Use of Atypical Antipsychotic Drugs in Patients with Dementia



FREE PREVIEW Log in or buy this issue to read the full article. AAFP members and paid subscribers get free access to all articles. Subscribe now.


FREE PREVIEW Subscribe or buy this issue. AAFP members and paid subscribers get free access to all articles.

Am Fam Physician. 2003 Jun 1;67(11):2335-2341.

Increasingly, atypical antipsychotic drugs are prescribed for elderly patients with symptoms of psychosis and behavioral disturbances. These symptoms often occur in patients with Alzheimer's disease, other dementias, or Parkinson's disease. As the average age of Americans increases, the prevalence of Alzheimer's disease and Parkinson's disease will rise accordingly. Although nonpharmacologic treatments for behavioral disturbances should be tried first, medications often are needed to enable the patient to be adequately cared for. Current guidelines recommend using risperidone and olanzapine to treat psychosis in patients with Alzheimer's dementia. Quetiapine and clozapine are recommended for treatment of psychosis in patients with Parkinson's disease. Additional research is needed for a recently approved agent, ziprasidone. To minimize side effects, these medications should be started at low dosages that are increased incrementally. Drug interactions, especially those involving the cytochrome P450 system, must be considered. Clozapine's potentially lethal side effects limit its use in the primary care setting. Informed use of atypical antipsychotic drugs allows family physicians to greatly improve quality of life in elderly patients with dementia and behavior disturbances.

Most family physicians are comfortable prescribing antidepressants, but anti-psychotic medications are less commonly prescribed and therefore less familiar. Antipsychotic drugs effectively treat psychosis caused by a variety of conditions (Table 1). Psychotic symptoms are classified as either positive or negative. Positive symptoms include hallucinations, delusions, thought disorders (manifested by marked incoherence, derailment, tangentiality), and bizarre or disorganized behavior. Negative symptoms include anhedonia, flattened affect, apathy, and social withdrawal.1 Psychotic symptoms in elderly patients always should be investigated thoroughly, and underlying medical conditions should be identified and treated. Although a family physician is less likely to manage schizophrenia in elderly patients, it is quite common for family physicians to treat patients who have Alzheimer's disease and Parkinson's disease. These patients frequently have psychotic symptoms that are treated without a specialist's aid.

TABLE 1

Some Causes of Psychotic Symptoms in Elderly Patients

Primary psychiatric conditions

Schizophrenia

Mood disorders with psychotic features

Substance abuse or intoxication

Delirium*

Dementia*

Intracranial lesions

Tumor

Stroke

Subdural hematoma


*—Syndromes with multiple potential etiologies.

TABLE 1   Some Causes of Psychotic Symptoms in Elderly Patients

View Table

TABLE 1

Some Causes of Psychotic Symptoms in Elderly Patients

Primary psychiatric conditions

Schizophrenia

Mood disorders with psychotic features

Substance abuse or intoxication

Delirium*

Dementia*

Intracranial lesions

Tumor

Stroke

Subdural hematoma


*—Syndromes with multiple potential etiologies.

Typical antipsychotic drugs, such as halo-peridol (Haldol), traditionally have been used to control psychotic and behavior disturbances in elderly patients, but these drugs have troubling side effects. Extrapyramidal symptoms can cause stiffness, immobility, and falls and are associated with significant morbidity. The newer atypical antipsychotic drugs offer distinct advantages over older agents, including decreased extrapyramidal symptoms and improved efficacy in treatment of the negative symptoms of psychosis. Family physicians should become familiar with the use of atypical antipsychotic drugs in elderly patients (Table 2).

