Use Of Neuroleptic Medication Research Articles

P1269EXERCISE TRAINING FOR IMPROVING SLEEP QUALITY IN PATIENTS WITH END-STAGE KIDNEY DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Background and Aims Sleep disorders are commonly experienced by patients with end-stage kidney disease (ESKD) which influence the quality of life severely and may cause high risk of cardiovascular events. People with ESKD may constrain the use of neuroleptic medications which can lead to dependence if used in the longer-term. As non-pharmacological intervention, exercise training was suggested as based therapy to improve the quality of life. We conducted a systematic review to assess the efficacy of exercise training for improving sleep quality in dialysis patients with ESKD. Method Randomised controlled trials (RCTs) that evaluated the effects of regular exercise training on sleep quality in patients with ESKD were included. Searching was conducted in CENTRAL, EMBASE, PUBMED, CINAHL, WEB OF SCIENCE, and 3 Chinese databases (CBM, CNKI, WANFANG), date from inception to May 2019. Risk of bias was assessed. The quality and strength of evidence were evaluated by GRADE framework. Study selection, data extraction and methodological quality assessment were performed independently by two researchers. Results were reported as mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI). This systematic review was registered in the PROSPERO (CRD42019141630). Results Twelve RCTs were included, which involving 753 participants. Methodological quality of studies and strength of evidence were assessed from low to moderate. Eleven trials included patients who receiving regular hemodialysis (HD) and one trial included patients that receiving either regular HD or continuous ambulatory peritoneal dialysis (CAPD). The major type of exercise was aerobic training during hemodialysis session (7 RCTs), followed by intradialytic resistance exercise, intradialytic mixed training, and interdialytic aerobic exercise. Most studies set exercise 3 times per week with moderate intensity, lasting 20∼60 minutes per session, and treatment duration for 2∼6 months. The Pittsburgh Sleep Quality Index (PSQI) questionnaire, Kidney Disease Quality of Life (KDQoL-SF) questionnaire, University of Massachusetts Weekly Sleep Questionnaire (UMass WSQ), visual analogue scale (VAS), and sleep fragmentation index (SFI) based on patient-reported outcomes were measured for testing sleep quality. By measuring with PSQI questionnaire (scale 0-21, lower is better), the sleep quality was improved with regular exercise comparing with usual care (5 RCTs, 296 participants, MD -4.92, 95%CI -6.54 to -3.30, I2=88%, moderate certainty evidence). The result was similar with KDQoL-SF questionnaire (4 items assessing sleep quality, higher is better) (3 RCTs, 328 participants, MD 8.75, 95%CI 2.06 to 15.43, I2=54%, low certainty evidence). However, there was no significant different in sleep diary by measuring with UMass WSQ (2 RCTs, 46 participants, MD -0.48, 95%CI -4.05 to 3.09, I2=59%, low certainty evidence). There was only one study measured with VAS and SFI, so we didn’t analyze it into meta-analysis. Conclusion Regular exercise appeared to be beneficial to improve sleep quality in patients with dialysis, especially intradialytic aerobic training. Given the growing challenge of pharmacological dependence, there is necessary to design high quality RCTs for non-pharmacological interventions such as exercise training.

Standing postural instability in patients with schizophrenia: Relationships with psychiatric symptoms, anxiety, and the use of neuroleptic medications

The purpose of this study was to assess postural instability in patients with schizophrenia using a pressure-sensitive platform and to examine the effects of anxiety, psychiatric symptoms, and the use of neuroleptic medications on postural sway. Participants were 23 patients with schizophrenia and 23 healthy controls. We found that the patients showed greater overall postural instability than the controls. Furthermore, they demonstrated greater instability when the test was performed with the eyes closed than with the eyes open. However, removal of visual input had less impact on the indices of postural instability in the patients than in the controls, suggesting that schizophrenia is associated with difficulties in integrating visual information and proprioceptive signals. Furthermore, in contrast to the controls, anxiety exacerbated postural instability in the patients. There were significant associations between postural stability and psychiatric symptoms in the patients without extrapyramidal symptoms, whereas medication dose did not significantly correlate with postural stability.

