching PubMed and Web of Science until 05/31/13, we conducted a systematic review and a meta-analysis of the effects of BDNF Val66Met polymorphism on antipsychotic-induced TD. Pooled odds ratio was calculated to assess the effects of BDNF Val66Met polymorphism on TD occurrence. Additionally, pooled standardized mean differences (Hedges' g) were calculated to assess the effects on Abnormal Involuntary Movement Scale (AIMS) total score. RESULTS Out of 699 potentially eligible hits, 6 studies (N=1740, mean age=46.0±10.4years; males=73.1%; Asians=80.5%, Caucasians=19.5%; schizophrenia=96.2%) were included in this meta-analysis. Pooling data from all studies, no significant associations were found between BDNF Val66Met polymorphism and TD (p=0.82) or AIMS total scores (p=0.11). However, in studies including only Caucasians (n=339), Met allele carriers had significantly higher AIMS total scores (Hedges' g=0.253, 95% confidence interval=0.030 to 0.476, p=0.026) and non-significantly higher TD occurrence (p=0.127). Conversely, there was no association between BDNF and AIMS scores (p=0.57) or TD (p=0.65) in Asians. CONCLUSION Although there was no significant association between BDNF Val66Met polymorphism and TD or AIMS scores across all patients, our results suggest that BDNF Val66Met polymorphism affects severity and, possibly, TD development in Caucasians. Since the number of studies and patients was still small, additional data are needed to confirm genotype-racial interactions. Furthermore, BDNF enhancing treatments for TD may require further study, especially in Caucasians.
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Affiliation(s)
- Itaru Miura
- The Zucker Hillside Hospital, Psychiatry Research, North Shore — Long Island Jewish Health System, Glen Oaks, NY, USA,Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Jian-Ping Zhang
- The Zucker Hillside Hospital, Psychiatry Research, North Shore — Long Island Jewish Health System, Glen Oaks, NY, USA,Hofstra North Shore LIJ School of Medicine, Hempstead, NY, USA,The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Masahiro Nitta
- The Zucker Hillside Hospital, Psychiatry Research, North Shore — Long Island Jewish Health System, Glen Oaks, NY, USA,Dainippon Sumitomo Pharma Co., Ltd., Tokyo, Japan
| | - Todd Lencz
- The Zucker Hillside Hospital, Psychiatry Research, North Shore — Long Island Jewish Health System, Glen Oaks, NY, USA,Hofstra North Shore LIJ School of Medicine, Hempstead, NY, USA,The Feinstein Institute for Medical Research, Manhasset, NY, USA,Albert Einstein College of Medicine, Bronx, NY, USA
| | - John M. Kane
- The Zucker Hillside Hospital, Psychiatry Research, North Shore — Long Island Jewish Health System, Glen Oaks, NY, USA,Hofstra North Shore LIJ School of Medicine, Hempstead, NY, USA,The Feinstein Institute for Medical Research, Manhasset, NY, USA,Albert Einstein College of Medicine, Bronx, NY, USA
| | - Anil K. Malhotra
- The Zucker Hillside Hospital, Psychiatry Research, North Shore — Long Island Jewish Health System, Glen Oaks, NY, USA,Hofstra North Shore LIJ School of Medicine, Hempstead, NY, USA,The Feinstein Institute for Medical Research, Manhasset, NY, USA,Albert Einstein College of Medicine, Bronx, NY, USA
| | - Hirooki Yabe
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Christoph U. Correll
- The Zucker Hillside Hospital, Psychiatry Research, North Shore — Long Island Jewish Health System, Glen Oaks, NY, USA,Hofstra North Shore LIJ School of Medicine, Hempstead, NY, USA,The Feinstein Institute for Medical Research, Manhasset, NY, USA,Albert Einstein College of Medicine, Bronx, NY, USA,Corresponding author at: Division of Psychiatry Research, The Zucker Hillside Hospital, 75-59 263rd Street, Glen Oaks, NY 11004, USA. Tel.: +1 718 470 4812; fax: +1 718 343 1659
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Deslauriers J, Desmarais C, Sarret P, Grignon S. Implication of the ERK/MAPK pathway in antipsychotics-induced dopamine D2 receptor upregulation and in the preventive effects of (±)-α-lipoic acid in SH-SY5Y neuroblastoma cells. J Mol Neurosci 2013; 52:378-83. [PMID: 24203573 DOI: 10.1007/s12031-013-0158-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 10/21/2013] [Indexed: 11/29/2022]
