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The population of elderly in the United States with substance use disorders (SUDs) is growing appreciably. SUDs among the elderly are often associated with poor outcomes and are frequently underdiagnosed. The current diagnostic criteria are less sensitive in identifying SUDs among the elderly. Routine screening with validated screening tools may improve the diagnosis of SUDs among the elderly. There is a dearth of data from controlled studies on SUDs among the elderly and the use of pharmacologic agents for treatment, although data indicate that older adults with SUDs respond well to treatments that are specifically designed for this age group.

Parkinson’s disease (PD) psychosis is a common condition and is associated with increased morbidity, mortality, and caregiver burden. Symptoms may include delusions and hallucinations, with one common example being paranoid accusations about a spouse’s infidelity. An initial work-up should rule out other medical causes and medication effects. Decreasing the number and dosage of dopaminergic medications used to treat PD may improve or alleviate the psychotic symptoms but may also worsen motor function. Antipsychotics can be used to treat symptoms, but with the risk of also worsening the motor symptoms of PD. Pimavanserin is a serotonin receptor inverse agonist that is approved by the U.S. Food and Drug Administration to treat psychosis associated with PD.

Psychotic symptoms are a common part of the natural course of most major neurocognitive disorders and cause significant distress and disruption to both patients and caregivers. Although the neurocognitive disorder itself is a sufficient cause, a medical work-up should always be conducted to identify additional factors. Nonpharmacologic interventions, including caregiver education and support, should be first-line approaches for non-urgent psychotic symptoms, with pharmacologic interventions limited to severe, dangerous, or highly distressing symptoms. Second-generation antipsychotics are used to treat psychotic symptoms in Alzheimer’s dementia, vascular dementia, and behavioral variants of frontotemporal dementia. They should be used with caution in Lewy body dementia due to the risk of acute impairment in mental status.

When a patient presents with new-onset psychosis within the setting of a medical condition, it is essential that a thorough history and physical examination and a detailed diagnostic work-up are completed. This will help determine whether the medical condition is the main cause of the psychosis, or an exacerbating factor. Acute psychotic symptoms can be managed with antipsychotics or benzodiazepines depending on the degree of distress and disruption to the patient, but the mainstay of treatment involves treating the underlying medical condition. Patients may also require inpatient psychiatric hospitalization for acute stabilization and to minimize the risk of harm to self or others.

The aim of this editorial is to evaluate the evidence for using pimavanserin for the treatment of Parkinson's disease psychosis (PDP) from randomized controlled trials (RCTs). We only identified two published trials that evaluated the use of pimavanserin among individuals with PDP. Both studies found that pimavanserin improved psychotic symptoms among individuals with PDP when compared to placebo. Pimavanserin was fairly well tolerated in both studies and did not appear to cause significant sedation or worsen motor symptoms among individuals with PDP. However, given the limited data, additional confirmatory studies are required before pimavanserin can be considered as a first line agent for the treatment of psychotic symptoms among individuals with PD.

In this chapter, we review the life course of older adults including developmental and transitional events.

In this chapter, we review various aspects of demographic and epidemiological aspects of aging.

In this chapter, we review various aspects of family and community as it relates to the care of older adults with mental health disorders.

In this chapter, we review the role of geriatric psychiatrists in healthcare systems including being content experts, educators, and patient advocates.

Behavioral and psychological symptoms including agitation are common in dementia, and are associated with decreased quality of life, increased risk of institutionalization, and greater patient and caregiver distress. Pharmacological agents used for management of behavioral and psychological symptoms of dementia are limited by their tolerability, prompting a need for identifying efficacious and safe pharmacological treatments for managing agitation in dementia. The combination of dextromethorphan and quinidine sulfate is approved for pseudobulbar affect, and may be effective in managing agitation in dementia. A review of literature found only one randomized controlled trial that evaluated the use of dextromethorphan-quinidine for the management of agitation in dementia when compared to placebo. Data from this trial demonstrated that dextromethorphan-quinidine decreased agitation in dementia, and was well tolerated. Although promising, further research is needed before dextromethorphan-quinidine combination can be accepted as a standard treatment for agitation in dementia.