Early Remission in Focal Tardive Dystonia Associated with the Use of Neuroleptic Medication: A Rare Case Report and Review of Literature

Abstract Tardive dystonia is a movement disorder which develops with twisting of one part of the body or abnormal posture because of severe muscle contractions. The most important factor in the occurrence of tardive dystonia is the use of antipsychotic medication. Tardive dystonia associated with long-term use of antipsychotic drugs may be focal, segmental or generalised. When tardive dystonia has occurred once, there is a tendency for it to be permanent and complete recovery is rare. The aim of this paper was to present a case of neuroleptic drug-associated tardive dystonia with focal involvement where early remission was observed and thus draw attention to the necessity of considering physical therapy approaches in addition to medication in the treatment choices. Key Words: Tardive dystonia, neuroleptic, early remission, physical therapy

INCOG recommendations for management of cognition following traumatic brain injury, part I: posttraumatic amnesia/delirium.

After traumatic brain injury (TBI) and emergence from coma, the majority of people experience posttraumatic amnesia (PTA), characterized by confusion, disorientation, retrograde and anterograde amnesia, poor attention, and sometimes agitation and delusions. An international team of researchers and clinicians developed recommendations for assessment and management of PTA. The experts met to select recommendations, then reviewed literature to ensure they were current. The team then prioritized recommendations for implementation and developed audit criteria to evaluate the adherence to the best practice recommendations. Evidence in support of assessment and management strategies during PTA is weak. It is recommended that duration of PTA be assessed prospectively using a validated tool. Consideration should also be given to use of a delirium assessment tool. No cognitive or pharmacological treatments are known to reduce PTA duration. Recommendations for environmental manipulations to reduce agitation during PTA are made. Minimizing use of neuroleptic medication is supported by animal research and 1 retrospective study. The duration of PTA is an important predictor of late outcome after TBI and should be monitored prospectively with a standardized tool. Neuroleptic medication should be avoided. There is a significant need for controlled studies evaluating the impact of therapy during PTA.

Aktuelles aus der Soteria – Die Förderung lebenspraktischer und sozialer Fertigkeiten von Menschen mit Schizophrenien aus phänomenologischer Sicht

Soteria is an alternative approach to the treatment of schizophrenia that focuses on human interaction ("being-with") within a residential community and the cautious use of neuroleptic medication. Despite forty years of promising clinical and empirical evidence, the need for facilities based on the Soteria paradigm is still largely grounded on humanitarian and "moral" reasons. In addition to this, we will try to demonstrate that Soteria might also prove to be a promising approach based on scientific reasons immanent to the disorder. From a phenomenological informed conception of schizophrenia we will explicate clinical implications, specifically the need for a holistic treatment in real life settings, and demonstrate how these conclusions can most adequately be implemented within Soteria.