Abstract
Chronic administration of antipsychotics (APs) has been associated with dopamine D2 receptor (D2R) upregulation and tardive dyskinesia. We previously showed that haloperidol, a first-generation AP, exerted a more robust increase in D2R expression than amisulpride, a second-generation AP and that (±)-α-lipoic acid pre-treatment reversed the AP-induced D2R upregulation. We also demonstrated that the Akt/GSK-3β/β-catenin pathway is involved in the control of D2R expression levels, but is unlikely implicated in the preventive effects of (±)-α-lipoic acid since co-treatment with haloperidol and (±)-α-lipoic acid exerts synergistic effects on Akt/GSK-3β activation. These findings led us to examine whether the ERK/MAPK signaling pathway may be involved in D2R upregulation elicited by APs, and in its reversal by (±)-α-lipoic acid, in SH-SY5Y human neuroblastoma cells. Our results revealed that haloperidol, in parallel with an elevation in D2R mRNA levels, induced a larger increase of ERK (p42/p44) phosphorylation than amisulpride. Pre-treatment with the selective ERK inhibitor U0126 attenuated haloperidol-induced increase in D2R upregulation. Furthermore, (±)-α-lipoic acid prevented AP-induced ERK activation. These results show that (1) the ERK/MAPK pathway is involved in haloperidol-induced D2R upregulation; (2) the preventive effect of (±)-α-lipoic acid on haloperidol-induced D2R upregulation is in part mediated by an ERK/MAPK-dependent signaling cascade. Taken together, our data suggest that (±)-α-lipoic acid exerts synergistic effects with haloperidol on the Akt/GSK-3β pathway, potentially involved in the therapeutic effects of APs, and antagonism of ERK activation and D2R upregulation, potentially involved in tardive dyskinesia and treatment resistance.
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Affiliation(s)
- Jessica Deslauriers
- Department of Physiology and Biophysics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e avenue Nord, Sherbrooke, QC, Canada, J1H 5N4
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Merrill RM, Lyon JL, Matiaco PM. Tardive and spontaneous dyskinesia incidence in the general population. BMC Psychiatry 2013; 13:152. [PMID: 23714238 PMCID: PMC3681708 DOI: 10.1186/1471-244x-13-152] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 05/21/2013] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND To identify the incidence rate of spontaneous dyskinesia (SD) and tardive dyskinesia (TD) in a general population and to examine the association between dykinesia and potential risk factors (exposure to metoclopramide [MCP], antipsychotic drugs, and history of diabetes and psychoses). METHODS A retrospective cohort study was conducted for the years 2001 through 2010, based on medical claims data from the Deseret Mutual Benefit Administrators (DMBA). RESULTS Thirty-four cases of TD and 229 cases of SD were identified. The incidence rate of TD among persons previously prescribed an antipsychotic or metoclopramide (MCP) (per 1,000) was 4.6 (1.6-7.7) for those with antipsychotic drug use only, 8.5 (4.8-12.2) for those with MCP use only, and 15.0 (2.0-28.1) for those with both antipsychotic and MCP use. In the general population, the incidence rate (per 100,000 person-years) of TD was 4.3 and of probable SD was 28.7. The incidence rates of TD and SD increased with age and were greater for females. Those with diabetes or psychoses had almost a 3-fold greater risk of TD than those without either of these diseases. Persons with schizophrenia had 31.2 times increased risk of TD than those without the disease. Positive associations also existed between the selected diseases and the incidence rate of probable SD, with persons with schizophrenia having 4.4 times greater risk of SD than those without the disease. CONCLUSIONS SD and TD are rare in this general population. Diabetes, psychoses, and especially schizophrenia are positively associated with SD and TD. A higher proportion of those with SD present with spasm of the eyelid muscles (blepharospasm) compared more with the TD cases who present more with orofacial muscular problems.
