Beyond the striking figures related to those suffering from defined mental disorders, there exist a number of groups of people who, because of extremely difficult circumstances or conditions, are at special risk of being affected by the burden of mental problems. These include persons in extreme poverty (such as slum-dwellers); children and adolescents experiencing disrupted nurturing; abused women; abandoned elderly people; persons traumatized by violence such as forced migrants and refugees.
Mental health problems among elderly people are frequent, and can be severe and diverse. In addition to Alzheimer's disease, seen almost exclusively in this age group, many other problems such as depression, anxiety and psychotic disorders also have a high prevalence. Suicide rates reach their peaks particularly among elderly men. Substance misuse, including alcohol and medication, is also highly prevalent, though largely ignored.These problems create a high level of suffering not only to the elderly people themselves, but also to their relatives.
Many medicines have not been studied specifically in older people. Therefore, it may not be known whether they work exactly the same way they do in younger adults or if they cause different side effects or problems in older people. There is no specific information comparing use of cabergoline in the elderly with use in other age groups.Antipsychotics are also referred to as neuroleptic drugs, or simply neuroleptics.One clinical indication, to some the indication, that a dosing regimen was adequate to treat psychosis was the presence of these motor symptoms, hence the emergence of the term neuroleptic.
The use of atypical antipsychotic agents to treat delirium are limited and conflicting, especially in regard to lorazepam, which has actually been shown to cause delirium.1 A recent meta-analysis of studies of the use of atypical antipsychotic drugs in elderly persons showed a high risk of death associated with the use of these agents.2 Gill et al. even suggest that deaths associated with delirium may be caused by antipsychotic drugs that are used to treat delirium.3 Until we reach an informed consensus on the use of atypical antipsychotic drugs in patients with delirium, these agents should not be considered as treatment options.
The role of typical antipsychotics has come into question recently as studies have suggested that atypical antipsychotics may increase the risk of death in elderly patients. A retrospective cohort study from the New England Journal of Medicine on Dec. 1, 2005 showed an increase in risk of death with the use of typical antipsychotics that was on par with the increase shown with atypical antipsychotics. This has led some to question the common use of antipsychotics for the treatment of agitation in the elderly, particularly with the availability of alternatives such as mood stabilizing and antiepileptic drugs.
Cycloplegic and mydriatic agents (including eyedrops containing anticholinergic drugs, such as atropine and cyclopentolate) are frequently prescribed for elderly persons. Systemic side effects (which are mainly cerebellar or cerebral and include visual and tactile hallucinations, incoherent speech, agitation, disorientation, memory loss, and acute psychotic reactions) have been described after topical administration of ocular cyclopentolate.5 Systemic reactions caused by absorption of such drugs transconjunctivally or through the nasolacrimal duct must be taken into account in the prevention and management of delirium in elderly patients in the hospital.
Major depression with dementia that occurs in elderly people may be an early sign of Alzheimer's. In such cases, it precedes Alzheimer's by 2 years or less. (It is, in fact, sometimes difficult to differentiate major depression from early stage Alzheimer's disease.) Antidepressants known as selective serotonin reuptake inhibitors (SSRIs), including fluoxetine (Prozac) and sertraline (Zoloft), may be effective in relieving depression, irritability, and restlessness associated with Alzheimer's in some patients.
Some of the drugs used often used in elderly Alzheimer's disease patients are known as anticholinergics and may offset the effects of the Alzheimer's disease pro -cholinergic drugs. Such drugs include antihistamines, antipsychotic drugs, and some anti-incontinence drugs.Confusion, hallucinations, falls causing bone and joint injuries, heart, lung, or stomach problems may be especially likely to occur in elderly patients, who are usually more sensitive than younger adults to the effects of apomorphine.
In addition to increasing use, there have been rapid shifts from first-generation conventional agents (e.g., phenothiazines and butyrophenones) to heavily marketed second-generation atypical agents (e.g., aripiprazole [Abilify], clozapine [Clozaril], olanzapine [Zyprexa], quetiapine [Seroquel], risperidone [Risperdal], and ziprasidone [Geodon])
An increased incidence of cerebrovascular adverse events (including fatalities) has been reported in elderly patients with dementia-related psychosis. Significant weight gain may occur.Half-life elimination was 1.5 times greater in elderly. Treatment of depression in Alzheimer's disease patients has the potential to improve functional ability. Of the behavioural symptoms experienced by patients with Alzheimer's disease, depression and anxiety occur most frequently during the early stages, with psychotic symptoms and aggressive behaviour occurring later. In view of the increasing numbers of elderly people, managing their well-being is a challenge for the future.
