PD symptoms reportedly occur in over 50% of all elderly patients receiving these agents and the cumulative annual incidence of TD in middle-aged and elderly patients is over 25%.56 The likelihood of reversing this potentially debilitating condition diminishes with age. Other adverse effects of these agents that are often intolerable in the older population include orthostatic hypotension and anticholinergic effects. Orthostasis is estimated

to occur in 5% to 30% of geriatric patients and is a major contributing factor to the occurrence of falls.57 The Inhibitors,research,lifescience,medical elderly are also more prone to the consequences of falls, such as bone fractures, injuries, and dependency. Low-potency antipsychotics and clozapine are more likely to cause significant drops in orthostatic blood pressure. Anticholinergic effects in the elderly may cause side effects, such as check details constipation, dry mouth, urinary retention, and cognitive impairment. The elderly are especially sensitive to these effects and the Inhibitors,research,lifescience,medical use of laxatives or stool softeners is already

particularly high in nursing homes. Cognitive impairments may lead to decreased independence, and a more rapid decline in cognitive functioning may occur in the elderly treated with antipsychotics than in the younger adult population. Clozapine has been used successfully in the elderly Inhibitors,research,lifescience,medical population at lower doses than adult patients. Mean dosages range from 50 to 300 mg/day with a much slower rate of titration. Inhibitors,research,lifescience,medical This may be a good choice for treating psychotic elderly patients with preexisting

PD, because of its lower affinity for D2 receptors in the striatum. Clinically, however, it is a poorly tolerated antipsychotic in geriatric patients and should Inhibitors,research,lifescience,medical be used with caution. The risk for agranulocytosis appears to be about 4% in the elderly population with older women being at highest risk.58 The risk for seizure activity is increased in the elderly59 and sedation is one of the major reasons for discontinuation.60 Clozapine therapy should be initiated at 12.5 to 25 mg/day given in two divided doses, titrating by increments of 12.5 STK38 mg over 5 to 7 days. Controlled studies examining the efficacy of clozapine in the elderly specifically for patients with schizophrenia are rare. Howanitz and colleagues61 studied clozapine (maximum 300 mg/day) compared with chlorpromazine (maximum 600 mg/day) in a 12-week, double-blind fashion in patients with chronic schizophrenia. Patients on clozapine tended to do better than the chlorpromazine group, although this did not reach significance, probably due to the sample size.62 Tachycardia and weight gain were problematic for clozapine-treated patients, while those treated with chlorpromazine were highly sedated. Clozapine should be used as a last resort in geriatric patients with schizophrenia and at least one trial of an SGA should be made first.