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Affiliation(s)
- Ray M Merrill
- Department of Health Science, Brigham Young University, 229-A Richards Building, Provo, UT 84602, USA.
| | - Joseph L Lyon
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, USA
| | - Paul M Matiaco
- Department of Health Science, Brigham Young University, 229-A Richards Building, Provo 84602, UT, USA
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7
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Chen L, Ascher-Svanum H, Lawson A, Stauffer VL, Nyhuis A, Haynes V, Schuh K, Kinon BJ. Movement disorder profile and treatment outcomes in a one-year study of patients with schizophrenia. Neuropsychiatr Dis Treat 2013; 9:815-22. [PMID: 23807848 PMCID: PMC3686240 DOI: 10.2147/ndt.s43574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND This study identified subgroups of patients with schizophrenia who differed on their movement disorder profile and compared their treatment outcomes. METHODS Data from a randomized, open-label, one-year study of patients with schizophrenia who were treated with antipsychotics in usual clinical care settings were analyzed (n = 640). Five measures of movement disorder were incorporated into a single Movement Disorder Index (MDI). Subgroups that differed in their movement disorder profile over the one-year study period were compared on clinical and functional outcomes. RESULTS THREE SUBGROUPS WERE IDENTIFIED: a worsening of MDI in 15% of patients, an improvement in 33%, and no change in 53%. Compared with the other two subgroups, the MDI-worsened subgroup had poorer symptom improvement measured by the Positive and Negative Syndrome Scale (PANSS) total score (mean changes of -11.0, -18.4, and -16.8 for the patients who had a worsening of MDI, no change, and an improvement, respectively), poorer symptom improvement on the PANSS positive and anxiety/depression subscale scores, worsening on the 36-Item Short Form Health Survey (SF-36) physical component summary score, and a higher rate of hospitalization (P < 0.05). CONCLUSION Patients with schizophrenia who experience worsening of their MDI score appear to have poorer clinical and functional outcomes, suggesting that such worsening may be a marker of poorer prognosis.
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Affiliation(s)
- Lei Chen
- Eli Lilly and Company, Indianapolis, IN, USA
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8
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Woerner MG, Correll CU, Alvir JMJ, Greenwald B, Delman H, Kane JM. Incidence of tardive dyskinesia with risperidone or olanzapine in the elderly: results from a 2-year, prospective study in antipsychotic-naïve patients. Neuropsychopharmacology 2011; 36:1738-46. [PMID: 21508932 PMCID: PMC3138649 DOI: 10.1038/npp.2011.55] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Tardive dyskinesia (TD) rates with second-generation antipsychotics (SGAs) are considered to be low relative to first-generation antipsychotics (FGAs), even in the particularly vulnerable elderly population. However, risk estimates are unavailable for patients naïve to FGAs. Therefore, we aimed to determine the TD incidence in particularly vulnerable, antipsychotic-naïve elderly patients treated with the SGA risperidone or olanzapine. The present work describes a prospective inception cohort study of antipsychotic-naïve elderly patients aged 55 years identified at New York Metropolitan area in-patient and out-patient geriatric psychiatry facilities and nursing homes at the time of risperidone or olanzapine initiation. At baseline, 4 weeks, and at quarterly periods, patients underwent assessments of medical and medication history, abnormal involuntary movements, and extra-pyramidal signs. TD was classified using Schooler-Kane criteria. Included in the analyses were 207 subjects (age: 79.8 years, 70.0% female, 86.5% White), predominantly diagnosed with dementia (58.9%) or a major mood disorder (30.9%), although the principal treatment target was psychosis (78.7%), with (59.4%) or without (19.3%) agitation. With risperidone (n=159) the cumulative TD rate was 5.3% (95% confidence interval (CI): 0.7, 9.9%) after 1 year (mean dose: 1.0±0.76 mg/day) and 7.2% (CI: 1.4, 12.9%) after 2 years. With olanzapine (n=48) the cumulative TD rate was 6.7% (CI: 0, 15.6%) after 1 year (mean dose: 4.3±1.9 mg/day) and 11.1% (CI: 0, 23.1%) after 2 years. TD risk was higher in females, African Americans, and patients without past antidepressant treatment or with FGA co-treatment. The TD rates for geriatric patients treated with risperidone and olanzapine were comparable and substantially lower than previously reported for similar patients in direct observation studies using FGAs. This information is relevant for all patients receiving antipsychotics, not just the especially sensitive elderly.
