Antipsychotic prescribing in older people

Abstract

Antipsychotic medications have made a significant contribution to the care of the mentally ill people over the past 50 years, with good evidence that both typical and atypical agents are effective in the treatment of schizophrenia and related conditions. In addition they are widely used to good effect in other disorders including psychotic depression, dementia and delirium. Both typical and atypical agents may cause severe side-effects and, in the elderly in particular, there is an increased propensity for drug interactions. If used with care, antipsychotics are usually well tolerated, especially the atypical drugs. Although antipsychotics are effective at reducing psychotic symptoms their limitations should be recognised. They do not 'cure' the underlying illness, and the management of psychotic and behavioural symptoms must take into consideration treatment of physical illness as well as psychosocial interventions. In addition, the antipsychotic effect may take one to two weeks to be evident so doses should not be increased too rapidly. Often small doses are effective in the elderly if they are given sufficient time to work. As our understanding of the mechanisms of psychosis improves it is hoped that new drugs will be developed with novel mechanisms of action with improved efficacy and reduced side-effects. There are several drugs in development, some sharing similarities to currently available agents whilst others have novel mechanisms of actions involving glutamate and nicotinic receptors. Pharmacogenetics is also likely to be increasingly important over the next few years. As the genetic basis of many psychiatric disorders becomes more clearly established it is likely that drugs specifically designed for particular sub-groups of receptors will be developed. Finally, although the pharmacological treatment of psychotic disorders in younger people has been given considerable attention, there is a paucity of good quality research on antipsychotic drug use in older people. There is a need to redress this balance to ensure that the prescribing of antipsychotics in older people is evidence based.

Comparative safety of antipsychotics in the WHO pharmacovigilance database: the haloperidol case

“…In the absence of controlled trials, oral administration with drops or fast-melt tablets represent a potential option [11]. While obviously more painful compared with intravenous, intramuscular administration is also a possibility [32].…”

Psychopharmacological approaches to modulating attention in the five-choice serial reaction time task: implications for schizophrenia

“…The present generation of antipsychotic drugs is indeed very effective in relieving many of the symptoms of schizophrenia, particularly in its acute phase. Nevertheless, little is known about their efficacy in patients with ongoing symptoms, for example in the elderly where there is an increased propensity for drug interactions (Neil et al 2003). What is clear, however, is that concepts regarding the psychopharmacology of schizophrenia are currently changing, with serotoninergic transmission being a focus of interest.…”

Post-stroke Movement Disorders: Clinical Manifestations and Pharmacological Management

“…Typical neuroleptic agents (i.e. haloperidol, pimozide, perphenazine and fluphenazine) block dopamine 1 (D1) and D2 receptors [33] and represent first line treatment of hemichorea-hemiballismus [2,34,35]. In particular, Ristic et al [35], studied, for a mean period of 30 months, a cohort 27 consecutive patients with hemiballismus as a first manifestation of ischemic strokes treated with haloperidol (<10 mg/day) or a combination of haloperidol and diazepam (<10 mg/day).…”