TABLE 2

Summary of Atypical Antipsychotic Drugs Used in Elderly Patients

Drug Evidence for use in patients with Alzheimer's disease? Evidence for use in patients with Parkinson's disease? Dosage in the elderly Common or major side effects* Cytochrome P450 system Cost per month

Clozapine (Clozaril)

Limited

Yes

6.5 to 75 mg per day

Agranulocytosis, hypotension, seizures, sialorrhea, weight gain, tachycardia, hyperthermia, hyperglycemia

1A2‡

$11 to $132

2D6§

Olanzapine (Zyprexa)

Yes

No

1.25 to 5 mg per day

Weight gain, hypotension, seizures, hyperglycemia

1A2‡

$78 to $184

Quetiapine (Seroquel)

No

Yes

12.5 to 200 mg per day

Hypotension, headache, weight gain, cataract formation

3A4ll

$22 to $151

Risperidone (Risperdal)

Yes

No

0.25 to 3 mg per day

Extrapyramidal symptoms, hypotension, hyperprolactinemia, insomnia, weight gain

2D6§

$84 to $164

Ziprasidone (Geodon)

No

No

Not studied

QT prolongation, rash, hypertension

3A4ll

N/A


N/A = not available.

*—All of these medications can cause sedation. All atypical antipsychotic agents can cause hyperglycemia (contributing to type II diabetes mellitus), although this most often occurs with olanzapine and clozapine.

†—Estimated cost to the pharmacist based on average wholesale prices in Red book. Montvale, N.J.: Medical Economic Data, 2002. Cost to the patient will be higher, depending on prescription-filling fee.

‡—1A2 inhibitors: cimetidine (Tagamet), fluoroquinolones, fluvoxamine (Luvox); can increase effects of the antipsychotic agent.

§—2D6 inhibitors: celecoxib (Celebrex), amiodarone (Cordarone), cimetidine, paroxetine (Paxil), fluoxetine (Prozac); can increase effects of the antipsychotic agent.

ll—3A4 inhibitors: ciprofloxacin (Cipro), fluoxetine, grapefruit juice, erythromycin, ketoconazole (Nizoral), diltiazem (Cardizem); can increase effects of the antipsychotic agent. 3A4 enhancer: phenytoin (Dilantin); can enhance metabolism of clozapine and quetiapine.

TABLE 2   Summary of Atypical Antipsychotic Drugs Used in Elderly Patients

View Table

TABLE 2

Summary of Atypical Antipsychotic Drugs Used in Elderly Patients

Drug Evidence for use in patients with Alzheimer's disease? Evidence for use in patients with Parkinson's disease? Dosage in the elderly Common or major side effects* Cytochrome P450 system Cost per month

Clozapine (Clozaril)

Limited

Yes

6.5 to 75 mg per day

Agranulocytosis, hypotension, seizures, sialorrhea, weight gain, tachycardia, hyperthermia, hyperglycemia

1A2‡

$11 to $132

2D6§

Olanzapine (Zyprexa)

Yes

No

1.25 to 5 mg per day

Weight gain, hypotension, seizures, hyperglycemia

1A2‡

$78 to $184

Quetiapine (Seroquel)

No

Yes

12.5 to 200 mg per day

Hypotension, headache, weight gain, cataract formation

3A4ll

$22 to $151

Risperidone (Risperdal)

Yes

No

0.25 to 3 mg per day

Extrapyramidal symptoms, hypotension, hyperprolactinemia, insomnia, weight gain

2D6§

$84 to $164

Ziprasidone (Geodon)

No

No

Not studied

QT prolongation, rash, hypertension

3A4ll

N/A


N/A = not available.

*—All of these medications can cause sedation. All atypical antipsychotic agents can cause hyperglycemia (contributing to type II diabetes mellitus), although this most often occurs with olanzapine and clozapine.

†—Estimated cost to the pharmacist based on average wholesale prices in Red book. Montvale, N.J.: Medical Economic Data, 2002. Cost to the patient will be higher, depending on prescription-filling fee.

‡—1A2 inhibitors: cimetidine (Tagamet), fluoroquinolones, fluvoxamine (Luvox); can increase effects of the antipsychotic agent.

§—2D6 inhibitors: celecoxib (Celebrex), amiodarone (Cordarone), cimetidine, paroxetine (Paxil), fluoxetine (Prozac); can increase effects of the antipsychotic agent.

ll—3A4 inhibitors: ciprofloxacin (Cipro), fluoxetine, grapefruit juice, erythromycin, ketoconazole (Nizoral), diltiazem (Cardizem); can increase effects of the antipsychotic agent. 3A4 enhancer: phenytoin (Dilantin); can enhance metabolism of clozapine and quetiapine.