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Affiliation(s)
- Margaret G Woerner
- The Zucker Hillside Hospital, North Shore—Long Island Jewish Health System, Glen Oaks, NY, USA
| | - Christoph U Correll
- The Zucker Hillside Hospital, North Shore—Long Island Jewish Health System, Glen Oaks, NY, USA,Department of Psychiatry, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Blaine Greenwald
- The Zucker Hillside Hospital, North Shore—Long Island Jewish Health System, Glen Oaks, NY, USA,Department of Psychiatry, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Howard Delman
- The Zucker Hillside Hospital, North Shore—Long Island Jewish Health System, Glen Oaks, NY, USA
| | - John M Kane
- The Zucker Hillside Hospital, North Shore—Long Island Jewish Health System, Glen Oaks, NY, USA,Department of Psychiatry, Albert Einstein College of Medicine, Bronx, NY, USA,Department of Psychiatry Research, The Zucker Hillside Hospital, 75-59 263rd Street, Glen Oaks, NY 11004, USA, Tel: +1 718 470 8141, Fax: +1 718 343 7739, E-mail: or
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9
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Abstract
Clinicians treating older patients with schizophrenia are often challenged by patients presenting with both depressive and psychotic features. The presence of co-morbid depression impacts negatively on quality of life, functioning, overall psychopathology and the severity of co-morbid medical conditions. Depressive symptoms in patients with schizophrenia include major depressive episodes (MDEs) that do not meet criteria for schizoaffective disorder, MDEs that occur in the context of schizoaffective disorder and subthreshold depressive symptoms that do not meet criteria for MDE. Pharmacological treatment of patients with schizophrenia and depression involves augmenting antipsychotic medications with antidepressants. Recent surveys suggest that clinicians prescribe antidepressants to 30% of inpatients and 43% of outpatients with schizophrenia and depression at all ages. Recent trials addressing the efficacy of this practice have evaluated selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, fluvoxamine and citalopram. These trials have included only a small number of subjects and few older subjects participated; furthermore, the efficacy results have been mixed. Although no published controlled psychotherapeutic studies have specifically targeted major depression or depressive symptoms in older patients with schizophrenia, psychosocial interventions likely play a role in any comprehensive management plan in this population of patients.Our recommendations for treating the older patient with schizophrenia and major depression involve a stepwise approach. First, a careful diagnostic assessment to rule out medical or medication causes is important as well as checking whether patients are adherent to treatments. Clinicians should also consider switching patients to an atypical antipsychotic if they are not taking one already. In addition, dose optimization needs to be targeted towards depressive as well as positive and negative psychotic symptoms. If major depression persists, adding an SSRI is a reasonable next step; one needs to start with a low dose and then cautiously titrate upward to reduce depressive symptoms. If remission is not achieved after an adequate treatment duration (8-12 weeks) or with an adequate dose (similar to that used for major depression without schizophrenia), switching to another agent or adding augmenting therapy is recommended.We recommend treating an acute first episode of depression for at least 6-9 months and consideration of longer treatment for patients with residual symptoms, very severe or highly co-morbid major depression, ongoing episodes or recurrent episodes. Psychosocial interventions aimed at improving adherence, quality of life and function are also recommended. For patients with schizophrenia and subsyndromal depression, a similar approach is recommended.Psychosis accompanying major depression in patients without schizophrenia is common in elderly patients and is considered a primary mood disorder; for these reasons, it is an important syndrome to consider in the differential diagnosis of older patients with mood and thought disturbance. Treatment for this condition has involved electroconvulsive therapy (ECT) as well as combinations of antidepressant and antipsychotic medications. Recent evidence suggests that combination treatment may not be any more effective than antidepressant treatment alone and ECT may be more efficacious overall.
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Affiliation(s)
- John W Kasckow
- VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania 15206,
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10
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Folsom DP, Lebowitz BD, Lindamer LA, Palmer BW, Patterson TL, Jeste DV. Schizophrenia in late life: emerging issues. DIALOGUES IN CLINICAL NEUROSCIENCE 2006. [PMID: 16640113 PMCID: PMC3181756 DOI: 10.31887/dcns.2006.8.1/dfolsom] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Schizophrenia in late life is emerging as a major public health concern worldwide. We discuss several areas of research and clinical care that are particularly pertinent to older persons with schizophrenia, including the public health challenge and the cost of care. We then discuss clinical issues relevant to late-life schizophrenia (course of illness and cognition), medical care and comorbidity in older psychiatric patients (general and illness-related), and treatment concerns related to the use of atypical antipsychotics in older persons with psychosis (efficacy and side effects). Clinical care for this ever-increasing segment of our population requires special consideration of the unique characteristics of older persons with schizophrenia.