Emerging evidence indicates that the use of benzodiazepines among older adults may increase the risk of development of dementia. A review of the literature identified 13 studies investigating this link. Eight studies found a positive association between the use of benzodiazepines and development of dementia. Two studies found no such association, two had mixed results and one study found that benzodiazepine use reduced the incidence of dementia. As none of these studies were controlled prospective studies, causality could not be ascertained. The association identified between the use of benzodiazepines and the development of dementia is a cause for concern among older adults.

Background: Frontotemporal dementia (FTD) describes a cluster of neurocognitive syndromes that present with impairment of executive functioning, changes in behavior, and a decrease in language proficiency. FTD is the second most common form of dementia in those younger than 65 years and is expected to increase in prevalence as the population ages. This goal in our review is to describe advances in the understanding of neurobiological pathology, classification, assessment, and treatment of FTD syndromes. Methods: PubMed was searched to obtain reviews and studies that pertain to advancements in genetics, neurobiology, neuroimaging, classification, and treatment of FTD syndromes. Articles were chosen with a predilection to more recent preclinical/clinical trials and systematic reviews. Results: Recent reviews and trials indicate a significant advancement in the understanding of molecular and neurobiological clinical correlates to variants of FTD. Genetic and histopathologic markers have only recently been discovered in the past decade. Current therapeutic modalities are limited, with most studies reporting improvement in symptoms with nonpharmacological interventions. However, a small number of studies have reported improvement of behavioral symptoms with selective serotonin reuptake inhibitor (SSRI) treatment. Stimulants may help with disinhibition, apathy, and risk-taking behavior. Memantine and cholinesterase inhibitors have not demonstrated efficacy in ameliorating FTD symptoms. Antipsychotics have been used to treat agitation and psychosis, but safety concerns and side effect profiles limit utilization in the general FTD population. Nevertheless, recent breakthroughs in the understanding of FTD pathology have led to developments in pharmacological interventions that focus on producing treatments with autoimmune, genetic, and molecular targets. Conclusion: FTD is an underdiagnosed group of neurological syndromes comprising multiple variants with distinct neurobiological profiles and presentations. Recent advances suggest there is an array of potential novel therapeutic targets, although data concerning their effectiveness are still preliminary or preclinical. Further studies are required to develop pharmacological interventions, as there are currently no US Food and Drug administration approved treatments to manage FTD syndromes.

The objective of this review was to assess the efficacy and tolerability of analgesics in reducing behavioral and psychological symptoms of dementia (BPSD) among older adults from published randomized controlled trials (RCTs). A literature search was conducted of PubMed, MEDLINE, SCOPUS, PsycINFO, and Cochrane collaboration databases for RCTs in the English language that evaluated the use of analgesics in reducing the severity of BPSD among older adults. Additionally, references of full-text articles that were included in this review were searched for extra studies. We identified a total of three unique RCTs that evaluated the use of analgesics among individuals with BPSD. One of the identified RCTs resulted in a total of three additional published papers in the literature, resulting in a total of six papers to be included in this review. All three RCTs identified some benefit for the use of analgesics in reducing BPSD. The analgesics appeared to be well tolerated in the included studies. Major study limitations include the use of data exclusively from published RCTs and limiting the search to English language publications. Additionally, we did not utilize statistical methods to evaluate the treatment outcomes including tolerability. In conclusion, available evidence although limited indicates that analgesics may reduce BPSD among some individuals with dementia living in nursing homes and are well tolerated.

Purpose of reviewThis paper provides an overview of biopsychosocial components of sexuality in older adults, sexual expression in older LGBTQ and cognitively impaired adults, and inappropriate sexual behaviors (ISBs) in dementia.Recent findingsSexual expression of older adults is influenced by diverse psychosocial and biologic determinants including ageist beliefs. Although the prevalence of sexual dysfunction increases with age, studies of sexual satisfaction reveal that only a minority experience significant distress. Stigma against sexual expression in LGBTQ older adults may cause concealment of sexual orientation from family or care providers due to fears of rejection. Cognitive impairment affects frequency of and satisfaction with sexual activity, as well as capacity to consent. Staff biases about sexuality can negatively impact sexual expression in healthcare settings. Dementia-related inappropriate sexual behaviors (ISBs) are common and distressing. Recent research has focused on early identification and prevention of ISB, in addition to management through non-pharmacologic and pharmacologic approaches. Sexuality remains integral to quality of life for many older adults and informed consideration of their needs is critical to healthcare delivery and institutional service planning. A comprehensive understanding of older adults' sexuality can enhance education, research, policy, and clinical care for this growing population.

