Psychotic disease

The prevalence rates of schizophrenia are lower in old age than in younger age groups (Copeland et al. 1998). The incidence of Alzheimer s disease with psychosis is much more frequent than the incidence of schizophrenia in old age (Jeste and Finkel 2000). For the frail Alzheimer s patients, medications may induce or aggravate the symptoms. 

For psychotic elderly first step is to remove any possible contributor. When the symptoms remain, antipsychotics should be considered. Doses should stay as low as 

Alagiakrishnan K and Wiens CA (2004) An approach to drug induced delirium in the elderly. Postgrad Med J 80(945) 388-393 

Ballard C, Hanney ML, Theodoulou M et al. (2009) The dementia antipsychotic withdrawal trial (DART-AD) long-term follow-up of a randomised placebo-controlled trial. The Lancet Neurology DOL10.1016/S1474-4422(08)70295-3 

Bassiony MM and Lyketsos CG (2003) Delusions and hallucinations in Alzheimer s disease review of the brain decade. Psychosomatics 44 (5) 388M01 

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Keywords Cognitive impairment Delirium Dementia Depression Anxiety Psychotic disease Neuro-psychiatric disorders... 

It is obvious when considering the pre- 1950s era that tremendous progress has been made in the treatment of psychotic diseases. It is equally apparent that the problem is nowhere near solved. Every theory of the causes of these mental diseases is flawed. Our understanding of the mechanisms by which even the effective drugs function is incomplete at best. 

Antipsychotic medications are indicated in the treatment of acute and chronic psychotic disorders. These include schizophrenia, schizoaffective disorder, and manic states occurring as part of a bipolar disorder or schizoaffective disorder. The co-adminstration of antipsychotic medication with antidepressants has also been shown to increase the remission rate of severe depressive episodes that are accompanied by psychotic symptoms. Antipsychotic medications are frequently used in the management of agitation associated with delirium, dementia, and toxic effects of both prescribed medications (e.g. L-dopa used in Parkinson s disease) and illicit dtugs (e.g. cocaine, amphetamines, andPCP). They are also indicated in the management of tics that result from Gilles de la Tourette s syndrome, and widely used to control the motor and behavioural manifestations of Huntington s disease. 

Haverkos HW, Pinsky PF, Drotman DP, etal Disease manifestation among homosexual men with acquired immunodeficiency syndrome a possible role of nitrites in Kaposi s sarcoma. Sex Transm Dis 12 203-208, 1985 Haverkos HW, Kopstein AN, Wilson H, et al Nitrite inhalants history, epidemiology, and possible links to AIDS. Environ Health Perspect 102 858-861, 1994 Hernandez-Avila CA, Ortega-Soto HA, Jasso A, et al Treatment of inhalant-induced psychotic disorder with carbamazepine versus haloperidol. Psychiatr Serv49 812— 815, 1998... 

Psychotic symptoms in late life (greater than 65 years of age) are generally a result of an ongoing chronic illness carried over from younger life however, a small percentage of patients develop psychotic symptoms de novo, defined as late-life schizophrenia. The 6-month prevalence rate of schizophrenia in the elderly is around 1%. However, other illnesses presenting with psychotic symptoms are common in this population, as approximately one-third of patients with Alzheimer s disease, Parkinson s disease, and vascular dementia experience psychotic symptoms. The majority of data for antipsychotic use in the elderly comes from experience treating these other disease states. 

These data show that for three psychotic disorders (schizophrenia, bipolar disorder and unipolar depression) the genetic contribution is over 50% but for reactive depression (in response to a traumatic life event ) and tuberculosis, an infectious disease caused by a species of Mycobacterium, environmental factors account for over 90% of the variance. 

In clinical psychiatric terms, the affective disorders can be subdivided into unipolar and bipolar disorders. Unipolar depression is also known as psychotic depression, endogenous depression, idiopathic depression and major depressive disorder. Bipolar disorder is now recognised as being heterogeneous bipolar disorder I is equivalent to classical manic depressive psychosis, or manic depression, while bipolar disorder II is depression with hypomania (Dean, 2002). Unipolar mania is where periods of mania alternate with periods of more normal moods. Seasonal affective disorder (SAD) refers to depression with its onset most commonly in winter, followed by a gradual remission in spring. Some milder forms of severe depression, often those with an identifiable cause, may be referred to as reactive or neurotic depression. Secondary depression is associated with other illnesses, such as neuro-degenerative or cardiovascular diseases, and is relatively common. 

Frontotemporal dementias are characterized by gross structural changes in the frontal and anterior temporal lobes, metabolic disturbances, and involvement of certain subcortical structures as well (Ishii et al. 1998). Whereas in Alzheimer s disease the early cognitive disturbances are in memory, in frontotemporal dementias the early manifestations are in executive and behavioral function (Pfeffer et al. 1999 Varma et al. 1999). This relative cognitive distinction persists throughout the course of the two disorders (Pachana et al. 1996). Disinhibition and disorganization are common, and psychotic symptoms may be prominent in frontotemporal dementia. 

The key has been to avoid using treatments that worsen the disease. In this instance, this means avoiding anticholinergic (acetylcholine-blocking) medications that worsen dementia. As a result, when newer antidepressants such as the SSRIs became available, they quickly replaced the older tricyclic antidepressants because the latter are potent anticholinergics. For the same reason, the low potency anti-psychotics like chlorpromazine (Thorazine) were replaced by the higher potency antipsychotics like haloperidol (Flaldol) and more recently by the atypical antipsychotics. 

Schizophrenia is a psychotic illness and is one of the most common psychotic disorders (a mental illness in which the sufferer loses contact with reality). About half a million people in the UK suffer from schizophrenia. It affects mainly adolescents and young adults, and there is a genetic component to the disease. Lay terms that have been used for the disorder are insanity, lunacy and madness. Hospitals that catered for such patients were formerly known as lunatic asylums. 

Disulfiram is used as an adjunct in the management of alcohol dependence. It is contraindicated in patients with a history of cerebrovascular accident, cardiac failure, coronary artery disease, hypertension and psychosis. Side-effects that may be present include initial drowsiness and fatigue, nausea, vomiting, halitosis, reduced libido, psychotic reactions, allergic dermatitis, peripheral neuritis and hepatic cell damage. 

Phenothiazines have a diverse use in medicine. They are primarily used as antipsy-chotics. Despite the fact that they do not cure the disease, they reduce psychotic symptoms to a point where the patient is provided with a better sense of reality. Phenothiazines are sometimes used for relieving severe anxiety, especially in panic attacks caused by dependence on amphetamines or lycergic acid diethylamide (LSD). Phenothiazines are used for alleviating behavioral problems in children that do not respond to treatment of other agents. Phenothiazines are sometimes used during the preoperational period because they relieve anxiety, control nausea, hiccups, diarrhea, and also cause muscle relaxation. 

For the treatment of psychoneurotic patients with depression or anxiety depression or anxiety associated with alcoholism or organic disease psychotic depressive disorders with associated anxiety including involutional depression and manic-depressive disorders. 

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