Muzumel A. Chaudhary, MD, Psychiatry Resident, University of British Columbia, Vancouver, BC.
Kiran Rabheru, MD, CCFP, FRCP, ABPN, Clinical Associate Professor, Department of Psychiatry, University of British Columbia; Geriatric Psychiatrist, Vancouver General, University of British Columbia, and Riverview Hospitals, Vancouver, BC.

New-onset paranoid symptoms are common among older individuals. They can signify an acute mental status change owing to medical illness, correspond to behavioural and psychological symptoms of dementia, or equate to an underlying affective or primary psychotic mental disorder. The implications of paranoid symptoms are considerable and affect patients, families, and caregivers alike. Accurate identification, diagnosis, and treatment of late-life paranoid symptoms present a unique clinical challenge as issues of morbidity and mortality are inherent both to the illness state and available treatment approaches.
Key words: paranoia, delusions, etiology, older adults, atypical antipsychotic.

Shailaja Shah, MD, Clinical Assistant Professor, Assistant Director Geriatric Psychiatry Fellowship, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.
Gautam Rohatgi, DO, Geriatric Psychiatry Fellow, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.
Daniela Ganescu, MD, Geriatric Psychiatry Fellow, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.

Alzheimer’s disease (AD) is the most common cause of dementia, affecting nearly 18 million people around the world. Alzheimer’s disease is characterized by cognitive, functional, and behavioural decline. As the condition progresses the affected individual becomes increasingly dependent on others for assistance in performing all activities of daily living. Neuropsychiatric symptoms (NPS) such as agitation, psychosis, and apathy are very common in dementia and especially in AD. Agitation and apathy contribute to a tremendous amount of caregiver distress. Treatment guidelines recommend utilizing nonpharmacologic behavioural approaches in all instances. When behavioural interventions fail or when the behaviour is severe, medications are recommended. At present, no psychotropic agent presently available within the United States is FDA-approved for use in dementia complicated with behaviour disturbance.
Key words: agitation, apathy, behaviour interventions, atypical antipsychotics, dementia.

Joseph H. Friedman, MD, Professor, Clinical Neurosciences, Brown University School of Medicine; Chief, Neurology; Director, Parkinson's Disease and Movement Disorders Center, Memorial Hospital of Rhode Island, Pawtucket, RI, USA.

Drug-induced parkinsonism, an often overlooked condition, is frequently an iatrogenic result of antipsychotic medications, particularly in older adults. Spontaneous features of parkinsonism are common in the community-dwelling older adult as well as in patients with the common dementing illnesses. Parkinsonism is associated with increased mortality and morbidity, and a greater need for support services. This article reviews current knowledge of parkinsonism and stresses the need for diligence. The newer antipsychotics, while reducing the incidence of tardive dyskinesia, are not all completely free of inducing extrapyramidal side effects, with parkinsonism being the most common.
Key words: drug-induced parkinsonism, atypical antipsychotics, extrapyramidal syndromes.

Anna Liachenko, BSc, MSc
Managing Editor,
Geriatrics & Aging

Due to a favourable side effect profile and high efficacy when compared with typical antipsychotics, atypical drugs are becoming increasingly recommended as first-line treatments for agitation and psychosis related to schizophrenia, manic depression, and behavioural disturbances associated with dementia. At the recent XXII International Congress of Neuro- psychopharmacology (CINP) in Brussels, a new study evaluating an intramuscular (IM) form of Olanzapine (Zyprexa) was presented. An IM form of antipsychotics can be crucial for the rapid control of a patient's psychotic symptoms in an emergency setting. This is the first time that an atypical antipsychotic is available in IM form. The study has just been completed and will be published shortly. Dr. Karena Meehan, M.D., clinical research physician for Eli Lilly and Company and the lead physician for the IM project with responsibility for the Canadian and American groups, agreed to answer a few questions about recent studies on Olanzapine and the use of this drug in the elderly.

Q: Your group has recently presented data comparing the effect of a new IM-formulation of the antipsychotic olanzapine with IM-haloperidol. What were the objectives and the results of your study?

A: The study was designed to compare olanzapine with an older typical antipsychotic.

Philip Dopp, BSc

Dementia manifests itself in many ways within elderly populations. Given that symptoms associated with dementia, such as psychosis or behavioral disturbances, are common reasons for nursing home placement, it is not surprising that between 40% and 90% of residents of such institutions have some degree of dementia.^1,2 In recent years, atypical antipsychotics such as risperidone and olanzapine have been used with increasing frequency to deal with these distressing symptoms of dementia. Because of their favorable side effect profile, when compared to typical antipsychotics, and because studies have shown them to have equal, if not greater efficacy than typical antipsychotics, many geriatric psychiatrists recommend atypical antipsychotics as first-line treatment for psychosis and aggression in dementia.

The behavioral problems associated with dementia can be categorized as either non-aggressive or aggressive. Nonaggressive behavior includes wandering, pacing, bossiness, complaining and attention-seeking acts, while aggressive behavior includes hitting, pushing, scratching, biting, kicking and screaming. Management of these problems depends upon both the severity of the problem and the potential for the patient to harm themselves or others. In all cases, nonpharmacologic interventions, such as distracting the patient from the problem behavior, creating a structured environment for the patient and developing support groups for the caregiver, are appropriate.