most numerous family physicians are...

most numerous family physicians are comfortable prescribing antidepressants, if it be not that antipsychotic medications are less commonly prescribed and therefore les familiar. Antipsychotic remedys effectively treat psychosis caused by way of a variety of conditions (Table 1) Psychotic symptoms are classified as either positive or negative. Positive symptoms include hallucinations, delusions, contemplation 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 somewhat advanced in life patients always should be investigated thoroughly, and underlying medical conditions should be identified and treated. Although a family physician is les likely to manage schizophrenia in somewhat old patients, it is quite everyday for family physicians to treat patients who have Alzheimer's disease and Parkinson's disease. These patients as a common thing [i]or[/i] matter have psychotic symptoms that are treated without a specialist's aid.

Typical antipsychotic remedys such as haloperidol (Haldol), traditionally have been used to repress psychotic and behavior disturbances in somewhat old patients, but these drugs have troubling side powers Extrapyramidal symptoms can cause stiffness, immobility, and falls and are associated with significant morbidity. The newer atypical antipsychotic unsalable articles 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 mix with drugss in elderly patients (Table 2)

Atypical antipsychotic put drugs intos are especially useful in treating symptoms associated with used by all neuropsychiatric disorders, such as Alzheimer's disease and Parkinson's disease. (2-4) As the number of somewhat old people in the United States increases, the use of atypical antipsychotic remedys is expected to increase substantially. The National Institutes of Health estimates that there will be 85 million Americans with Alzheimer's disease by the agency of the year 2030. (5) Psychotic symptoms are not past nor future in at least 25 percent of mildly dement patients with Alzheimer's disease and in 50 percent of patients with advanced Alzheimer's disease. (6) Among individuals older than 65 years, the incidence of Parkinson's disease is 2 percent (7) Hallucinations happen in up to 20 percent of patients with Parkinson's disease; delusions, paranoia, and subcortical dementia also may come about (8,9)

Treatment of Behavior Disturbances

Initial interventions for behavior disturbances should include cognitive, environmental, and social techniques. Many dement patients with behavior disturbances will not ne psychotropic medication yet can be managed successfully with nonpharmacologic techniques, of the like kind as the use of familiar intents maintenance of sleep-wake cycles, redirection, and oft-repeated reorienting (verbally or by posting a calendar in their room)

There are many differences of opinion about when medications are indicated. There is plane conflicting evidence about the efficacy of medications in treating behavior symptoms in dementia. (1011) Therefore, decisions to use these medications should be made forward a case-by-case basis. Most guidelines call for the use of medications solitary when other methods have failed. The Health Care Financing Administration has produc regulations governing the use of psychotropic medications in nursing firesides Several authors have adapted these regulations into clinically useful guidelines (Table 3) (1213)

Typical Antipsychotic Agents

Psychotic symptoms traditionally have been treated with so-called "typical" antipsychotic drugs--older agents as it is as haloperidol and thioridazine (Mellaril). These medications have a variety of pharmacologic actions. Their ability to block up the dopamine ([D.sub.2]) receptor in the mesolimbic scheme reduces positive symptoms of psychosis. The [Dsub2] blockade in the nigrostriatal pathway causes extrapyramidal symptoms, which include drug-induced parkinsonism, akathisia, acute dystonia, and tardive dyskinesia. The [D.sub.2]-receptor blockade in the tuberoinfundibular pathway increases serum of the same heights of prolactin, which may at hand clinically as breast tenderness, galactorrhea, or erectile dysfunction. (1) Younger patients may not absent with amenorrhea.

Atypical Antipsychotic Agents

The pharmacodynamic action of atypical antipsychotic mix with drugss is attributed to their action in succession both the serotonergic and dopaminergic classifications Some experts argue that this combination of relative imports on dopamine and serotonin allows atypical antipsychotic mix with drugss to treat both positive and negative symptoms of psychosis while producing fewer extrapyramidal symptoms and decreasing iatrogenic hyperprolactinemia. (14)

There is growing touch over recent reports of hyperglycemia in patients who are taking certain atypical antipsychotic physics The increased rate of hyperglycemia appears to be independent of weight gain. These findings have l an investigators to recommend screening for diabetes twice a year in patients who are taking atypical antipsychotic medicines (15)