A3 Studying and managing the behavioural phenotypes of Huntington's disease

Honorary Consultant in Neuropsychiatric Genetics. David graduated in Medicine from London University (St. Bartholomew9s) in 1976 and moved to Manchester to study Psychiatry in 1979. After completing his training in general psychiatry, he arranged a temporary secondment to Clinical Genetics in 1986 to pursue an interest in the genetic aspects of psychiatric disorders, and ended up “going native”. He is now a senior lecturer and honorary consultant in neuropsychiatric genetics. His research interests are concerned mainly with the neuropsychiatric aspects of Huntington9s disease (HD), and with the psychological and social impact of predictive DNA testing for late-onset genetic disorders. He set up the UK9s first multidisciplinary management clinic for HD, currently the largest contributing site to the European HD Network (EHDN) case registry, and is actively involved in a number of European and worldwide research projects and clinical trials. He is a member of the Scientific Review Committee of the EHDN, leads the EHDN Behavioural Phenotype Working Group and is a former Secretary-General of the World Federation of Neurology Research Group on HD. He is co-Director of the MSc programme and teaches on the Clinical Genetics and Advanced Genetic Counselling modules. Behavioural symptoms have been recognised as a key component of the clinical phenotype of HD ever since the first description by Huntington in 1872, but remain a relatively under-researched aspect of the condition. Depression has received more attention than other psychiatric symptoms, but factor analysis of several large datasets has revealed that apathy and irritability are more common, and arguably cause more distress and disability. Longitudinal analysis of behavioural symptoms has confirmed that these three symptom clusters follow different trajectories over time, suggesting that each has a different neurobiological basis, and recent imaging studies lend some support to this hypothesis. It has long been recognised that many affected individuals display characteristic behavioural changes for some years before the onset of motor symptoms, and there has been considerable recent interest in the possibility of using these early manifestations as end points for clinical trials of disease-modifying interventions in known gene carriers prior to diagnosis. However, it has proved difficult to detect substantial changes in well-conducted longitudinal studies of pre-manifest subjects such as PREDICT and TRACK-HD. One reason may be the emergence of impaired insight (or denial) as the behavioural symptoms begin to occur, a phenomenon which has been noted by clinicians for many years; another is likely to be the use of concomitant medication for symptomatic treatment. Mood disturbances, anxiety, irritability and perseveration all respond to treatment with serotonin reuptake inhibitors, but apathy may be exacerbated by the use of neuroleptic medication for symptomatic treatment of involuntary movements or aggressive behaviours.

Possible Paliperidone-Induced Neuroleptic Malignant Syndrome: A Case Report

Possible Paliperidone-Induced Neuroleptic Malignant Syndrome: A Case Report

Tardive Dyskinesia: Treatment with Aripiprazole

Tardive dyskinesia is characterized by choreiform movements, or rhythmic abnormal involuntary movements of the face, mouth, tongue, trunk, and limbs. It is frequently associated with the use of neuroleptic medications. The choreiform movements are irreversible in some patients, even after the drug is withdrawn. Although no reliable treatment for tardive dyskinesia exists, atypical antipsychotics are associated with a significantly lower incidence of tardive dyskinesia than typical antipsychotics. Moreover, recent reports suggest that atypical antipsychotics may have a beneficial effect on tardive dyskinesia remission. Until recently, evidence for the effectiveness of aripiprazole on tardive dyskinesia has been mixed. Aripiprazole has a unique mechanism of action and has various effects in tardive dyskinesia. The drug acts as a partial D2 receptor agonist that can stabilize D2 up-regulation, and as a partial 5-HT1A receptor agonist and a 5-HT2A receptor antagonist, and can increase the release of dopamine in the striatum.

Klinische und soziale Risikofaktoren für Wiederaufnahmen in die stationäre Psychiatrie bei Patienten mit Schizophrenie: Eine Langzeitanalyse

In recent years, admission rates to psychiatric inpatient care have steadily increased, whilst the number of beds has progressively decreased, at least in german-speaking countries. A better understanding of risk factors concerning psychiatric readmissions is indispensable in order to avoid unnecessary inpatient treatment. The aim of our study was to test the influence of various clinical and social factors on the time to readmission. We analysed data of an observational study considering especially vulnerable patients with schizophrenia (N = 103). We applied multivariate time-hazards models (survival analysis) to examine the predictors of the time to readmission within 12 months. Independent variables were either time-varying (e.g. Needs for care Assessment Scale (NCA)) or time-invariant (e.g. age). About 50% of the patients were readmitted during the observation period, many of them within the first few weeks. In the final models clinical needs, and a social need increased the risk of readmission, whereas the use of neuroleptic medication reduced the risk. There was an interaction effect between social support and time. Both, clinical and social factors influence the risk of psychiatric readmission. Therefore, the prevention of readmissions should focus on the patients' skills to manage his/her illness and on the social support that the patients receive.

