Atypical antipsychotics in the elderly: a review of therapeutic trends and clinical outcomes

Recent emerging data regarding the safety and tolerability of atypical antipsychotics in elderly patients with dementia have called into question common prescribing practices. Although the lifetime risk of developing significant psychopathology in dementia patients approaches nearly 100%, treatment options remain scant and controversial. Millions of people are suffering the consequences of these debilitating dementias. Yet the lack of regulatory approval or even recognition of the problem creates a dilemma for clinicians in practice who are trying to care for severely ill patients. There are data indicating that certain behavioral features can be treated successfully with atypical antipsychotics, offset by a high rate of adversity. This does not lead to the simple conclusion that they should never be used, since the alternatives are either fraught with the same shortcomings or actually lack evidence of benefit altogether. Further, it is not realistic to assume that nonpharmacological approaches, although preferred, will always carry the day. Since we do not have the evidence to define best practice for treating psychopathology, we are forced to make the most of the data we have and exercise best judgment about risk and benefit on a case-by-case basis.     

曲马多与芬太尼预注对小儿全麻苏醒期的影响

目的:观察曲马多与芬太尼联合使用对小儿瑞芬太尼一丙泊酚全麻苏醒期的影响。方法:45例择期行扁桃体和腺样体切除术的患儿,随机分为三组,每组15例。麻醉维持均选用瑞芬太尼与丙泊酚持续输注。诱导插管后,C组静注生理盐水2 mL,T组与T-F组均注入曲马多2 mL/kg,同时T-F组手术结束前10 min静注芬太尼lμg/kg。记录术毕患儿自主呼吸恢复时间、拔管时间、离室时间及客观疼痛不适评分(OPDS)、躁动评分、恶心、呕吐,呼吸抑制等不良反应。结果:T-F组自主呼吸恢复时间、拔管时间均较C组和T组延长(P<0.01),但离室时间三组差异无显著意义。拔管后,OPDS及躁动评分C组>T组>T-F组(P<0.05);躁动发生率C组>T组>T-F组,其中T组、T-F组与C组比较差异有显著性(P<0.05)。结论:曲马多与芬太尼联合应用,对于预防小儿瑞芬太尼一丙泊酚全麻苏醒期躁动、哭闹安全有效。     

全凭静脉与吸入全身麻醉苏醒期躁动发生率的临床观察

目的比较丙泊酚、地氟烷、七氟烷复合瑞芬太尼全身麻醉苏醒期躁动的发生情况。方法90例ASAⅠ～Ⅱ级择期全身麻醉下行乳腺癌根治术及鼓室成形术。随机分成三组：丙泊酚组、地氟烷组、七氟烷组。观察各组苏醒期躁动发生率和睁眼时间、拔管时间，监测躁动发生前后血压、心率及脉搏血氧饱和度。结果地氟烷组和七氟烷组苏醒期躁动发生率分别为31．03％和33．33％，高于丙泊酚组的3．33％（P〈0．05）；睁眼时间、拔管时间差异不具有显著性意义（P〉0．05）；躁动发生前后血压、脉搏血氧饱和度差异无显著性意义（P〉0．05），而心率在躁动发生后明显增快（P〈0．05）。结论地氟烷、七氟烷吸入麻醉苏醒期躁动发生率明显高于丙泊酚全身麻醉。     

Emergence agitation in paediatric patients after sevoflurane anaesthesia and no surgery: a comparison with halothane

This study was designed to compare the emergence characteristics of sevoflurane with halothane anaesthesia in paediatric patients having no surgical intervention. We randomized 32 ASA I or II paediatric outpatients scheduled for magnetic resonance imaging scans to receive either halothane or sevoflurane anaesthesia. The primary outcome measure was the percentage of patients with emergence agitation, as defined by two different criteria. Time to discharge from the postanaesthesia care unit (PACU) and the secondary recovery unit (SRU) were compared. Sevoflurane patients had a greater incidence of emergence delirium when a high threshold for agitation was defined (33% vs. 0%, P = 0.010) and a lower threshold for agitation was applied (80% vs. 12%, P<0.0001). Discharge times from the PACU and the SRU were not different. We conclude that there is an increased incidence of emergence agitation with sevoflurane anaesthesia compared to halothane independent of any painful stimulus.     

Behavioral symptoms in residential care/assisted living facilities: prevalence, risk factors, and medication management

OBJECTIVES: To examine the prevalence, correlates, and medication management of behavioral symptoms in elderly people living in residential care/assisted living (RC/AL) facilities. DESIGN: Cross-sectional study. SETTINGS: A stratified random sample of 193 RC/AL facilities in four states (Florida, Maryland, New Jersey, North Carolina). PARTICIPANTS: A total of 2,078 RC/AL residents aged 65 and older. MEASUREMENT: Behavioral symptoms were classified using a modified version of the Cohen-Mansfield Agitation Inventory. Additional items on resistance to care were also examined. RESULTS: Approximately one-third (34%) of RC/AL residents exhibited one or more behavioral symptoms at least once a week. Thirteen percent exhibited aggressive behavioral symptoms, 20% demonstrated physically nonaggressive behavioral symptoms, 22% expressed verbal behavioral symptoms, and 13% resisted taking medications or activities of daily living care. Behavioral symptoms were associated with the presence of depression, psychosis, dementia, cognitive impairment, and functional dependency, and these relationships persisted across subtypes of behavioral symptoms. Overall, behavioral symptoms were more prevalent in smaller facilities. More than 50% of RC/AL residents were taking a psychotropic medication, and two-thirds had some mental health problem indicator (dementia, depression, psychosis, or other psychiatric illness). CONCLUSION: Integrating mental health services within the process of care in RC/AL is needed to manage and accommodate the high prevalence of behavioral symptoms in this evolving long-term setting.     