Atypical antipsychotic drugs are especially useful in treating symptoms associated with common neuropsychiatric disorders, such as Alzheimer's disease and Parkinson's disease.24 As the number of elderly people in the United States increases, the use of atypical antipsychotic drugs is expected to increase substantially. The National Institutes of Health estimates that there will be 8.5 million Americans with Alzheimer's disease by the year 2030.5 Psychotic symptoms are present in at least 25 percent of mildly demented patients with Alzheimer's disease and in 50 percent of patients with advanced Alzheimer's disease.6 Among persons older than 65 years, the incidence of Parkinson's disease is 2 percent.7 Hallucinations occur in up to 20 percent of patients with Parkinson's disease; delusions, paranoia, and subcortical dementia also may occur.8,9

Treatment of Behavior Disturbances

Initial interventions for behavior disturbances should include cognitive, environmental, and social techniques. Many demented patients with behavior disturbances will not need psychotropic medication but can be managed successfully with nonpharmacologic techniques, such as the use of familiar objects, maintenance of sleep-wake cycles, redirection, and frequent reorienting (verbally or by posting a calendar in their room).

There are many differences of opinion about when medications are indicated. There is even conflicting evidence about the efficacy of medications in treating behavior symptoms in dementia.10,11  Therefore, decisions to use these medications should be made on a case-by-case basis. Most guidelines call for the use of medications only when other methods have failed. The Health Care Financing Administration has produced regulations governing the use of psychotropic medications in nursing homes. Several authors have adapted these regulations into clinically useful guidelines (Table 3).12,13

Typical Antipsychotic Agents

Psychotic symptoms traditionally have been treated with so-called “typical” antipsychotic drugs—older agents such as haloperidol and thioridazine (Mellaril). These medications have a variety of pharmacologic actions. Their ability to block the dopamine (D2) receptor in the mesolimbic system reduces positive symptoms of psychosis. TheD2 blockade in the nigrostriatal pathway causes extrapyramidal symptoms, which include drug-induced parkinsonism, akathisia, acute dystonia, and tardive dyskinesia. The D2-receptor blockade in the tuberoinfundibular pathway increases serum levels of prolactin, which may present clinically as breast tenderness, galactorrhea, or erectile dysfunction.1 Younger patients may present with amenorrhea.

TABLE 3

Appropriate Use of Antipsychotic Agents in the Elderly*

Use only one antipsychotic agent at a time.

Use an antipsychotic drug only if the clinical record documents one of the following conditions:

Schizophrenia

Schizo-affective disorder

Delusional disorder

Psychotic mood disorders

Acute psychotic episodes

Brief reactive psychosis

Schizophreniform disorder

Atypical psychosis

Tourette's syndrome

Huntington's disease

Organic mental syndromes associated with psychotic or agitated features as defined by at least one of the following:

Specific behaviors (biting, kicking, scratching), quantitatively documented by the facility, that cause the resident to present a danger to himself/herself or others (including staff) or that interfere with the staff's ability to provide care

Continuous crying out, screaming, yelling, or pacing, if these behaviors impair functional capacity and if they are quantitatively documented by the facility

Psychotic symptoms (hallucinations, paranoia, delusions) not exhibited as specific behaviors in schizophrenia and schizo-affective disorder, if these behaviors impair functional capacity

Gradual dosage reduction should be attempted every six months after therapy begins. Gradual dosage reductions should be targeted to the lowest possible dosage to control symptoms.

