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Objective: The goal of this exploratory study was to predict which long-term care residents with dementia would experience improvements in their sundowning symptoms after listening to personalized music playlists. Methods: We studied 101 residents with moderate to severe dementia from 15 long-term care facilities across 8 months. We observed residents’ behavioral responses to individualized music while they listened and recorded sundowning symptoms both before and after each listening session. Results: As hypothesized, residents who exhibited a greater number of positive reactive behaviors while listening to music also evidenced more improvements in their confusion, disengagement, unresponsiveness, and restlessness after their music-listening session. Discussion: Our results reveal that observing behavioral responses during music listening is an effective way to determine when nursing home residents are benefiting from personalized music playlists. These findings inform music programs in long-term care settings by identifying residents whose sundowning symptoms are most amenable to music intervention.

ObjectivesThis study aimed to replicate music’s positive effects on dementia-related symptoms, determine whether a 6-month intervention would lead to greater positive outcomes than typical 3- to 4-month interventions, and examine changes in sundowning symptoms after music listening.Methods282 nursing home residents with dementia listened to personalized music playlists 1–3 times weekly for 30 minutes across 6 months. Standardized assessments of affect, behavior, and cognition and direct observations of sundowning symptoms comprised the outcomes.ResultsResults documented significant improvements in residents’ general neuropsychiatric symptoms, agitation, and depression across the first 3 months, but no additional improvements across the subsequent 3 months. Seven sundowning symptoms significantly improved following music listening, with some (e.g., disengagement) being more amenable to music than others (e.g., aggression).DiscussionResults support short-term individualized music listening as an effective non-pharmacological approach for improving dementia-related symptoms in nursing home residents and suggest new applications of music-related interventions.

This chapter presents various issues of models of practice for the private sector. Medicare, commercial insurance, Medicaid, HMOs and private-pay options are discussed as the underpinnings for the design of the model for the private practitioner in geriatric psychiatry. The discussion of the development of models of care for older adult programs in psychiatry is preceded by a review of the literature, which reflects the opinions of individuals involved in geriatric psychiatry around the country. The literature on care for the mentally ill elderly describes the need for comprehensive systems. Financial issues in providing care for the elderly psychiatric patient are written about by Freudenheim, Barsa et al., and Gottlieb. Private health insurance in most cases for the elderly falls into the category of “medigap” coverage. Salaried individuals in the public sector can and will continue to provide services through state, county, and Veterans’ Administration facilities.

Abstract. Existing research has primarily evaluated music therapy (MT) as a means of reducing the negative affect, behavioral, and/or cognitive symptoms of dementia. Music listening (ML), on the other hand, offers a less-explored, potentially equivalent alternative to MT and may further reduce exposure to potentially harmful psychotropic medications traditionally used to manage negative behavioral and psychological symptoms of dementia (BPSD). This 5-month prospective, naturalistic, interprofessional, single-center extended care facility study compared usual care (45 residents) and usual care combined with at least thrice weekly personalized ML sessions (47 residents) to determine the influence of ML. Agitation decreased for all participants (p < .001), and the ML residents receiving antipsychotic medications at baseline experienced agitation levels similar to both the usual care group and the ML patients who were not prescribed antipsychotics (p < .05 for medication × ML interaction). No significant changes in psychotropic medication exposure occurred. This experimental study supports ML as an adjunct to pharmacological approaches to treating agitation in older adults with dementia living in long-term care facilities. It also highlights the need for additional research focused on how individualized music programs affect doses and frequencies of antipsychotic medications and their associated risk of death and cerebrovascular events in this population.