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Affiliation(s)
- David P Folsom
- University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0664, USA
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11
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Jeste DV, Dunn LB, Palmer BW, Saks E, Halpain M, Cook A, Appelbaum P, Schneiderman L. A collaborative model for research on decisional capacity and informed consent in older patients with schizophrenia: bioethics unit of a geriatric psychiatry intervention research center. Psychopharmacology (Berl) 2003; 171:68-74. [PMID: 12768273 DOI: 10.1007/s00213-003-1507-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2002] [Accepted: 04/04/2003] [Indexed: 10/26/2022]
Abstract
RATIONALE The numbers of older persons with psychiatric disorders are expected to rise rapidly in coming decades, yet most studies of the safety and efficacy of treatments for such disorders have focused on younger adults. A substantial expansion in research involving older patients is needed to meet the treatment needs of this fast growing group. A critical issue in intervention research is ensuring a patient's decision-making capacity. Considerable heterogeneity exists in this regard even within diagnostic groups. Cognitive changes as well as increased complexity of medication regimens in elderly patients may make it particularly difficult for some older persons to fully understand, appreciate, and/or reason about the risks and benefits of participating in any particular study. OBJECTIVES Empirical research into assessing and possibly improving decisional capacity is warranted in older people with severe mental illness. Such research may be accomplished through collaborations among specialists from various related disciplines and, importantly, with active involvement of community partners. METHODS We present one model of this type of collaboration, the Bioethics Unit of an Intervention Research Center, comprising a multi-disciplinary team along with a Community Advisory Board. RESULTS Preliminary studies in our Center suggest that older individuals with psychotic disorders vary considerably in their decisional capacity, and many subjects appear to be fully capable for consenting to research projects. Furthermore, the patients' level of understanding of the consent material can be improved significantly through repetition and clarification of key elements in the consent form. CONCLUSIONS The decisional capacity for a given research protocol is not necessarily an unmodifiable trait, but can be enhanced with improvements in consenting procedures, even in older persons with psychotic disorders.
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Affiliation(s)
- Dilip V Jeste
- Department of Psychiatry and Neurosciences, University of California San Diego and VA San Diego Healthcare System, San Diego, CA 92161 USA.
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12
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Zaudig M. A risk-benefit assessment of risperidone for the treatment of behavioural and psychological symptoms in dementia. Drug Saf 2000; 23:183-95. [PMID: 11005702 DOI: 10.2165/00002018-200023030-00002] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The importance of behavioural and psychological symptoms in dementia (BPSD) is increasingly being recognised. Symptoms such as verbal and physical aggression, agitation, sleep disturbances and wandering are common, cause great distress to caregivers and are likely to lead to institutionalisation of patients. At present, these symptoms are also more amenable to treatment compared with the progressive intellectual decline caused by dementing illnesses. The care of individuals with BPSD involves a broad range of psychosocial treatments for the patient and his or her family. If pharmacotherapy is deemed necessary to manage BPSD, a careful balance must be struck between the benefits of symptom control and the inherent risks associated with most psychotropic agents in the elderly. Elderly patients in general, and patients with dementia in particular, are more sensitive to medication adverse effects, including anticholinergic effects, orthostatic hypotension, sedation, parkinsonism, tardive dyskinesia and cognitive impairment than younger patients with dementia or individuals without dementia. To date, treatment of symptoms of aggression and psychosis has relied on the empirical use of antidepressants, anxiolytics, typical antipsychotics (neuroleptics) and other agents. Treatment-limiting adverse effects are frequently reported with all of these agents. However, it is the typical antipsychotics and the atypical antipsychotic clozapine that are associated with the greatest risk of adverse effects in the elderly. The present review highlights the issues that limit the use of older psychotropic agents in the elderly, and presents an assessment of the available evidence concerning the efficacy, safety and tolerability of the atypical antipsychotic risperidone, in the treatment of BPSD in elderly patients with dementia. The extensive clinical development programme for risperidone has shown the drug to be effective and well tolerated in many fragile patients. As a result of its efficacy and safety profile, risperidone can be used for the treatment of behavioural and psychological symptoms in patients with dementia. Risperidone therefore represents a significant addition to the armamentarium for BPSD. While efforts continue in the development of treatment for the cognitive decline associated with dementia, treatment is now available for the noncognitive symptoms. By treating the latter, risperidone has the potential to be of substantial benefit to patients with dementia, their carers and the costs of healthcare.