Use of a listed antipsychotic drug should be avoided if one or more of the following behaviors is the only indication for its use:

Wandering

Poor self-care

Restlessness

Impaired memory

Anxiety

Depression

Insomnia

Unsociability

Indifference to surroundings

Fidgeting

Nervousness

Uncooperativeness

Unspecified agitation


*—Recommendations are based on standards from the Health Care Financing Administration

Adapted with permission from Ruby CM, Kennedy DH. Psychopharmacologic medication use in nursing home care: indicators for surveyor assessment of the performance of drug regimen reviews, recommendation for monitoring, and non-pharmacologic alternatives. Clin Fam Pract 2001;3:577–98, with information from reference13.

TABLE 3   Appropriate Use of Antipsychotic Agents in the Elderly*

View Table

TABLE 3

Appropriate Use of Antipsychotic Agents in the Elderly*

Use only one antipsychotic agent at a time.

Use an antipsychotic drug only if the clinical record documents one of the following conditions:

Schizophrenia

Schizo-affective disorder

Delusional disorder

Psychotic mood disorders

Acute psychotic episodes

Brief reactive psychosis

Schizophreniform disorder

Atypical psychosis

Tourette's syndrome

Huntington's disease

Organic mental syndromes associated with psychotic or agitated features as defined by at least one of the following:

Specific behaviors (biting, kicking, scratching), quantitatively documented by the facility, that cause the resident to present a danger to himself/herself or others (including staff) or that interfere with the staff's ability to provide care

Continuous crying out, screaming, yelling, or pacing, if these behaviors impair functional capacity and if they are quantitatively documented by the facility

Psychotic symptoms (hallucinations, paranoia, delusions) not exhibited as specific behaviors in schizophrenia and schizo-affective disorder, if these behaviors impair functional capacity

Gradual dosage reduction should be attempted every six months after therapy begins. Gradual dosage reductions should be targeted to the lowest possible dosage to control symptoms.

Use of a listed antipsychotic drug should be avoided if one or more of the following behaviors is the only indication for its use:

Wandering

Poor self-care

Restlessness

Impaired memory

Anxiety

Depression

Insomnia

Unsociability

Indifference to surroundings

Fidgeting

Nervousness

Uncooperativeness

Unspecified agitation


*—Recommendations are based on standards from the Health Care Financing Administration

Adapted with permission from Ruby CM, Kennedy DH. Psychopharmacologic medication use in nursing home care: indicators for surveyor assessment of the performance of drug regimen reviews, recommendation for monitoring, and non-pharmacologic alternatives. Clin Fam Pract 2001;3:577–98, with information from reference13.

Atypical Antipsychotic Agents

The pharmacodynamic action of atypical antipsychotic drugs is attributed to their action on both the serotonergic and dopaminergic systems. Some experts argue that this combination of relative effects on dopamine and serotonin allows atypical antipsychotic drugs to treat both positive and negative symptoms of psychosis while producing fewer extrapyramidal symptoms and decreasing iatrogenic hyperprolactinemia.14

There is growing concern over recent reports of hyperglycemia in patients who are taking certain atypical antipsychotic drugs. The increased rate of hyperglycemia appears to be independent of weight gain. These findings have led some investigators to recommend screening for diabetes twice a year in patients who are taking atypical antipsychotic drugs.15

RISPERIDONE

Risperidone (Risperdal) usage in Alzheimer's disease and Parkinson's disease has mixed results. Significant evidence demonstrates the efficacy of risperidone in the treatment of psychotic and behavior symptoms in patients with dementia.10,16,17 [References 10 and 17—Evidence level A, randomized controlled trials (RCTs)] However, risperidone exacerbates movement disorders in patients with Parkinson's disease and has been shown to be less effective than clozapine (Clozaril) in controlling psychosis in these patients.1820

Initial dosages of 0.25 mg per day are titrated slowly upward to achieve the desired effect. In two studies10,17 documenting the efficacy of risperidone in patients with dementia, the mean dosages were 1.1 mg per day and 1.2 mg per day. Risperidone causes extrapyramidal symptoms in a dosage-dependent manner, so the lowest effective dosage is used.