Objective The authors compared efficacy of olanzapine versus placebo and risperidone as measured by the Neuropsychiatric Inventory and Clinical Global Impression–Severity of Psychosis scale in patients with dementia-related psychosis. Methods Patients with moderate-to-severe psychotic symptoms associated with dementia were recruited from outpatient or residential settings and randomly assigned to 10-week, double-blind, flexible-dose treatment with olanzapine (N = 204; 2.5 mg–10 mg/day; mean: 5.2 mg/day), risperidone (N = 196; 0.5 mg–2 mg/day; mean: 1.0 mg/day) or placebo (N = 94). Results Most measures of neuropsychiatric functioning improved in all treatment groups, including the placebo group, and no significant treatment differences occurred. Overall discontinuation was lowest in the placebo group, and the olanzapine group had a significantly higher incidence of discontinuation due to adverse events (16.2%) relative to placebo (3.2%) and risperidone (8.7%) groups. Treatment-emergent extrapyramidal symptoms were more numerous for risperidone- than placebo- or olanzapine-treated patients. Abnormally high prolactin levels occurred in 78.0% of risperidone patients, compared with 16.7% for olanzapine and 5.0% for placebo. The incidence of weight gain greater than 7% from baseline was higher in the olanzapine group relative to risperidone, but neither active-treatment group showed a statistical difference from placebo (1.1%). No other statistically significant and clinically relevant differences were seen for any other vital sign, electrocardiographic measure, or laboratory hematology and chemistry, including glucose, except for cholesterol, which decreased from baseline to endpoint in both active-treatment groups. Conclusions Patients' neuropsychiatric functioning improved with olanzapine, risperidone, and placebo treatment. There was a substantial response in the placebo group, and no significant differences emerged among treatments.

Objectives Psychotic symptoms and behavioral disturbances are a concern in the care of elderly patients with Alzheimer's dementia (AD). This study was conducted to compare the efficacy of olanzapine versus placebo in patients with psychotic symptoms associated with AD in long-term or continuing-care settings. Methods Patients (n = 652) with AD and delusions or hallucinations were randomly assigned to 10 weeks of double-blind treatment with placebo or fixed-dose olanzapine (1.0, 2.5, 5.0, 7.5 mg/day). Results Mean age was 76.6±10.4 years. Repeated-measures analysis showed significant improvement from baseline in NPI/NH Psychosis Total scores (sum of Delusions, Hallucinations items—primary efficacy measure) in all five treatment groups (p

Objectives The objective of this study was to investigate risk of diabetes among elderly patients during treatment with antipsychotic medications. Design We conducted a longitudinal, retrospective study assessing the incidence of new prescription claims for antihyperglycemic agents during antipsychotic therapy. Setting Prescription claims from the AdvancePCS claim database were followed for 6 to 9 months. Participants Study participants consisted of patients in the United States aged 60+ and receiving antipsychotic monotherapy. The following cohorts were studied: an elderly reference population (no antipsychotics: n = 1,836,799), those receiving haloperidol (n = 6481) or thioridazine (n = 1658); all patients receiving any conventional antipsychotic monotherapy (n = 11,546), clozapine (n = 117), olanzapine (n = 5382), quetiapine (n = 1664), and risperidone (n = 12,244), and all patients receiving any atypical antipsychotic monotherapy (n = 19,407). Measurements We used Cox proportional hazards regression to determine the risk ratio of diabetes for antipsychotic cohorts relative to the reference population. Covariates included sex and exposure duration. Results New antihyperglycemic prescription rates were higher in each antipsychotic cohort than in the reference population. Overall rates were no different between atypical and conventional antipsychotic cohorts. Among individual antipsychotic cohorts, rates were highest among patients treated with thioridazine (95% confidence interval [CI], 3.1–5.7), lowest with quetiapine (95% CI, 1.3–2.9), and intermediate with haloperidol, olanzapine, and risperidone. Among atypical cohorts, only risperidone users had a significantly higher risk (95% CI, 1.05–1.60; P = 0.016) than for haloperidol. Conclusions about clozapine were hampered by the low number of patients. Conclusion These data suggest that diabetes risk is elevated among elderly patients receiving antipsychotic treatment. However, causality remains to be demonstrated. As a group, the risk for atypical antipsychotic users was not significantly different than for users of conventional antipsychotics.