Premorbid personality traits have been implicated as risk factors for the development of behavioral and psychological symptoms of dementia (BPSD), although there is a paucity of studies investigating this relationship. In this narrative review, a number of studies found that premorbid neuroticism has consistently been observed to have a significant association with the development of BPSD symptoms while premorbid conscientiousness, extraversion, openness and agreeableness may be protective factors against future BPSD symptoms. In conclusion, premorbid personality traits appear to affect the risk of BPSD symptoms among individuals with dementia.

The purpose of this systematic review is to evaluate the data on the use of antipsychotics, antidepressants, anticonvulsants, melatonin, and benzodiazepines for the treatment of behavioral and psychological symptoms of dementia (BPSD) from meta-analyses. We performed a literature search of PubMed, MEDLINE, EMBASE, PsycINFO, and Cochrane collaboration databases through August 31, 2016 using the following keywords: dementia, meta-analysis, antipsychotics, antidepressants, anticonvulsants, melatonin, and benzodiazepines. We found a total of 24 meta-analyses that assessed the use of antipsychotics, antidepressants, anticonvulsants, melatonin, and benzodiazepines among individuals with dementia. Sixteen of these meta-analyses evaluated the use of antipsychotics among individuals with dementia. One of the 16 meta-analyses not only evaluated the use of antipsychotics but also antidepressants and mood stabilizers for BPSD. A total of three meta-analyses assessed the use of antidepressants among individuals with dementia, two meta-analyses evaluated the use of mood stabilizers, two meta-analyses evaluated the use of melatonin, and one meta-analysis evaluated the use of melatonin, trazodone, and ramelteon for sleep disturbances among individuals with dementia. There was no meta-analysis for the use of benzodiazepines among individuals with dementia. Data from this systematic review indicates that antipsychotics demonstrate modest efficacy in the treatment of BPSD. Antidepressants appear to improve symptoms of depression among individuals with dementia and may improve some behavioral symptoms among these individuals. Anticonvulsants appear to have no beneficial effects when used in individuals with dementia. Melatonin appears to improve some sleep parameters and some behavioral symptoms among these individuals. Trazodone appears to improve some sleep parameters among individuals with dementia but has not demonstrated efficacy in managing BPSD. The use of antipsychotics and anticonvulsants in this population is limited by their adverse effect profile.

Lewy body dementia (LBD) is an umbrella term for major neurocognitive disorders caused by Lewy body pathology. Parkinson's disease dementia (PDD) and Dementia with Lewy bodies (DLB) are the two main syndromes in LBD. LBDs typically present with cognitive impairment, cholinergic deficiency, neuropsychiatric symptoms such as visual hallucinations and paranoid delusions, as well as parkinsonian symptoms. Due to the urgency in diagnosing LBD early in the disease course to provide the most optimal management of these syndromes, it is important that clinicians elicit the most clinically significant symptoms during patient encounters. The focus of this chapter is to discuss current LBD classification systems and assessments, neuropathology of LBDs, behavioral symptomatology, contemporary management options, and possible future targets of treatment. PubMed was searched to obtain reviews and studies that pertain to classification, behavioral symptomatology, neurobiology, neuroimaging, and treatment of LBDs. Articles were chosen with a predilection to more recent clinical trials and systematic reviews or meta-analyses. Updates to diagnostic criteria have increased clinical diagnostic sensitivity and specificity. Current therapeutic modalities are limited as there is no current disease-modifying drug available. Cholinesterase inhibitors have been reported to be effective in decreasing neuropsychiatric and cognitive symptoms. Neuroleptics should be avoided unless clinically indicated. There is a paucity of studies investigating treatment options for mood symptoms. Current novel targets of treatment focus on decreasing α-synuclein burden. LBDs are a group of dementia syndromes that affect a significant portion of the elderly population. Early diagnosis and treatment is necessary to improve patient quality of life with current treatment options more focused on alleviating severe symptomatology rather than modifying disease pathology.