Agitated behaviours among the institutionalized elderly with dementia: validation of the Korean version of the Cohen-Mansfield Agitation Inventory

OBJECTIVES: To analyze the factor structure, the criterion validity, the internal consistency, inter-rater reliability and test-retest reliability of the Korean version of Cohen-Mansfield Agitation Inventory, to provide data on the frequency and distribution of agitated behaviours, and to compare patterns of agitated behaviours among the institutionalized elderly with Alzheimer's disease (AD) or Vascular dementia (VaD). METHODS: The Korean version of the Cohen-Mansfield Agitation Inventory (CMAI-K) was administered to a total of 257 elderly with AD or VaD in a nursing home in Seoul, Korea. Three kinds of reliability and criterion validity were tested. Factor analysis using principal component analysis with the varimax rotation was performed. To identify different patterns of agitated behaviours, multiple logistic regression analysis was used. RESULTS: This study demonstrated satisfactory reliability and validity for the CMAI-K as an instrument measuring agitation in Korean dementia sufferers in nursing homes. Eighty-three percent of the subjects manifested one or more agitated behaviours at least once a week. Factor analysis yielded four subtypes of agitation: physically aggressive behaviours, physically nonaggressive behaviours, verbally agitated behaviours, and hiding/hoarding behaviours. CONCLUSION: These results indicate that the CMAI-K is a reliable and valid instrument to measure agitated behaviours in Korean elderly with AD or VaD. These results validate and expand previous research on the agitation in dementia, and guide in the development of interventions.     

Opioid treatment for agitation in patients with advanced dementia

BACKGROUND: Some patients with advanced dementia cannot convey the experience of pain verbally and may react to pain with aggressive and agitated behaviors. We hypothesized that unrecognized pain could contribute to agitation and that low dose opioid therapy might reduce agitation by reducing pain. We therefore attempted to determine the effect of opioids on agitation in demented patients. METHODS: We administered placebo for 4 weeks and a long-acting opioid for another 4 weeks to nursing home patients with advanced dementia and severe agitation despite treatment with psychotropic drugs. Patients and study nurses did not know if the medication administered was placebo or opioid. We measured the Cohen-Mansfield Agitation Inventory (CMAI) score at baseline and every two weeks. RESULTS: Among 47 patients who entered the study, 25 completed the two phases. The median age for the 25 patients was 85.5 years. Analyses of the data of these 25 patients and of the patients <85 years-old showed no significant differences in agitation level between the placebo and opioid phases. However, among the 13 patients who completed the study and were > or =85 years old, the agitation level at the end of the opioid phase was significantly lower than at the end of the placebo phase (mean change in CMAI score: -6.4; 95% confidence interval (CI): -10.96, -1.8). The decrease in agitation in the patients > or =85 years old persisted after adjusting for sedation. The results remained unchanged when we expanded the analyses to include four > or =85 patients who dropped out of the study after the second week of the opioid phase. CONCLUSION: Low dose, long-acting opioids can lessen agitation that is difficult to control in very old (> or =85) patients with advanced dementia.     

Temporal patterns of disruptive vocalization in elderly nursing home residents

This study used computer-assisted real-time data collection procedures to study temporal patterns of disruptive vocalization (DV) in demented nursing home residents. Residents (N = 68) were observed from 8 a.m. to 8 p.m. and total mean duration of DV within hourly blocks was calculated. Analysis of the temporal distribution of DV exhibited by the group of 68 residents indicated a significant cubic trend. Exploratory cluster analysis uncovered three distinct temporal patterns of DV; although two of the patterns are generally supportive of sundowning. Cluster 1 showed a relatively constant pattern of low rate DV. Clusters 2 and 3 showed cyclic trends. Peaks in DV were observed during noontime and in the evening for Cluster 2. Cluster 3 showed peaks in DV in the early morning hours and late afternoon. MANOVA was employed to examine any differences among clusters in age, cognitive status, and ADL status. Univariate analyses indicated that cognitive status was the only factor that differed significantly among clusters, with members of Cluster 1 (constant low rate DV) manifesting higher cognitive status scores than Clusters 2 and 3. A step-wise discriminant function analysis also showed cognitive status to be the only statistically significant predictor of cluster membership. The authors' note that the scientific literature on agitation is fraught with contradictory findings and assert that inconsistencies may be due to differences across studies in problem definition, method of measurement, and sample size. The results are discussed in relation to these methodological issues and clinical implications of the findings.     

手术患者不同时机导尿对苏醒期躁动和适应性比较

目的比较全麻手术患者不同时机导尿后全麻苏醒期躁动和术后1天尿管耐受性。方法将180例全麻手术患者随机分为三组,I组为术晨在病房导尿;II组为手术前1日,由巡回护士访视患者,进行心理护理后,麻醉前在手术室导尿;III组为全身麻醉平稳后由巡回护士导尿。对患者就不同时机进行导尿所引起的不舒适感、麻醉苏醒时的躁动情况及术后1日对尿管适应性进行比较。结果III组患者麻醉苏醒期躁动率明显高于I、II组,有统计学意义（P〈0.05）。术后1日患者尿管适应度,II组术后留置尿管的适应度较好,III组患者较差。结论麻醉前对患者进行心理护理后导尿可提高手术患者对留置尿管的适应度,大大降低麻醉苏醒时的躁动率。