Objective Olanzapine (OLZ) is unique among currently available antipsychotic medications in its antagonism of a range of receptor systems including dopamine, norepinephrine, serotonin, acetylcholine, and histamine. Olanzapine's mechanistic complexity provides a broad efficacy profile in patients with schizophrenia and acute, pure or mixed mania. Patients experience symptomatic relief of mania, anxiety, hallucinations, delusions, and agitation/aggression and reduced depressive, negative, and some cognitive symptoms. This paper will review the safety profile of OLZ, focusing on the elderly, where data are available.Method Preclinical and clinical studies of OLZ are reviewed, with emphasis on its possible effects on the cholinergic system and the histamine 11, receptor. Weight change and related metabolic considerations, cardiac and cardiovascular safety, and motor function during treatment with OLZ are also reviewed.Results and Conclusion In vitro receptor characterization methods, when done using physiologically relevant conditions allow accurate prediction Of the relatively low rate of anticholinergic-like adverse events, extrapyramidal symptoms, and cardiovascular adverse events during treatment with OLZ. Currently available clinical data suggest olanzapine is predictably safe in treating adult patterns of any age with schizophrenia and acute bipolar mania, as well as in treatment of patients with some type, of neurodegenerative disorders. Copyright (C) 2001 John Wiley Sons, Ltd.

Depression is a common problem in older patients and a significant contributor to morbidity and mortality in this population. The identification and treatment of depression is more complex in older patients because of difficulty in diagnosis, coexisting illnesses, and concurrent drug therapy. In addition, a variety of medical conditions and drugs can cause depression. Treatment often has to be modified in consideration of other illnesses, medications, and the reduced ability of the elderly to metabolize drugs. Duration of treatment may be longer than with young patients because older adults may respond more slowly to antidepressants.

We conducted a review of drugs that were most commonly associated with inducing seizures in the elderly population. The method for determining the risk of these agents includes evaluating the utilisation and the percentage of adverse events in previous studies and case reports. Classes of medications, such as anti-psychotics and antidepressants, are extensively reviewed to provide the clinician with treatment options in high risk patients. The risk of seizures secondary to the withdrawal of alcohol (ethanol) and benzodiazepines, and methods employed to minimise the risk are discussed. In addition, the management of patients with drug-induced seizures is delineated. Drug-induced seizures are a potentially serious adverse effect. It is important that clinicians are aware of which classes of medications and individual medications are associated with reducing seizure threshold.

Patients with serious mental illness are living longer. Yet, there remain few studies that focus on healthcare utilization and its relationship with comorbidities in these elderly mentally ill patients.Comparative study. Information on demographics, comorbidities, and healthcare utilization was taken from an electronic medical record system.Wishard Health Services senior care and community mental health clinics.Patients age 65 years and older-255 patients with serious mental illness (schizophrenia, major recurrent depression, and bipolar illness) attending a mental health clinic and a representative sample of 533 nondemented patients without serious mental illness attending primary care clinics.Patients having serious mental illness had significantly higher rates of medical emergency department visits (p = 0.0027) and significantly longer lengths of medical hospitalizations (p0.0001) than did the primary care control group. The frequency of medical comorbidities such as diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, thyroid disease, and cancer was not significantly different between the groups. Hypertension was lower in the mentally ill group (p0.0001). Reported falls (p0.0001), diagnoses of substance abuse (p = 0.02), and alcoholism (p = 0.0016) were higher in the seriously mentally ill. The differences in healthcare utilization between the groups remained significant after adjusting for comorbidity levels, lifestyle factors, and attending primary care.Our findings of higher rates of emergency care, longer hospitalizations, and increased frequency of falls, substance abuse, and alcoholism suggest that seriously mentally ill older adults remain a vulnerable population requiring an integrated model of healthcare.

During a schizophrenia treatment episode, persistence with the initial antipsychotic may indicate optimal pharmacotherapy and be a precursor to longer-term effectiveness and other positive outcomes. The objective of this study was to examine the ability of selected variables to predict antipsychotic persistence among patients receiving olanzapine or risperidone as initial treatment.Data for this analysis, which was not defined in the original study protocol, came from a naturalistic, randomized, open-label trial comparing costs and effectiveness of first-line antipsychotic treatment options in schizophrenia. Predictor variables were as follows: (1) patients' initial antipsychotic (olanzapine [n = 222] or risperidone [n = 218]); (2) current (within 30 days) comorbid diagnosis of substance abuse; and (3) nine self-report items from the Rating of Medication Influence (ROMI) scale, including an item assessing patients' perceptions of the role of their therapeutic alliance in their adherence.For the primary analysis, a stepwise logistic regression was used in predicting antipsychotic persistence of at least 180 days. Variables found to be significantly predictive were included in a second analysis that assessed persistence at additional thresholds (90 days,270 days, and completion of the 1-year study).Four variables predicted longer antipsychotic persistence; olanzapine as initial antipsychotic (p = 0.004), absence of comorbid substance abuse (p = 0.025), and two of the ROMI items representing patients' subjective response to treatment--positive relationship with clinical staff (p = 0.048) and fulfillment of life goals (p = 0.050).Within a randomized trial design, this study corroborated the influence of several factors on antipsychotic persistence in schizophrenia. Results support the importance of the initial antipsychotic treatment option, presence of a comorbid substance abuse diagnosis, and the role of patients' subjective responses. Additional research is needed to further explore these and other factors as predictors of antipsychotic persistence, and of subsequent treatment outcomes.