Objectives: The aim of this systematic review is to identify published randomized controlled trials (RCTs) that evaluated the use of acetylcholinesterase inhibitors for delirium in older adults (≥60 years). Methods: A literature search was conducted of PubMed, MEDLINE, EMBASE, PsycINFO, and Cochrane collaboration databases for RCTs in any language that evaluated the use of acetylcholinesterase inhibitors for delirium in older adults (≥60 years). Also, bibliographic databases of the published articles were searched for additional studies. Results: A total of 7 RCTs that evaluated the use of acetylcholinesterase inhibitors for delirium in older adults (≥60 years) were identified. In 5 of the 7 studies, there was no benefit for the acetylcholinesterase inhibitor in either the prevention or the management of delirium. In one study, there was a trend toward benefit for the active drug group on the incidence of delirium and the length of hospital stay, but both outcomes did not attain statistical significance. One study found a longer duration of delirium and a longer length of hospital stay in the active drug group when compared to the placebo group. The acetylcholinesterase inhibitors were well tolerated in 4 of the 7 studies. In 1 study, the mortality rate was found to be almost 3 times higher in the group receiving haloperidol and rivastigmine when compared to the group receiving haloperidol and placebo. Conclusion: Current evidence does not suggest efficacy of acetylcholinesterase inhibitors for the prevention or management of delirium in older adults.

Background : Antidepressant related movement disorders have been reported in individuals who are ≤ 65 years in age, but a review of such cases in individuals who are ≥ 65 years from medical literature has not yet been conducted. Objectives : To review case reports of antidepressant related movement disorders in individuals who are ≥ 65 years in age from medical literature. Methods : A systematic search of PubMed, Medline, PsychINFO, Embase and Cochrane Library was conducted through January, 31, 2014 for case reports of antidepressant related movement disorders in the elderly. Results : A total of 40 reports (43 individual cases) of movement disorders related to antidepressant use in the elderly were identified. The most common movement disorders noted in these cases were dyskinesias, myoclonus and Parkinsonism. Approximately 80% of the cases occurred in women. About 40% of the cases involved Selective Serotonin Reuptake Inhibitors (SSRIs), with paroxetine being the most commonly noted drug in this class with a total of six cases. Discontinuation of the antidepressant resulted in a resolution of the abnormal movements in a majority of the cases. Conclusions : Antidepressant related movement disorders are uncommon among older adults.

In the United States, major financing for the healthcare for older adults comes from Medicare and Medicaid programs. Recent healthcare policies and legislations appear to have a major impact on the financing of healthcare for the elderly. In this chapter we review important aspects of Medicare and Medicaid and also recent policies and legislation that clinicians caring for older adults with psychiatric disorders should be aware of so that they can provide better care for their clients.

To evaluate the ethical, legal and forensic issues that is faced by the older adult population. Many older individuals will face a host of ethical, medical and legal issues associated with their care. Most prominent among these issues are the maintenance of autonomy while ensuring their safety and the safety of individuals who care for them. Decisions regarding end of life including the formulation of advance directives add to the complexity of care for these older adults. A significant portion of individuals in the criminal justice system are aging and many of these individuals have psychiatric disorders. Their care is compromised due to the lack of appropriate services within criminal justice system for providing care for these individuals. Ethical, legal and forensic issues among older are not uncommon and complicate the care of these vulnerable individuals.

Depressive disorders and bipolar and related disorders are not uncommon among older adults. These disorders are associated with significant morbidity and mortality among individuals who suffer from them. Additionally, the neurobiology these disorders indicate greater burden of medical comorbidities. These disorders are often under- or misdiagnosed among older adults due to limited awareness of their prevalence, lack of standardized diagnostic protocols, and the ageist attitudes toward older adults with psychiatric disorders. Emerging data indicates the efficacy for both psychotherapy and pharmacotherapy in the management of these disorders. In this chapter we review the epidemiology, neurobiology, diagnosis, and the available treatments for these important disorders among older adults.

