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... continued from part 1 of 2 ------------------------------------------------------- 1997 Dose-response relationships for the antipsychotic effects and Parkinsonian side-effects of typical neuroleptic drugs: practical and theoretical implications. ------------------------------------------------------- 1. From a review of published literature it is concluded that the minimum dose of a neuroleptic drug (NLD) required to alleviate psychosis is very similar to that producing minimal parkinsonian side effects (PSE). This conclusion is reached both from group comparisons and individual comparisons of dose/response relations (DRR) for the two effects. 2. A lower dose of NLD is usually sufficient to prevent relapse in well stabilized patients than is needed to check an active psychotic state. 3. Anticholinergic agents used to reduce side effects of typical NLD can retard the therapeutic process during neuroleptic treatment of acute psychosis. Although it is not fully established that this is a central interaction, it is consistent with the idea that minimal side effects are a necessary condition for therapeutic effectiveness with typical antipsychotic drugs. 4. In relapse-free maintenance of psychosis-prone patients, tolerance occurs to PSE. Thus few patients need experience prolonged side effects during maintenance treatment with neuroleptics. 5. The evidence reviewed is discussed with respect to a previous hypothesis of the supposedly "indirect" action of typical neuroleptic drugs in therapy for psychosis. The evidence is consistent with the idea of a close causal relation between minimal PSE of these drugs, and their therapeutic effectiveness in the acute stage of treatment. Prog Neuropsychopharmacol Biol Psychiatry 1997 Oct;21(7):1059-94 Miller R University of Otago Medical School, Dunedin, New Zealand. PMID: 9421824, UI: 9808360 ------------------------------------------------------- 1997 Neuropsychiatric adverse effects of antiparkinsonian drugs. Characteristics, evaluation and treatment. ------------------------------------------------------- Parkinson's disease (PD) is a progressive neurological condition that causes considerable disability in the elderly. Drugs used to treat PD, such as levodopa, offer symptomatic relief but often have neuropsychiatric adverse effects, most prominently psychosis and delirium. Aged patients and those with dementia are particularly vulnerable to these adverse effects. Evaluating PD patients with drug-induced neuropsychiatric adverse effects is made difficult by their complex clinical presentations. The treatment of drug-induced psychosis and delirium begins with manipulating the antiparkinsonian drug regimen, but this frequently worsens motor function. Atypical antipsychotics such as clozapine have been successfully employed to treat the psychosis without worsening the motor disability. Patient intolerance of clozapine therapy has prompted open-label studies with newer agents such as risperidone, remoxipride, zotepine, mianserin and ondansetron. Drugs Aging 1997 May;10(5):367-383 Young BK, Camicioli R, Ganzini L Portland Veterans Affairs Medical Center, Oregon, USA PMID: 9143857, MUID: 97288925 ------------------------------------------------------- 1997 Hallucinosis in idiopathic Parkinson's disease ------------------------------------------------------- BACKGROUND: Hallucinosis is a complication of the treatment of idiopathic Parkinson's disease commonly thought to afflict older, chronically medicated, cognitively impaired patients. However, patients with idiopathic Parkinson's disease of short duration experiencing hallucinosis on relatively low doses of dopaminergic medication have been found. The aim, therefore, was to investigate the homogeneity of a population of patients with idiopathic Parkinson's disease and hallucinosis. METHODS: The clinical, demographic, and cognitive correlates of hallucinosis were investigated in a sample of 129 patients with idiopathic Parkinson's disease. RESULTS: There were two subgroups of patients with idiopathic Parkinson's disease experiencing hallucinosis. In patients with a disease duration of five years or less, hallucinosis was associated with rapid progression of the motor component of the disease but not cognitive impairment. In patients with idiopathic Parkinson's disease of longer than five yearsduration, hallucinosis was associated with postural instability, global cognitive impairment, and lack of depressive affect. In all patients with idiopathic Parkinson's disease, hallucinosis was more prevalent when they were treated with a direct acting dopamine receptor agonist. Hallucinosis was not associated with age at onset of idiopathic Parkinson's disease or dosage of dopaminergic medication. CONCLUSION: Hallucinosis in idiopathic Parkinson's disease is heterogeneous, falling into two groups. The difference in the pathophysiological basis of hallucinosis in these two groups of patients is discussed. J Neurol Neurosurg Psychiatry 1997 Oct;63(4):434-440 Graham JM, Grunewald RA, Sagar HJ University of Sheffield, Royal Hallamshire Hospital, UK. PMID: 9343119, MUID: 98001284 ------------------------------------------------------- 1997 Inappropriate Medication Prescribing ------------------------------------------------------- OBJECTIVE: To estimate the prevalence of inappropriate medications prescribed by office-based physicians for patients 65 years or older. DESIGN: A nationwide cross-sectional survey of office visits by the elderly. SETTING: The National Ambulatory Medical Care Survey (NAMCS) 1992, a national probability sample survey of office visits by ambulatory patients within the continental US. SUBJECTS: A national probability sample of patients 65 years or older visiting office-based physicians. National estimates are based on the National Center for Health Statistics weighting procedure for the NAMCS sample. MAIN OUTCOME MEASURES: Prevalence of 20 inappropriate medications that should be