Significant side effects of risperidone include insomnia, hypotension, weight gain, and extrapyramidal symptoms. Extrapyramidal symptoms are more likely when the dosage is more than 6 mg per day.21 Risperidone is metabolized by the cytochrome P450 2D6 system. Any medication that affects this enzyme (e.g., celecoxib [Celebrex], amiodarone [Cordarone], cimetidine [Tagamet], fluoxetine [Prozac], paroxetine [Paxil]) can alter the efficacy of risperidone. Risperidone causes a significant elevation in prolactin levels. Caution should be used when prescribing risperidone with other medications that cause hypotension.

OLANZAPINE

Studies indicate that olanzapine (Zyprexa) is an effective treatment for psychotic and behavior symptoms in patients with Alzheimer's disease.22,23 [Reference 22—Evidence level A, RCT] However, in patients with Parkinson's disease, olanzapine was found to increase motor symptoms and to be less effective than clozapine. Therefore, current recommendations discourage the use of olanzapine in patients with Parkinson's disease.24 [Evidence level B, uncontrolled study]

In patients with Alzheimer's disease and psychotic symptoms, dosages should start at 1.25 to 2.5 mg per day and increase to 5 mg per day, if necessary. Surprisingly, dosages of 10 or 15 mg per day are less effective than dosages of 5 mg per day.2226 Common side effects of olanzapine include sedation and weight gain. Special considerations in elderly patients include the risk of orthostatic hypotension and seizures. In pre-marketing testing, olanzapine was associated with a 0.9 percent rate of seizures. Seizures occurred in patients with confounding factors; consequently, this medication should be used with caution in patients who have a lowered seizure threshold.21 Olanzapine is metabolized by the cytochrome P450 1A2 system, as well as multiple other hepatic pathways, and therefore has a low potential for drug-drug interactions.

QUETIAPINE

Quetiapine (Seroquel) has shown promise in the treatment of psychosis in elderly patients with Alzheimer's disease and Parkinson's disease. It improves psychosis in patients with Parkinson's disease without exacerbating movement disorders. This feature has led some experts to recommend it as the first-line agent for treatment of psychosis in patients with Parkinson's disease.27,28 [Reference 28—Evidence level B, uncontrolled study] It has been shown to be safe in patients with Alzheimer's disease, but more controlled trials are needed before its use in these patients can be endorsed.29

Quetiapine should be initiated at a dosage of 12.5 mg at bedtime and titrated every three to five days until the desired effect is achieved or side effects emerge. Common side effects include sedation, headache, and orthostatic hypotension. Cataract formation was noticed in pre-marketing studies, but a causal relationship has not been found. Screening for cataract formation is recommended at the initiation of therapy and at six-month intervals thereafter.21 Quetiapine is metabolized by the cytochrome P450 3A4 system. Serum levels of quetiapine can be affected by inducers or inhibitors of this enzyme system (e.g., keto-conazole [Nizoral], erythromycin, diltiazem [Cardizem], fluoxetine, ciprofloxacin [Cipro], grapefruit juice, and phenytoin [Dilantin]).21

ZIPRASIDONE

Because ziprasidone (Geodon) was recently released, clinical data are lacking to support its use in patients with either Parkinson's disease or Alzheimer's disease. Side effects of ziprasidone include rash, hypertension, and (rarely) non–dose-dependent QT-interval prolongation. Ziprasidone should be avoided in patients at risk for significant electrolyte abnormalities and in patients with histories of significant cardiovascular illness, recent acute myocardial infarction, uncompensated heart failure, and cardiac arrhythmia. Ziprasi-done is metabolized by the cytochrome P450 3A4 system.21

CLOZAPINE

Research on clozapine in the geriatric population has had mixed results. Clozapine is highly effective in treating psychosis in patients with Parkinson's disease.30 [Evidence Level A, RCT] The American Academy of Neurology states that clozapine appears to be the most effective agent in the treatment of drug-induced psychosis in patients with Parkinson's disease.18,30 Clozapine has shown some efficacy in controlling psychosis and behavior disturbances in patients with Alzheimer's disease.16,31 Initial dosages can start as low as 6.5 mg per day and are titrated upward.