The objective of this review is to summarize the available data on the use of melatonin and melatonin agonist for the prevention and management of delirium in the elderly patients from randomized controlled trials (RCTs). A systematic search of 5 major databases PubMed, MEDLINE, PsychINFO, Embase, and Cochrane Library was conducted. This search yielded a total of 2 RCTs for melatonin. One study compared melatonin to midazolam, clonidine, and control groups for the prevention and management of delirium in individuals who were pre- and posthip post-hip arthroplasty. The other study compared melatonin to placebo for the prevention of delirium in older adults admitted to an inpatient internal medicine service. Data from these 2 studies indicate that melatonin may have some benefit in the prevention and management of delirium in older adults. However, there is no evidence that melatonin reduces the severity of delirium or has any effect on behaviors or functions in these individuals. Melatonin was well tolerated in these 2 studies. The search for a melatonin agonist for delirium in the elderly patients yielded 1 study of ramelteon. In this study, ramelteon was found to be beneficial in preventing delirium in medically ill individuals when compared to placebo. Ramelteon was well tolerated in this study.

Introduction Anxiety disorders are encountered frequently in late life, and contribute to distress, disability, and increased mortality. Late-life GAD has been linked to increased risk of incident stroke [3]. Anxiety is associated with an increased risk for cognitive impairment and dementia in community dwelling older adults independent of psychosocial risk factors [6]. Despite these impairments, late-life anxiety disorders are largely untreated in primary care, with only 36.3% of recurrent cases in a community sample receiving treatment [7]. Antidepressants are considered to be first-line pharmacological treatment for anxiety disorders [8]. Current evidence for the treatment of anxiety disorders in the elderly is extrapolated from studies on younger adults. However, older adults suffer from medical conditions that affect renal, hepatic, and cardiac function. Pharmacokinetic considerations such as variable drug absorption and decreased volume of distribution may also contribute to reduced safety and tolerability of antidepressants in the elderly [5]. To date, there has not been a systematic review on the use of antidepressants for anxiety disorders in older adults. The aim of this systematic review is to provide updated information on the efficacy and tolerability of antidepressants in treatment of anxiety disorders among older adults from randomized controlled studies. Methods This systematic review was conducted in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The objective of this review is to summarize the results from published randomized controlled clinical trials of antidepressants for late-life anxiety. We performed a literature search of PubMed, MEDLINE, EMBASE, PsychINFO, and Cochrane collaboration databases through October 18th, 2018, using the following keywords: “late life”, “elderly”, aged, “senior citizen”, or “geriatric” combined with the keywords “anxiety” or “anxiety disorder”, and “antidepressant” or “antidepressive agents” or their pharmaceutical names. The search was restricted to English-language studies conducted in human subjects. We reviewed the bibliographic databases of the published articles for additional studies. Results Our search yielded a total of 12 randomized controlled trials. Two of these studies [14, 15] were pooled analyses of randomized controlled trials, which have been included as they fulfilled our selection criteria. We found 8 trials of selective serotonin reuptake inhibitors (SSRIs): 3 studies on sertraline [16, 17, 18], 2 each on citalopram [19, 20] and escitalopram [21, 22], and 1 trial of paroxetine [23]. We found 3 studies on serotonin-norepinephrine reuptake inhibitors (SNRIs), including 1 study on duloxetine [24], and 1 study each on duloxetine [14] and venlafaxine [15] reporting pooled analyses. There was 1 study of a tricyclic antidepressant (TCA), namely imipramine [25]. Three studies were rated “good”, 8 were rated “fair” and 1 was rated “poor” according to our quality appraisal criteria. Conclusions This systematic review supports the use of antidepressants as an efficacious and well-tolerated treatment option for late-life anxiety. Future research should focus on other anxiety disorders such as phobias and post-traumatic stress disorders, and should include older adults as well as those with cognitive impairment to increase their generalizability to community settings. Long term trials are needed to assess the efficacy of antidepressants in maintenance and prevention of relapse of anxiety, and provide necessary data on long-term tolerability. Head-to-head trials of antidepressants and other agents used for anxiety such as gabapentin and quetiapine are needed to compare their efficacy and safety. Future studies should include treatment modalities commonly used in the elderly such as problem-solving therapy, as well as newer modes of service delivery such as tele-psychiatry and home-visits to conceptualize efficacious treatment options for anxiety disorders in late-life that are commonly encountered in clinical settings. This research was funded by The authors did not receive any funding for this study

A United Nations report indicates that there will be an increase in the number of older adults during this century compared with the last century [101]. It is postulated that by 2050, the number of older persons in the world will exceed the number of younger adults for the first time in history. The percentage of older adults in the world will double to almost 21% over the next 40 years. Worldwide, the number of people who are aged 65 years and older will increase from 500 million to 1.5 billion over the next three decades.

