Richard W. Shulman, MDCM, FRCPC
Geriatric Psychiatrist, Trillium
Health Centre, Mississauga, Ontario
Member, Division of Geriatric Psychiatry,
University of Toronto, Toronto, Ontario

In elderly patients suffering from schizophrenia, psychosis due to Alzheimer's disease, or other illnesses, first line treatment with a second-generation (atypical) antipsychotic--as compared to a first generation (conventional) antipsychotic--should be considered standard therapy. The advantage of treatment with a second-generation antipsychotic is, at least in part, due to improved neurologic side effect profiles. The Canadian Clinical Practice Guidelines for the Treatment of Schizophrenia state that treatment with clozapine, olanzapine, quetiapine, and risperidone (at lower doses) markedly reduces acute extra-pyramidal side effects (EPSE).¹

Elderly patients treated with relatively low doses of first-generation antipsychotics have been shown to have a 29% cumulative annual incidence of tardive dyskinesia (TD). The incidence of TD in patients treated with atypical antipsychotics is likely to be lower given that EPSE has been found to be a risk factor for TD.²

Olanzapine (Zyprexa‚) is a second-generation antipsychotic that has shown promise as a safe and effective drug for the treatment of elderly patients suffering from either schizophrenia or psychosis secondary to dementia.

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.