Clozapine is well known for its side effects, which include agranulocytosis (with a fatality rate as high as 30 percent), sedation, seizures, sialorrhea, hypotension, weight gain, tachycardia, and hyperthermia.21 A complete blood count must be checked frequently in patients taking this medication. Because of its serious and potentially lethal side effects, clozapine generally is used only after other options have failed. Clozapine is metabolized by the cytochrome P450 1A2 and 2D6 systems.

The Authors

CHARLES D. MOTSINGER, CAPT, USAF, MC, is a family practice psychiatrist and chief of the life-skills support center at Osan Air Force Base, South Korea. He received his medical degree from the Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine, Bethesda, Md., and completed a residency in the combined National Capital Consortium family practice/psychiatry program, also in Bethesda.

GREGORY A. PERRON, CAPT, USAF, MC, is a family physician and faculty member in the Malcolm Grow Medical Center family practice program at Andrews Air Force Base, Md. He received his medical degree from the Washington University School of Medicine, St. Louis, and completed a family practice residency at Malcolm Grow Medical Center.

TIMOTHY J. LACY, LTCOL, USAF, MC, is assistant professor of psychiatry and family practice at the Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine. He also is program director for the combined National Capital Consortium family practice/psychiatry residency program.

Address correspondence to Capt. Charles D. Motsinger, 715 West View Terr., Alexandria, VA 22301 (e-mail: charles.motsinger@osan.af.mil). Reprints are not available from the authors.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force Medical Corps or the U.S. Air Force at large.

The authors report that they do not have any conflicts of interest. Sources of funding: none reported.

REFERENCES

1. Hales RE, Yudofsky SC, Talbott JA. The American Psychiatric Press Textbook of psychiatry. 3d ed. Washington, D.C.: American Psychiatric Press, 1999.

2. Doody RS, Stevens JC, Beck C, Dubinsky RM, Kaye JA, Gwyther L, et al. Practice parameter: management of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56:1154–66.

3. Wolters EC. Dopaminomimetic psychosis in Parkinson's disease patients: diagnosis and treatment. Neurology. 1999;52suppl 3:s10–3.

4. Small GW, Rabins PV, Barry PP, Buckholtz NS, DeKosky ST, Ferris SH, et al. Diagnosis and treatment of Alzheimer disease and related disorders: consensus statement of the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society. JAMA. 1997;278:1363–71.

5. National Institute on Aging, Alzheimer's Disease Education & Referral Center (National Institute on Aging), National Institutes of Health. Progress report on Alzheimer's disease 1999. Bethesda, Md.: National Institutes of Health, National Institute on Aging, 1999.

6. Cummings JL, Miller B, Hill MA, Neshkes R. Neuropsychiatric aspects of multi-infarct dementia and dementia of the Alzheimer type. Arch Neurol. 1987;44:389–93.

7. Aminoff MJ. Parkinson's disease. Neurol Clin. 2001;19:119–28,vi.

8. Sanchez-Ramos JR, Ortoll R, Paulson GW. Visual hallucinations associated with Parkinson disease. Arch Neurol. 1996;53:1265–8.

9. Fogel BS, Schiffer RB, Rao SM, eds. Neuropsychiatry. Baltimore: Williams & Wilkins, 1996:807–9.

10. De Deyn PP, Rabheru K, Rasmussen A, Bocks-berger JP, Dautzenberg PL, Eriksson S, et al. A randomized trial of risperidone, placebo, and haloperidol for behavioral symptoms of dementia. Neurology. 1999;53:946–55.

11. Teri L, Logsdon RG, Peskind E, Raskind M, Weiner MF, Tractenberg RE, et al. Treatment of agitation in AD: a randomized, placebo-controlled clinical trial. Neurology. 2000;55:1271–8.

12. Ruby CM, Kennedy DH. Psychopharmacologic medication use in nursing home care: indicators for surveyor assessment of the performance of drug regimen reviews, recommendations for monitoring, and non-pharmacologic alternatives. Clin Fam Pract. 2001;3:577–98.