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Affiliation(s)
- M Zaudig
- Windach Institute and Hospital of Neurobehavioural Research and Therapy (WINTR), Psychosomatic Hospital, Germany.
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13
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Abstract
Atypical antipsychotics are expected to be better tolerated than older antipsychotics because of their lower propensity to cause certain adverse effects. All atypical drugs have been shown to cause fewer acute extrapyramidal symptoms (EPS) than a standard typical agent (usually haloperidol) and some (clozapine, sertindole and quetiapine) appear to cause these effects no more often than placebo. In the longer term, clozapine, olanzapine and (less robustly) other atypical antipsychotics are thought to cause less tardive dyskinesia than typical antipsychotics. Problems caused by hyperprolactinaemia occur less often with some atypical antipsychotics than with typical drugs although risperidone and amisulpride appear to have no advantages in this respect. Other adverse effects may occur as frequently with some atypical antipsychotics as with some typical drugs. Clozapine, risperidone and quetiapine are known to cause postural hypotension; clozapine, olanzapine and quetiapine are clearly sedative; and anticholinergic effects are commonly seen with clozapine, and, much less frequently, with olanzapine. Some adverse effects are more frequent with atypical drugs. Idiosyncratic effects seem particularly troublesome with clozapine and, to a lesser extent, sertindole, olanzapine and zotepine. Bodyweight gain is probably more problematic with atypical antipsychotics than with typical drugs. Overall tolerability, as judged by withdrawals from therapy, is not clearly proven to be better with atypical drugs, although some individual trials do indicate an advantage with atypical agents. Differences in tolerability between individual atypical antipsychotics have not been clearly shown. The tolerability profile of atypical drugs certainly benefits from a lower incidence of acute EPS effects, along with less certain or less uniform benefits in symptomatic hyperprolactinaemia or tardive dyskinesia. Other, perhaps more trivial, adverse effects militate against their good tolerability, and effects such as bodyweight gain may severely reduce tolerability. Without clear advantages in tolerability in patient groups used in trials, drug choice in regard to adverse effects should continue to be on a patient to patient basis.
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Affiliation(s)
- C Stanniland
- Pharmacy Department, Maudsley Hospital, London, England.
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14
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Abstract
OBJECTIVE Most patients with tardive dystonia have a focal onset involving the cranial-cervical region. Because of its resemblance to idiopathic cranial dystonia, a common form of dystonia, it often poses a diagnostic problem. To compare clinical features and response to botulinum toxin (BTX) injections between patients with tardive and idiopathic oromandibular dystonia (OMD). METHODS Patients seen in a movement disorder clinic who satisfied the inclusion criteria for tardive or idiopathic OMD were studied. The clinical variables and responses to BTX between the two groups of patients were compared. In the tardive group, we also compared the clinical variables between those with oro-facial-lingual stereotypies, and those without. RESULTS Twenty four patients with tardive OMD and 92 with idiopathic OMD were studied. There were no differences in the demographic characteristics. Most were women, with duration of symptoms longer than 8 years. The mean duration of neuroleptic exposure was 7.1 (SD 7.9) years. Jaw closure was the most frequent subtype of OMD (tardive=41.7%, idiopathic=51.1%). Idiopathic patients were more likely to have coexistent cervical dystonia (p<0.05), whereas isolated OMD was significantly higher in tardive patients (p<0.05). Limb stereotypies, akathisia, and respiratory dyskinesia were seen only in the tardive OMD. Frequency of oro-facial-lingual stereotypy was significantly higher in the tardive than the idiopathic group (75.0% v 31.5%, p<0.0001). The peak effect of BTX was similar in both groups. CONCLUSIONS Oro-facial-lingual stereotypies were significantly more frequent in the tardive than the idiopathic group. Presence of stereotypic movements in the limbs, akathisia, and respiratory dyskinesias in patients with OMD strongly suggests prior neuroleptic exposure. Dystonia in tardive OMD is more likely to be restricted to the oromandibular region, whereas in patients with idiopathic OMD, there is often coexistent cervical dystonia. BTX is equally effective in both groups of patients.
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Affiliation(s)
- E K Tan
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA
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