Michael J. Passmore, MD, FRCPC, Clinical Assistant Professor, Department of Psychiatry, Geriatric Psychiatry Program, University of British Columbia, Vancouver, BC.

The following review uses case studies to illustrate the importance of a biopsychosocial approach to the assessment and management of behavioural and psychological symptoms of dementia (BPSD). Practical BPSD assessment strategies are reviewed, in addition to evidence-based and guideline-supported recommendations for acute and long-term BPSD management.
Key words: dementia, behaviour, agitation, antipsychotic, memantine.

Tarek Rajji, MD, Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto, Toronto, ON.
Benoit H. Mulsant, MD, MSc, FRCPC, Western Psychiatric Institute and Clinic and Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA; Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto, Toronto, ON.
Hiroyuki Uchida, MD, PhD, PET Centre, Centre for Addiction and Mental Health, Toronto, ON.
David Mamo, MD, MSc, FRCPC, PET Centre and Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto; Centre for Addiction and Mental Health, Toronto, ON.

Antipsychotics are increasingly being prescribed to older patients for the management of a variety of neuropsychiatric conditions. Available evidence supports the use of second-generation antipsychotics (SGAs) when treating these conditions. However, given their modest clinical effect for certain conditions (e.g., behavioural and psychological symptoms of dementia), their adverse effects, and their safety profile, a careful analysis of their risks and benefits is needed before initiating treatment with an SGA for an older patient. Among SGAs, choice of medication should be guided by their respective clinical indications and adverse effect profile, with use of lower initial and target doses (compared to younger adults) and periodic reviews of whether or not their continued use is warranted.
Key words: antipsychotics, older adults, dementia, delirium, schizophrenia.

Abi Rayner, MD, MPH, Buller Medical Service, Westport, New Zealand.

Hallucinations and delusions increase the risk of developing dementia, delirium, functional impairment, and of death. The differential diagnosis includes isolated hallucinations, delirium, depression with psychotic symptoms, late-onset schizophrenia, and unrecognized dementing disorder, including Lewy Body disease and frontotemporal dementia. Optimum management requires diagnosis, assessment of the goals of treatment, and understanding the risks and benefits associated with psychoactive medications. Atypical neuroleptics are appropriate first-line agents for most patients with dementia and psychotic symptoms. Response to medications is modest and a second agent (including acetylcholinesterase inhibitors, antidepressants, and anticonvulsants) may be necessary to reduce behaviour to acceptable levels. In addition, decline in cognitive status and increased risk of cerebrovascular events and death are associated with the use of antipsychotic medications. Change in functional status and time alter the impact of behavioural symptoms. Periodic reassessment and reduction of medication dosage over time appears safe, usually without re-emergence of symptoms.
Key words: psychotic symptoms, older adult, dementia, antipsychotics, behavioural disturbance.

Sudeep S. Gill, MD, MSc, FRCPC, Assistant Professor, Division of Geriatric Medicine, Queen’s University, Kingston, ON.

Delirium is common among hospitalized older adults and is associated with significant morbidity and excess mortality. Despite its prevalence and consequences, delirium is often underrecognized and undertreated. Antipsychotic drugs are commonly used to manage symptoms of delirium, but few controlled trials exist to support their efficacy and safety in this setting. Several recent studies have focussed on preventing delirium in high-risk populations. Clinical trials have demonstrated benefits with multifaceted nonpharmacological interventions, but widespread implementation of these interventions has not yet occurred. Two recent drug trials evaluated an antipsychotic and a cholinesterase inhibitor to prevent delirium, but neither trial demonstrated a reduction in incident delirium. At present, the most promising approach involves targeted, multifactorial interventions that focus on preventing delirium in high-risk patient groups. More work is needed to facilitate the implementation of these evidence-based strategies.
Key words: delirium, prevention, treatment, antipsychotic drugs, cholinesterase inhibitors.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Ann Schmidt Luggen, PhD, GNP, Professor, Department of Nursing and Health Professions, Northern Kentucky University, Highland Heights, KY; Gerontological Nurse Practitioner, Evercare, Cincinnati, OH, USA.