Delirium among elderly general medical patients in a New Zealand hospital

Overseas studies suggest that delirium is a common and serious health problem of hospitalized elderly. There is very little information in New Zealand. To study prospectively the frequency and effect of delirium on a cohort of elderly general medical patients. Over 2 months, 317 patients were admitted to general medical wards; 70% were aged 65 years and above. These patients were screened for delirium. Comparisons were made between the delirious and non-delirious patients. Fifty-six of the 216 patients screened had delirium. The prevalence and incidence of delirium were 23.4 and 5.7%, respectively. Thirty-one per cent of delirious patients had a previous history of dementia; 48% of delirious patients had multiple precipitants, most commonly infections. Delirium was associated with higher complication rates--94 versus 39% in the non-delirious patients--and a doubling in the length of hospital stay. Over 50% of delirious patients required increased supports on discharge with a general trend towards higher frequency of institutionalization. The presence of delirium was associated with increased use of neuroleptic medications, special nursing care, cot sides and restraints. A non-significant trend towards increased mortality was seen in the delirious group. Delirium is a common health problem in elderly patients, associated with multiple adverse outcomes. This study highlighted the prognostic importance of diagnosing delirium. Recommendations included improved health professional education, development of guidelines including rational use of neuroleptic medication and measures to improve follow up for these patients.

Dementia Care Requires Team Approach

Bruce K. Dixon is with the Chicago bureau of Elsevier Global Medical News. The excessive off-label use of neuroleptic medications in nursing homes is largely the fault of the American health care system's emphasis on provider-based, rather than team-based management of dementia, according to Dr. Malaz Boustani, MPH. In his address at the Alzheimer's Association Dementia Care Conference Dr. Boustani said the stressors that cause agitation and other dementia symptoms and lead to overmedication should be alleviated by changing the way dementia is treated. “We shouldn't blame nursing homes, long-term care, home care, or hospitals. We should blame a system that has us in a situation where we don't know how to deal with dementia in these settings, so we use unapproved medicines whose harm can outweigh their benefits,” said Dr. Boustani, assistant professor of medicine at Indiana University (IU) School of Medicine in Indianapolis. “Instead of one doctor or one nurse providing care for a patient, a team of professionals should be responsible for that care, and depending on where the patient is located, the team could consist of a primary care physician, a dementia care provider, a psychologist or psychosocial psychologist, a registered nurse, and formal or informal caregivers,” Dr. Boustani said in an interview. At the Indiana University Center for Aging Research, Dr. Boustani and his colleagues created a cooperative care model that decreased the behavioral symptoms among dementia patients 30% without increasing the use of psychotropic drugs. Led by Dr. Christopher M. Callahan, professor of medicine at IU, the Indianapolis researchers tested the model in a controlled clinical trial whose results were published last year and showed that collaborative care for the treatment of Alzheimer's disease results in “significant improvement in the quality of care and in behavioral and psychological symptoms of dementia among primary care patients and their caregivers” (JAMA 2006;295:2148–57). In that study, 84 intervention patients received 1 year of care management by an interdisciplinary team led by an advanced-practice nurse working with the patient's family caregiver and integrated within primary care. An additional 69 patients received augmented usual care. The team used standard protocols to initiate treatment and to identify, monitor, and treat behavioral and psychological symptoms of dementia, stressing nonpharmacologic management. Intervention patients and their caregivers received collaborative care management for a maximum of 12 months by a team led by their primary care physician and a geriatric nurse practitioner who served as the care manager. All intervention patients were recommended for treatment with cholinesterase inhibitors (or memantine) unless contraindicated. The minimum intervention that all treatment group caregivers and patients received included education on communications skills, caregiver coping skills, legal and financial advice, patient exercise guidelines with a guidebook and videotape, and a caregiver guide provided by the local chapter of the Alzheimer's Association. All components of this minimum intervention, as well as behavioral interventions, were provided by a geriatric nurse practitioner serving as the care manager. On the basis of caregivers' reports, 89% of intervention patients triggered at least one protocol for behavioral and psychological symptoms of dementia with a mean of four per patient from a total of eight possible protocols. Intervention patients were significantly more likely to receive cholinesterase inhibitors (80% vs. 55% in the usual care group) and antidepressants (45% vs. 27.5%). In addition, intervention patients had significantly fewer behavioral and psychological symptoms of dementia as measured by the total neuropsychiatric inventory score at 1 year and at 18 months. Caregivers reported significant improvements in distress at 1 year, and improvements in depression at 18 months. This team approach to dementia care is not necessarily more costly, Dr. Boustani added, but it is more work. First, you set a reasonable goal, then create your team and give them time and space to interact; you get support from the leadership or stakeholder; then you give the team time lines before modifying the results to suit the needs of that facility, he said, stressing that the process must be kept flexible and adaptive.