Background: The aim of this systematic review is to identify published randomized controlled trials (RCTs) that evaluated the use of oxytocin in individuals with frontotemporal dementia (FTD). Methods: A literature search was conducted of PubMed, MEDLINE, EMBASE, PsycINFO and Cochrane collaboration databases for RCTs in any language that evaluated the use of oxytocin in individuals with FTD. Bibliographic databases of published articles were also searched for additional studies. Results: A total of two RCTs that evaluated the use of oxytocin in individuals with FTD were identified. In one study, the use of oxytocin in individuals with FTD produced a reduction in identification of negative facial expressions (anger and fear) which can be hypothesized to improve trust and increase cooperation in these individuals. Both studies noted oxytocin was well tolerated and showed short term benefits on behavioral symptoms in individuals with FTD. Conclusions: Oxytocin appears to improve social aspects of cognition and behavioral symptoms in individuals with FTD and is well tolerated. However, positive data from larger and longer duration RCTs are needed before the routine use of oxytocin in individuals with FTD can be recommended.

Although not as commonly reported as in younger individuals, substance use disorders are not uncommon in late life. Given the growth in the population of older adults in the United States, it is estimated that the number of older adults with a substance use disorders will increase significantly in the future. Available evidence indicates that current diagnostic criteria are less sensitive in identifying substance use disorders in late life compared to younger individuals. It is expected that the development of specialized screening tools and specific diagnostic criteria for older adults will improve the diagnostic accuracy for substance use disorders in late life. Routine screening for substance use disorders and prompt interventions will also improve outcomes in these individuals. Available data indicate that older adults with substance use disorders respond as well as younger adults to treatments, if these treatments are specifically designed for this age group.

In the United States, anxiety disorders are the most prevalent group of psychiatric disorders [1]. They cause significant social and functional impairments in individuals who are affected by these disorders [2]. Current data indicates that the prevalence of anxiety disorders in greater in the older adults than previously acknowledged [3]. The rates of anxiety symptoms that did meet the criteria for a psychiatric diagnosis in older adults were 15% to 20% in the general community and primary care samples [4]. The National Comorbidity Survey Replication (NCS-R) found that among adults older than 60 years in age, the prevalence of any anxiety disorder was 15.3%. Among the anxiety disorders, specific phobia was the most prevalent (7.5%) followed by social phobia (6.6%), generalized anxiety disorder (GAD) (3.6%), posttraumatic stress disorders (PTSD) (2.5%), panic disorder (2%), agoraphobia without panic (1%) and obsessive compulsive disorder (OCD) (0.7%) [1].

Delirium is a common neuropsychiatric disorder in the elderly. Delirium often has multifactorial etiologies and the condition emerges due to the interaction between the different predisposing and precipitating factors. If delirium is left untreated, it can lead to significantly higher rates of morbidity and mortality. Unfortunately, many cases of delirium in the elderly are missed or this condition is misdiagnosed as a depressive or a neurocognitive disorder. Emerging data indicates that a significant number of cases of delirium can be prevented. Evidence indicates that both non-pharmacological and pharmacological treatment methods have shown benefit in reducing the incidence of delirium, mitigating its severity, decreasing the duration of the episode and also shortening the length of hospital stay. In this review, we discuss the evidence based prevention and the management of delirium in the elderly.

The objective of this review is to summarize the available data on the use of benzodiazepines for the treatment of behavioral and psychological symptoms of dementia (BPSD) from randomized controlled trials (RCTs). A systematic search of 5 major databases, PubMed, MEDLINE, PsychINFO, EMBASE, and Cochrane Collaboration, yielded a total of 5 RCTs. One study compared diazepam to thioridazine, 1 trial compared oxazepam to haloperidol and diphenhydramine, 1 trial compared alprazolam to lorazepam, 1 trial compared lorazepam to haloperidol, and 1 trial compared intramuscular (IM) lorazepam to IM olanzapine and placebo. The data indicates that in 4 of the 5 studies, there was no significant difference in efficacy between the active drugs to treat the symptoms of BPSD. One study indicated that thioridazine may have better efficacy than diazepam for treating symptoms of BPSD. In 1 study, the active drugs had greater efficacy in treating BPSD when compared to placebo. There was no significant difference between the active drugs in terms of tolerability. However, in 2 of the 5 studies, about a third of the patients were noted to have dropped out of the studies. Available data, although limited, do not support the routine use of benzodiazepines for the treatment of BPSD. But these drugs may be used in certain circumstances where other psychotropic medications are unsafe for use in individuals with BPSD or when there are significant medication allergies or tolerability issues with certain classes of psychotropic medications.