13. Gurvich T, Cunningham JA. Appropriate use of psychotropic drugs in nursing homes. Am Fam Physician. 2000;61:1437–46.

14. Stahl SM. Essential psychopharmacology: neuro-scientific basis and practical application. 2d ed. New York, N.Y.: Cambridge University Press, 2000.

15. Luna B, Feinglos MN. Drug-induced hyperglycemia. JAMA. 2001;286:1945–8.

16. Tariot PN, Ryan JM, Porsteinsson AP, Loy R, Schneider LS. Pharmacologic therapy for behavioral symptoms of Alzheimer's disease. Clin Geriatr Med. 2001;17:359–76.

17. Katz IR, Jeste DV, Mintzer JE, Clyde C, Napolitano J, Brecher M. Comparison of risperidone and placebo for psychosis and behavioral disturbances associated with dementia: a randomized, double-blind trial. Risperidone Study Group. J Clin Psychiatry. 1999;60:107–15.

18. Olanow CW, Watts RL, Koller WC. An algorithm (decision tree) for the management of Parkin-son's disease (2001): treatment guidelines. Neurology. 2001;56suppl 5:S1–88.

19. Mohr E, Mendis T, Hildebrand K, De Deyn PP. Risperidone in the treatment of dopamine-induced psychosis in Parkinson's disease: an open pilot trial. Mov Disord. 2000;15:1230–7.

20. Ellis T, Cudkowicz ME, Sexton PM, Growdon JH. Clozapine and risperidone treatment of psychosis in Parkinson's disease. J Neuropsychiatry Clin Neurosci. 2000;12:364–9.

21. Mosby's GenRx: a comprehensive reference for generic and brand prescription drugs. 11th ed. St. Louis, Mo.: Mosby, 2001.

22. Street J, Mitan S, Tamura R, et al. Olanzapine in the treatment of psychosis and behavioral disturbances associated with Alzheimer's disease Eur J Neurology. 1998;5:S39.

23. Satterlee WG, Reams SG, Burns PR, Hamilton S, Tran PV, Tollefson GD. A clinical update on olanzapine treatment in schizophrenia and in elderly Alzheimer's disease patients. Psychopharmacol Bull. 1995;31:534.

24. Goetz CG, Blasucci LM, Leurgans S, Pappert EJ. Olanzapine and clozapine: comparative effects on motor function in hallucinating PD patients. Neurology. 2000;55:789–94.

25. Jeste DV, Rockwell E, Harris MJ, Lohr JB, Lacro J. Conventional vs. newer antipsychotics in elderly patients. Am J Geriatr Psychiatry. 1999;7:70–6.

26. Daniel DG. Antipsychotic treatment of psychosis and agitation in the elderly. J Clin Psychiatry. 2000;61suppl 14:49–52.

27. Fernandez HH, Friedman JH, Jacques C, Rosenfeld M. Quetiapine for the treatment of drug-induced psychosis in Parkinson's disease. Mov Disord. 1999;14:484–7.

28. Dewey RB Jr, O'Suilleabhain PE. Treatment of drug-induced psychosis with quetiapine and clozapine in Parkinson's disease. Neurology. 2000;55:1753–4.

29. Tariot PN, Salzman C, Yeung PP, Pultz J, Rak IW. Long-term use of quetiapine in elderly patients with psychotic disorders. Clin Ther. 2000;22:1068–84.

30. Low-dose clozapine for the treatment of drug-induced psychosis in Parkinson's disease. The Parkinson Study Group. N Engl J Med. 1999;340:757–63.

31. Menza MA, Liberatore BL. Psychiatry in the geriatric neurology practice. Neurol Clin. 1998;16:611–33.

Richard W. Sloan, M.D., R.Ph., coordinator of this series, is chairman and residency program director of the Department of Family Medicine at York (Pa.) Hospital and clinical associate professor in family and community medicine at the Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, Pa.


Copyright © 2003 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Article Tools

  • Download PDF
  • Print page
  • Share this page
  • AFP CME Quiz

Information From Industry

More in Pubmed

Navigate this Article