Selective loss of dopamine D2 receptors in temporal cortex in dementia with Lewy bodies, association with cognitive decline

Dementia with Lewy bodies (DLB) is a progressive dementia frequently accompanied by psychotic symptoms. Similar symptoms can occur in Alzheimer's disease (AD) to a lesser extent. The use of neuroleptic medication to treat psychosis in both diseases is of modest efficacy and can induce severe adverse reactions in DLB. Dopamine D2 receptors in the cerebral cortex are the putative target for the antipsychotic action of these drugs, but the status of these receptors in DLB is unknown. Autoradiography was used to examine the density D2 receptors in postmortem temporal cortex tissue from prospectively assessed patients with neuropathologically confirmed DLB and AD. D2 receptors were substantially (over 40%) and significantly (P < 0.001) reduced in temporal cortex in DLB, and in DLB with concomitant Alzheimer pathology, but was not significantly changed in AD. This reduction correlated with greater cognitive decline (P < 0.01), but was not significantly related to visual or auditory hallucinations or delusions. D2 receptor density was inversely correlated with cortical Lewy body pathology in the neocortex (P < 0.001). The specific loss of D2 receptors associated with Lewy body pathology, in conjunction with our previous finding of low D2 receptors in striatum in DLB, provides a possible explanation for neuroleptic intolerance. That the reduction of D2 receptors correlated with cognitive decline suggests that neuroleptics, as dopamine D2 receptor antagonists, may have a deleterious effect on cognition in DLB.

Postpsychiatry: Mental Health in a Postmodern World

Back to table of contents Previous article Next article Book ReviewFull AccessPostpsychiatry: Mental Health in a Postmodern WorldScott E. Provost M.M., M.S.W.Scott E. Provost M.M., M.S.W.Search for more papers by this authorPublished Online:1 May 2007https://doi.org/10.1176/ps.2007.58.5.718aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The President's New Freedom Commission on Mental Health called for a consumer-centered mental health system ( 1 ). Unfortunately, many consumers "find it little more than a vehicle for delivering medications, sometimes under the cloud of court orders" ( 2 ). Postpsychiatry represents a framework for mental health through the lens of critical psychiatry and consumer involvement in treatment. The authors are affiliated with the Centre for Citizenship and Community Mental Health, School of Health Studies, University of Bradford in the United Kingdom and specialize in hermeneutics, phenomenology, narrative, and community development. Concepts in this book were previously published in an article on critical psychiatry ( 3 ). The book contains ten chapters organized into three sections. The first section provides context about the mental health profession and how treatment is delivered to consumers. Section 2 reviews the philosophy of science, including the work of postmodern philosophers such as Foucault and Wittgenstein as applied to mental health practice. It also critiques current trends in psychiatry, including the perceived control that pharmaceutical companies exert on academic psychiatry through the marketing of medications for depression and schizophrenia. The final section describes the influence that narrative, recovery, community development, and consumer-centered social policies and programs can have on shaping postpsychiatry. This section contains examples of innovative community development and consumer empowerment programs, including the Soteria project developed to help individuals during acute psychotic episodes without the use of neuroleptic medication. In addition to the three main sections, the book also includes six fictional vignettes from a consumer perspective highlighting illustrative points. Overall, Postpsychiatry is quite relevant to readers of this journal. Themes in this book will resonate with those interested in comparative mental health policy, consumer empowerment, human rights, and action research. The authors also emphasize the importance of including humanities and cultural studies in medical education, which could be offered as a source of dissenting opinion for training in evidence-based psychiatry. To truly appreciate this book, it is helpful if the reader has an understanding of the philosophy of science. A drawback is that the book does not specifically include a concluding summary chapter. Although readers may argue that postpsychiatry is simply antipsychiatry, the authors assert that "postpsychiatry is our attempt to subdue the bright light of medical science: not because we want to get rid of or deny its benefits, but because we believe that the insights of other approaches are equally important and valuable. We hope that our critique of the central assumptions of the psychiatric canon will open a space in which other voices will be heard and taken seriously. We believe that these voices will hold the key to the future." Although the authors do not include any specific policy prescriptions, the postpsychiatry framework may help to engage clinicians, consumers, program managers, and policy makers in a dialogue about directions to take in transforming the mental health system.Mr. Provost is affiliated with the Alcohol and Drug Abuse Treatment Program, McLean Hospital, Belmont, Massachusetts.

