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.

Kiran Rabheru, MD, CCFP, FRCP(C)
Active Staff, Geriatrics Psychiatry,
London Psychiatric Hospital, London, ON.

Psychotic disorders in older adults, characterized by a loss of touch from reality, are common and challenging to manage in primary care. Symptoms include delusions, hallucinations, thought disorder and bizarre behaviour. As psychiatric wards many of which still house many older patients with psychosis, close across the country, nursing homes are quickly taking over their role as the "psychiatric hospitals of tomorrow." Nursing homes are often not well equipped to care for older patients with psychosis, many of whom also suffer from dementia, depression and other medical conditions. There are virtually no demographics available on older people with psychosis who live on our streets. The social and economic burden of these disorders is high. The spectrum of psychotic disorders in the elderly is broader than that in younger adults, with some important clinical and epidemiological differences.

DSM-IV differentiates between primary psychotic disorders and disorders with secondary delusions. Although the secondary causes of psychosis in older adults are extremely important to consider, the focus of this article will be on the most common causes of primary psychotic disorders.