Recently, the Food and Drug Administration (FDA) issued an advisory stating that atypical antipsychotic medications increase mortality among elderly patients.Study suggested that the greatest increases in risk occurred soon after therapy was initiated and with higher dosages of conventional antipsychotic medications. Increased risks associated with conventional as compared with atypical antipsychotic medications persisted in confirmatory analyses performed with the use of propensity-score adjustment and instrumental-variable estimation.So ,conventional drugs should not be used to replace atypical agents discontinued in response to the FDA warning.
A new study adds to growing evidence that antipsychotic drugs raise death rates among elderly people, who are sometimes given them when their behavioral problems become too much for doctors or families to handle.
"For individual patients, the risk is small," said study author Dr. Sudeep Gill, an assistant professor at Queen's University in Kingston, Ontario, Canada. Still, "patients and their families need to talk to their doctors about the potential risks and benefits, and this study would suggest only using these drugs when other less risky approaches have been exhausted."
Antipsychotic drugs have been around since the 1950s and are typically used to treat people with mental illness, such as schizophrenia. Over time, Gill said, doctors began using them to treat behavioral problems associated with senility, also known as dementia.
The drugs had some side effects -- including Parkinson's disease-like symptoms -- but then a new generation of the medications known as atypical antipsychotics appeared. In the 1990s, they were thought to be better for elderly people and their use increased, according to Gill.
In fact, a Canadian study found that the percentage of elderly adults using antipsychotics grew from 2.2 percent in 1993 to 3 percent in 2002.
But then reports appeared suggesting the drugs were dangerous. In 2005, the U.S. Food and Drug Administration warned doctors about atypical antipsychotics, specifically olanzapine (Zyprexa), aripiprazole (Abilify), risperidone (Risperdal), and quetiapine (Seroquel).
Fifteen of 17 studies of elderly patients with dementia -- which included more than 5,100 patients -- found a 1.6- to 1.7-fold increase in death rates in those who took the drugs. Heart problems and infections like pneumonia were the most common causes of death.
For the new study, researchers looked at the risks of both the newer atypical antipsychotics and the older "conventional" drugs -- haloperidol (Haldol), loxapine (Loxitane), thioridazine (Mellaril), chlorpromazine (Thorazine) and perphenazine (Trilafon). The study authors followed 27,259 pairs of older adults in the province of Ontario who were treated for dementia between 1997 and 2003.
The patients were "paired" so the researchers could compare the death rates of patients who took atypical antipsychotics to those who didn't, and those who took conventional antipsychotics to those who took atypical antipsychotics. The researchers looked at the risk of death 30, 60, 120 and 180 days after the drugs were first given to the patients.
The researchers found that both types of antipsychotics appeared to boost death rates by 1.31 to 1.55 times. Conventional antipsychotics seemed to be the more dangerous of the two types of drugs, the researchers said.
However, the researchers said the study had limitations because it didn't look at the causes of death, and many patients didn't keep using the drugs after 30 days.
Why does the increased risk appear to exist?
"I suspect this is because older patients are more vulnerable to adverse effects, since they much more often have underlying heart disease and problems swallowing, and the antipsychotic drug effects are the 'last straw' that precipitates a lethal event," Gill said.
Dr. James S. Goodwin, director of the Sealy Center on Aging at the University of Texas Medical Branch in Galveston, agreed with the researchers about the study's drawbacks.
An "observational" study like this one, in which researchers do not control which people take a drug, raises the prospect that the results may be caused by something other than a drug, he said.
"So the same underlying reasons that led physicians to put a patient on a treatment might be the reason for the poor or good outcome," he said. "In this case, to give just one example, patients with delirium are much more likely to be given antipsychotics, and patients with delirium are at higher risk of death."
Goodwin added that many doctors think antipsychotics are overused in older patients. However, he said, "there is a class of demented patients with real bad behavioral problems, like striking other residents in a nursing home, where antipsychotics might be the least bad solution."
Depressive disorder is common among elderly people: studies show that 820% being cared for in the community and 37% being cared for at the primary level are suffering from depression. A recent study on a community sample of people over 65 years of age found depression among 11.2% of this population (Newman et al. 1998). Another recent study, however, found the point prevalence of depressive disorders to be 4.4% for women and 2.7% for men, although the corresponding figures for lifetime prevalence were 20.4% and 9.6%. Depression is more common among older people with physically disabling disorders (Katona & Livingston 2000). The presence of depression further increases the disability among this population. Depressive disorders among elderly people go undetected even more often than among younger adults because they are often mistakenly considered a part of the ageing process.
We are, today, in a position to make better use of a wealth of knowledge and technologies that allows us more effectively to manage, treat and prevent a wide range of mental health and neurological problems. It is time to review priorities and commitments and to recognize the substantial benefits that will accrue through investing in mental health.
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