Oral health of people with dementia

Oral health of people with dementia

Cancer risk among users of neuroleptic medication: a population-based cohort study

It has been suggested that neuroleptic medication may decrease cancer risk. We compared cancer risks in a population-based cohort study of 25 264 users (⩾2 prescriptions) of neuroleptic medications in the county of North Jutland, Denmark, during 1989–2002, with that of county residents who did not receive such prescriptions. Statistical analyses were based on age-standardisation and Poisson regression analysis, adjusting for age, calendar period, COPD, liver cirrhosis or alcoholism, use of NSAID, and, for breast cancer, additionally for use of hormone therapy, age at first birth, and number of children. Use of neuroleptic medications was associated with a decreased risk for rectal cancer in both women and men (adjusted IRRs of 0.61 (95% confidence interval, 0.41–0.91) and 0.82 (0.56–1.19), respectively) and for colon cancer in female users (0.78; 0.62–0.98). Some risk reduction was seen for prostate cancer (0.87; 0.69–1.08), but breast cancer risk was close to unity (0.93; 0.74–1.17). Overall, treatment with neuroleptic medications was not related to a reduced risk of cancer, but for cancers of the rectum, colon and prostate there were suggestive decreases in risk.

Pneumonia in the elderly—diagnosis and treatment in general practice

AbstractPneumonia is common in the elderly and clinical manifestations are frequently atypical. Pneumonia should be considered in any older person presenting with falls, confusion, incontinence, worsening comorbidities or a deterioration in functional status. The respiratory rate is the most reliable sign to alert the health carer to the presence of pneumonia. Therapy should follow the recommendations of the South African Pneumonia Guidelines. Prevention strategies include the prevention and management of aspiration, reduction in the use of neuroleptic medication, influenza vaccination, maintenance of oral hygiene, smoking cessation and possibly the use of the newer antiviral preparations.

What is the risk of developing parkinsonism following neuroleptic use?

Use of neuroleptic medications is common among elderly patients. Using multivariate models, the authors found that use of antipsychotic medications, age, and disability were strong predictors of developing self-reported Parkinson disease (PD) in the subsequent year among 1992 to 2000 Medicare Current Beneficiary Survey participants. Although more research is needed, these data suggest that 126 Medicare beneficiaries would need to be treated with neuroleptic medications to cause one additional case of self-reported PD.

Neuroleptic Malignant Syndrome Associated With Metoclopramide in a Burn Patient

Neuroleptic malignant syndrome (NMS) is an uncommon, potentially fatal syndrome that occurs with the use of neuroleptic medications. In view of the rarity of this syndrome and the overlap with the pathophysiologic manifestations of a burn, the burn surgeon may not readily recognize NMS on presentation. We describe the case of a 27-year-old man with 15% TBSA burns who developed NMS as a result of metoclopramide use. Recognition and treatment resulted in a prompt resolution of symptoms. Initial treatment should include immediate withdrawal of all neuroleptic agents, measures aimed at decreasing body temperature, supportive care, and restoration of dopamine balance. Various authors have advocated treatment with various medications, including benzodiazepines, dantrolene, and dopaminergic agents. It is important for burn unit personnel to be aware of this syndrome because the early institution of therapy can be life saving.