The authors compared efficacy of olanzapine versus placebo and risperidone as measured by the Neuropsychiatric Inventory and Clinical Global Impression-Severity of Psychosis scale in patients with dementia-related psychosis.Patients with moderate-to-severe psychotic symptoms associated with dementia were recruited from outpatient or residential settings and randomly assigned to 10-week, double-blind, flexible-dose treatment with olanzapine (N=204; 2.5 mg-10 mg/day; mean: 5.2 mg/day), risperidone (N=196; 0.5 mg-2 mg/day; mean: 1.0 mg/day) or placebo (N=94).Most measures of neuropsychiatric functioning improved in all treatment groups, including the placebo group, and no significant treatment differences occurred. Overall discontinuation was lowest in the placebo group, and the olanzapine group had a significantly higher incidence of discontinuation due to adverse events (16.2%) relative to placebo (3.2%) and risperidone (8.7%) groups. Treatment-emergent extrapyramidal symptoms were more numerous for risperidone- than placebo- or olanzapine-treated patients. Abnormally high prolactin levels occurred in 78.0% of risperidone patients, compared with 16.7% for olanzapine and 5.0% for placebo. The incidence of weight gain greater than 7% from baseline was higher in the olanzapine group relative to risperidone, but neither active-treatment group showed a statistical difference from placebo (1.1%). No other statistically significant and clinically relevant differences were seen for any other vital sign, electrocardiographic measure, or laboratory hematology and chemistry, including glucose, except for cholesterol, which decreased from baseline to endpoint in both active-treatment groups.Patients' neuropsychiatric functioning improved with olanzapine, risperidone, and placebo treatment. There was a substantial response in the placebo group, and no significant differences emerged among treatments.

Patients with symptoms of mood, behavior, and thought disturbances are regularly treated in the primary care setting. More often than not, the disorders associated with these symptoms are overlooked or misdiagnosed by physicians, in part because these patients present symptomatic complaints that are seemingly unrelated to the underlying disorder. Recognition of comorbid psychiatric symptoms allows physicians to treat the whole person more effectively. Furthermore, patients and their caregivers benefit greatly from the early intervention and treatment that is frequently provided in the primary care setting. With the appropriate training so that they may readily recognize these symptoms, osteopathic physicians can help prevent the further progression of--or potential unfavorable outcomes from--otherwise untreated or inadequately treated illnesses.

Background: Recently, much attention has been focused on the increased rate of metabolic syndrome componen ts among psychiatric patients, including glucose intolerance, hyperglycemia, diabetes mellitus, hyperlipidemia, hypertension, and weight gain. Various reports have identified cases of newly diagnosed diabetes during treatment with atypical antipsychotic agents. However, the question remains whether there is a relationship between atypical antipsychotic use and the metabolic syndrome or whether there is a higher risk in this population irrespective of medication use. Method: Many articles on antipsychotics and metabolic issues are reviews of case reports or small, cross-sectional laboratory studies highlighting the suspected potential for differing rates of new-onset diabetes cases. We conducted a retrospective review of the literature from 1998 through 2002, using the MEDLINE database, and recent studies presented at major psychiatric medical conferences to create a broader perspective on the metabolic issues. Results: We identified over 70 abstracts and published manuscripts, including case reports; cross-sectional lab studies; retrospective analyses of head-to-head, controlled clinical studies; retrospective database studies; pharmacoepidemiology studies; and prospective head-to-head studies presented in the past 4 years. Studies assessed differences in fasting plasma glucose, oral glucose tolerance tests (OGTT), modified OGTT, frequently sampled intravenous glucose tolerance tests, homeostasis model assessment–insulin resistance, odds or hazard ratios, prevalence, and incidence, as well as other elements of the metabolic syndrome. Conclusion: Data from this large body of scientific evidence indicate that the psychiatric patient population may be at a higher risk for the development of obesity, glucose homeostasis dysregulation, and hyperlipidemia compared with the general population. The available data do not demonstrate a consistent or clinically significant difference in the risk of new-onset diabetes during treatment with the various atypical antipsychotic agents.