Mild cognitive impairment (MCI) represents an intermediate stage between normal cognitive changes associated with aging and dementia. Individuals with MCI have been identified as having a faster rate of progression to dementias. Risk factors for progression include greater cognitive deficits at baseline, ApoE4 carrier status, brain volume changes, cerebrospinal fluid (CSF) changes, and the presence of behavioral and psychological symptoms. Refinements in the diagnostic criteria for MCI and the identification of biomarkers to predict the progression to dementias have resulted in the appropriate diagnosis of this condition being made and the development of possible prevention and treatment strategies. Available data indicate that cognitive and physical training appears to slow the progression of the disease process. Studies of pharmacotherapeutic agents do not indicate benefit for cholinesterase inhibitors, the anti-inflammatory drug rofecoxib, or antioxidants in slowing the progression of MCI to dementias.

A recent New York Times article highlighted the issue on the overuse of psychotropic medications in older adults with dementias who live in the United States. It was mentioned in this report that the US government had concerns regarding the inappropriate use of antipsychotic medications like aripiprazole, risperidone, olanzapine and clozapine in individuals with dementias who lived at home or at assisted living facilities and nursing homes. In view of this recent report, it is prudent to evaluate the evidence for the use of antipsychotic medications for treating behavioral symptoms of dementia.

Background: The purpose of this review is to evaluate the data on the use of antipsychotics in individuals with dementia from meta-analyses. Methods: We performed a literature search of PubMed, MEDLINE, EMBASE, PsycINFO and Cochrane collaboration databases through 30 November, 2015 using the following keywords: ‘antipsychotics’, ‘dementia’ and ‘meta-analysis’. The search was not restricted by the age of the patients or the language of the study. However, in the final analysis we only included studies involving patients that were published in English language journals or had official English translations. In addition, we reviewed the bibliographic databases of published articles for additional studies. Results: This systematic review of the literature identified a total of 16 meta-analyses that evaluated the use of antipsychotics in individuals with dementia. Overall, 12 meta-analyses evaluated the efficacy of antipsychotics among individuals with dementia. Of these, eight also assessed adverse effects. A further two studies evaluated the adverse effects of antipsychotics (i.e. death). A total of two meta-analyses evaluated the discontinuation of antipsychotics in individuals with dementia. Overall, three meta-analyses were conducted in individuals with Alzheimer’s disease (AD) whereas one focused on individuals with Lewy Body Dementia (LBD). The rest of the 12 meta-analyses included individuals with dementia. Conclusions: Antipsychotics have demonstrated modest efficacy in treating psychosis, aggression and agitation in individuals with dementia. Their use in individuals with dementia is often limited by their adverse effect profile. The use of antipsychotics should be reserved for severe symptoms that have failed to respond adequately to nonpharmacological management strategies.

Objectives The aim of this systematic review is to identify case reports of citalopram use resulting in QTc prolongation, torsades de pointes, or both, in the medical literature. Methods A literature search was conducted of PubMed, MEDLINE, EMBASE, Scopus, and PsycINFO databases for case reports published in any language that reported the relationship between citalopram use and the development of QTc prolongation or torsades de pointes or both. In addition, bibliographic databases of published articles were searched for additional cases. Results A total of 18 case reports of citalopram use resulting in QTc prolongation were identified. Of these, 10 cases were also associated with the development of torsades de pointes. A total of 14 cases occurred in women and 4 in men. There were 7 cases involving an overdose with citalopram. Of the 18 cases, 12 occurred in individuals who were aged 60 years. In 8 of the 18 cases, the individuals were taking a dose between 20 and 60 mg of citalopram in a day. Hypertension was the most common comorbid medical condition, as seen in 5 of the cases. Conclusions QTc prolongation or torsades de pointes are infrequently reported adverse effects associated with citalopram use.