entirely avoided in the elderly, using criteria developed by a panel of national experts in geriatric medicine and geriatric pharmacology. RESULTS: In the US during 1992, an estimated 8.47 million (95% CI 7.66 =3D million to 9.28 million) office visits by the elderly indicated prescribing of at least 1 of the 20 inappropriate medications. Approximately 7.75 million (95% CI=3D 6.98 million to 8.52 million) visits by the elderly involved 1 inappropriate medication and 0.72 million (95% CI 0=.51 million to 0.93 million) visits included 2 inappropriate medications. According to the NAMCS, office-based physicians prescribed at least 1 inappropriate medication to 7.58% of the elderly who received prescriptions. The most frequently prescribed inappropriate medications were propoxyphene, amitriptyline, dipyridamole, diazepam, and chlorpropamide. Elderly patients rarely received prescriptions from office-based physicians for drugs such as secobarbital, isoxsuprine, trimethobenzamide, and carisoprodol. Furthermore, office-based physicians did not prescribe cyclandelate, pentobarbital, or phenylbutazone for the elderly. CONCLUSIONS: The prescribing of inappropriate medications by office-based physicians raises concerns regarding the quality of care for the elderly in ambulatory settings. The crux of improving patient care in ambulatory settings rests with collaborative efforts between physicians and pharmacists. Ann Pharmacother 1997 Jul;31(7-8):823-829 Aparasu RR, Fliginger SE College of Pharmacy, South Dakota State University, Brookings 57007 USA. [log in to unmask] PMID: 9220038, MUID: 97363746 ------------------------------------------------------- 1997 Clozapine + Drug-Induced Psychosis in PD ------------------------------------------------------- Clozapine, the only commercially available atypical neuroleptic, is approved for the treatment of schizophrenic patients who are unresponsive to or intolerant of typical neuroleptics. It has an unusual pharmacologic profile compared with standard neuroleptics, and it follows that clinical response to this drug is also different. It has shattered the notion that a drug must be capable of inducing or worsening parkinsonism to be a potent antipsychotic. Based on these findings, it is being used increasingly by neurologists for psychiatric and nonpsychiatric problems in patients with movement disorders. The most common use for clozapine among neurologists is in the management of drug-induced psychosis in Parkinson's disease (PD). This problem has been a source of increased morbidity and mortality in PD because of a lack of adequate therapeutic intervention. At this time, because of success in numerous open trials, with improvement of >= 80% of patients, clozapine therapy for psychosis in PD is becoming the standard of care. It also appears to be of value in the management of some motor features of PD, including tremors and dyskinesia and possibly even sensory symptoms such as akathisia and pain. The literature also suggests that clozapine may be of potential benefit in hyperkinetic movement disorders including essential tremor, Huntington's disease, and tardive dyskinesia. We review the current data concerning the use of clozapine in patients with these movement disorders and others. Mov Disord 1997 Jul;12(4):483-496 Factor SA, Friedman JH Albany Medical College, Department of Neurology, New York, USA. PMID: 9251065, MUID: 97394752 ------------------------------------------------------- 1995 Drug-induced psychiatric states frequent in PD ------------------------------------------------------- In the prelevodopa era, depression and other psychiatric disorders were described in PD, but in untreated patients psychosis was rare. Since the development of levodopa and other pharmacological treatments for PD, however, psychotic symptoms have become much more common (10-50%). In some individuals these problems can be more disabling than the motor features of PD and, as a result, pose a serious threat to the patient's ability to maintain independence. The drug-induced psychoses consist of several distinct psychiatric syndromes that can be divided broadly into those occurring on a background of a clear sensorium and those which are accompanied by confusion and clouding of consciousness. Benign organic hallucinosis is the most common of these syndromes (30%). It usually occurs on a background of a clear sensorium and may not be a particularly troublesome problem if the patient is able to retain insight into the nature of these symptoms. More disabling syndromes usually include delusional thinking that is frequently paranoid, confusion and even frank delirium. Although all these psychotic syndromes can occur in isolation, there is a tendency for mild symptoms to progress to more disabling ones if adequate and timely treatment is not instituted. Abnormal dreaming and sleep disruption often precede these difficulties by weeks to months and may provide an important early clue to their onset. The mechanisms responsible for drug-induced psychotic symptoms in PD are unknown, but dopaminergic (especially mesolimbic) and serotoninergic systems are likely to be involved. The treatment of the drug-induced psychoses in PD should be undertaken in a stepwise manner. A detailed discussion of this approach, including the use of anti-PD medication adjustment, clozapine, and other medications (neuroleptic and nonneuroleptic) and ECT is provided. Although drug-induced psychoses are the most important of the drug-induced psychiatric states, mania, anxiety, and hypersexuality may also occur. Depression is also common in PD, but it is unlikely to occur as a side effect of antiparkinsonian medications. Adv Neurol 1995;65:115-138 Factor SA, Molho ES, Podskalny GD, Brown D Albany Medical College, Department of Neurology, New York, 12208, USA PMID: 7872135, MUID: 95176970 ------------------------------------------------------- janet paterson - 51/10 - almonte/ontario/canada http://www.newcountry.nu/pd/members/janet/ [log in to unmask]