Medical management of Alzheimer’s disease patients involves drugs that temporarily relieve or stabilize symptoms, or lessen the expected decline in cognition, function, and behaviour, but ultimately fail to halt progression of the disease. Commonly used agents in the management of early- to mid-stage dementias--albeit with modest outcomes--are the cholinesterase inhibitors (ChEIs). Antipsychotics have been used with mixed success to treat psychiatric symptoms that occur in 30-60% of patients with moderate-to-severe AD. In the terminal stages of dementia, palliation of symptoms and a focus on comfort care is important. Management of pain and relief from depression and anxiety are useful.

Key words: dementia, Alzheimer’s disease, cholinesterase inhibitors, behaviour, antipsychotics.

David J Burn, MD, MA, FRCP, Consultant & Senior Lecturer in Neurology, Regional Neurosciences Centre, Newcastle General Hospital, Westgate Road Newcastle upon Tyne, UK.

Ian G McKeith, MD, FRCPsych, Professor of Old Age Psychiatry, Department of Old Age Psychiatry, Institute for Ageing and Health Wolfson Research Centre, Newcastle General Hospital, Newcastle upon Tyne, UK.

Introduction
Parkinsonism is a common problem, particularly in the elderly. One percent of the population over the age of 65 has Parkinson's Disease (PD), rising to 2% over the age of 80. Parkinsonism is also a core feature of dementia with Lewy bodies (DLB), the second most common cause of neurodegenerative dementia, after Alzheimer disease (AD). To differentiate patients with PD who develop cognitive impairment from DLB, Consensus Criteria stipulate that parkinsonism must be present for 12 months or less for a patient with dementia to qualify for a diagnosis of DLB.¹ If the extrapyramidal features are present for longer than this before the dementia develops, the diagnosis is referred to as PD with dementia.

Although parkinsonism occurs in numerous other neurodegenerative diseases, including multiple system atrophy, progressive supranuclear palsy and corticobasal degeneration, as well as AD, hallucinations are less common.

Monica Lee, BSc (Phm), MSc
Research Pharmacist
Baycrest Centre for Geriatric Care,
Toronto, ON.

Julie Dergal, MSc
Kunin-Lunenfeld Applied Research Unit
Baycrest Centre for Geriatric Care,
Toronto, ON.

Introduction
Older people often take multiple drug therapies for the treatment of various, concomitant chronic conditions. As a result, older adults are at increased risk of developing adverse drug events. It is important for physicians to regularly review the drug regimen of any older patient, and to discontinue any drug therapies that are no longer required or indicated. Physicians may also have to discontinue a particular drug therapy for other reasons including: if the drug therapy is ineffective; if it causes intolerable adverse effects; if newer and safer alternative drug therapies become available; or if the patient refuses to continue the treatment. It is important that physicians know how to appropriately discontinue or switch an older person's drug therapy in order to avoid adverse events.

There are currently limited practice guidelines available for discontinuing or switching psychotropic drug therapies. When discontinuing a medication, physicians need to consider whether it can be withdrawn abruptly or gradually tapered.

Anna Liachenko, BSc, MSc

Although anti-psychotic medications produce substantial side effects in the elderly, these drugs are extensively prescribed in nursing homes. Nursing home studies conducted in the United States in the 1980s showed that anti-psychotics were often used to manage disturbing behavior that did not fall into the clinical definition of psychosis. In 1987, the use of anti-psychotics was restricted by the Nursing Home Reform Amendments of the Omnibus Budget Reconciliation Act (OBRA87). The reform spelled out the exact guidelines for the use of each anti-psychotic drug in the elderly, thereby substantially reducing the amount of prescribed medication in nursing homes. Whether Canadian physicians also overprescribe anti-psychotic drugs is not clear. At present, clinical studies are being conducted to estimate the extent of anti- psychotic use and to find strategies to safely reduce the amount of medication when possible.

Mental illnesses, dementia in particular, are often accompanied by behavioral disturbances. This is often the primary reason for placing the older person in a nursing home. Thus, the prevalence of behavioral disturbances in nursing home residents is high and is estimated to be close to 60%. Only 10% of these behaviors are psychotic, i.e. accompanied by "delusions or prominent hallucinations, with the hallucinations occurring in the absence of insight into their pathological nature" (DSM-IV).