Primary care physicians increasingly have treated depressive disorders over the last decade. Unrecognized bipolar disorder, sometimes misdiagnosed as unipolar depression, may lead to treatment resistance or nonresponse. We describe differences between unipolar and bipolar disorders, focusing on recognition, diagnosis, and treatment of bipolar spectrum disorders such as bipolar I, bipolar II, antidepressant-induced mania, and cyclothymia. Broadening the understanding of these different disorders and their presentation in primary care settings can enable earlier and more targeted treatment. Though 3 mood stabilizers are U.S. Food and Drug Administration–approved for treatment of acute mania, no medications are currently approved for treating bipolar depression.

Primary care practitioners are in an ideal position to initiate treatment for patients with behavior, mood, and thought disturbances. It is believed that early identification and treatment of these symptomatic features of primary or secondary central nervous system disorders may significantly reduce morbidity and benefit the patient, his/her family, and involved caregivers, including the primary care physician. A broad list of central nervous system-active medications are utilized by family physicians to treat patients who exhibit symptoms of agitation, altered mood, and disordered thought. Some medications have demonstrated superiority over placebo or active medicines in reported clinical trials. This article is a brief overview of the safety and efficacy from reported studies of the use of medications frequently used to treat symptoms related to behavior, mood, and thought disturbances, with a specific focus on the clinical applicability of olanzapine.

This chapter presents a review of the current status of depression treatment for the elderly. The authors describe currently available antidepressants and discuss special considerations when they are used to treat elderly patients.

Three cases of elderly depressed patients with symptoms of tardive dyskinesia (TD) subsequently treated with electrocon vulsive therapy (ECT) are presented. These cases are discussed in relation to several cases reported in the literature of ECT and TD. The possibility of improvement in symptoms of TD in certain patients is discussed.

Treatment with electroconvulsive therapy (ECT) of medically ill geriatric patients with affective disorders is described. Of 135 patients to whom ECT was administered in 6 years, 55% were over 60 years of age. One-third (45) exhibited cardiovascular (62%), central nervous system (15%), or other medical conditions (22%) increasing the risks of the treatment. Treatment strategies are described.

Background Late-life depression is a common, chronic and recurring disorder for which guidelines recommend long-term therapy. The safety and efficacy of duloxetine for the treatment of major depressive disorder (MDD) were evaluated using data from elderly patients (age ≥ 65 years; n = 101) who participated in a large, multinational, open-label study. Methods Patients meeting DSM-IV criteria for MDD received duloxetine 80 mg/d (40 mg twice daily (BID)) to 120 mg/d (60 mg BID) for up to 52 weeks. Efficacy measures included the Clinical Global Impression of Severity (CGI-S) scale, the 17-item Hamilton Rating Scale for Depression (HAMD17), the Beck Depression Inventory-II (BDI-II), the Patient Global Impression of Improvement (PGI-I) scale, and the Sheehan Disability Scale (SDS). Safety and tolerability were evaluated using discontinuation rates, spontaneously reported adverse events, and changes in vital signs, ECG, and laboratory analytes. Results Mean changes in HAMD17 total score at Weeks 6, 28, and 52 were -13.0, -17.4 and -17.5 (all p-values 10% of patients included dizziness, nausea, constipation, somnolence, insomnia, dry mouth, and diarrhea. Most events occurred early in the study. Mean changes at endpoint in blood pressure and body weight were less than 2.0 mm Hg, and -0.1 kg, respectively. Conclusions In this open-label study, duloxetine was effective, safe, and well tolerated in the long-term treatment of MDD in patients aged 65 and older.