Non-neuroleptic catecholaminergic drugs for neuroleptic-induced tardive dyskinesia

Tardive dyskinesia (TD) is a disabling movement disorder associated with the prolonged use of neuroleptic medication. Several strategies have been examined in the treatment of TD. Currently, however, there is no clear evidence of the effectiveness of these drugs in TD and they have been associated with many side effects. One particular strategy would be to use pharmaceutical agents which are known to influence the catecholaminergic system at various junctures. To determine whether catecholaminergic drugs for people with schizophrenia or other chronic mental illnesses are associated with a reduction in neuroleptic-induced tardive dyskinesia. We searched the Cochrane Schizophrenia Group's Register (January 1996), Biological Abstracts (1982-1995), EMBASE (1980-1995), LILACS (1982-1996), MEDLINE (1966-1995) and PsycLIT (1974-1995). We searched the Cochrane Schizophrenia Group's Register again in December 2002 and September 2005. We also searched references of all relevant studies for further trial citations and contacted principal authors of trials. We selected studies if they were randomised controlled trials focusing on people with schizophrenia or other chronic mental illnesses who also suffered from neuroleptic-induced tardive dyskinesia. We compared the use of catecholaminergic interventions versus placebo or no intervention. We independently extracted data. For homogenous dichotomous data, we calculated the random effects, relative risk (RR), and 95% confidence interval (CI) and, where appropriate, the numbers needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD). We excluded 20 studies, mainly due to an inability to extract data from the first arm of the study crossover. One included study has shown that patients on placebo were no more likely to leave the study early than those on tiapride (n=24). The other included study (n=35) also reported equivocal data (RR 5.28 CI 0.3 to 102.6) for leaving the study early when participants were randomised to either celiprolol or placebo. However, in both studies, sample size was limited. Although there has been a large amount of research in this area, most studies were excluded due to inherent problems in the nature of their crossover designs. Usually data are not reported before the crossover and the nature of TD and its likely response to treatments makes it imprudent to use this data. The review provides little usable information for service users or providers and more well designed and reported studies are indicated.

Positive behavioural disturbances in the rehabilitation phase after severe traumatic brain injury: an historic cohort study

Primary objective: To investigate the association of post-traumatic amnesia (PTA) with positive behavioural disturbances (PBD) in an historic cohort of patients with severe traumatic brain injury (TBI) and to evaluate the use and effects of neuroleptic drugs in this cohort.Research design: Historic cohort study.Methods: The medical files of 60 patients with severe TBI, selected for inpatient rehabilitation during a period of 5.5 years, were independently examined for the presence of PTA and PBD at admission in the rehabilitation centre as well as for the concomitant use of neuroleptic drugs. All TBI patients with PBD at admission were subjected to special nursing measures consisting of a structured and safe environment, a minimum number of caregivers and provision of simple and consistent feedback. As a basic policy, the use of neuroleptic medication was minimized or stopped.Results: Of the 28 patients suffering from PTA at admission, 16 demonstrated PBD (positive predictive value 0.57 (95% CI 0.45–0.70)). In contrast, all the 32 patients without PTA but one did not show PBD (negative predictive value 0.97 (95% CI 0.93–1.00)). Seven of the 17 patients with PBD (41%) had been prescribed neuroleptic medication, of whom five patients (81%) experienced undesired side effects. Because of the special nursing measures, these drugs could be stopped or substituted by non-neuroleptic behaviour-modifying drugs in all patients within 3 weeks, without aggravation of their PBD.Conclusions: These results suggest that impaired attention and memory may play a critical role in the development of PBD in patients with severe TBI. From this perspective, maximum effort must be made to improve TBI patients’ level of attention, memory and orientation instead of using mechanical or chemical restraints.