Best Management of Antipsychotics in Epilepsy: Affected by Government Shutdown?

It’s uncommon to get a question from a neurologist about which antipsychotics lower the seizure threshold the least in patients with seizure disorders. In fact, I usually have to run a PubMed literature search. But I got this initial message from PubMed that I’m sure others have noticed:

“PubMed is open, however it is being maintained with minimal staffing due to the lapse in government funding. Information will be updated to the extent possible, and the agency will attempt to respond to urgent operational inquiries. For updates regarding government operating status see”

More specifics on how the government shutdown affects us can be found at Government Shutdown |

Admittedly, the PubMed issue related to minimal staffing hardly slows me down, but it brought home to me the realization that politics, especially politics for its own sake without regard to the consequences for the people, can be a very bad thing.

I finally got the answer to consultee’s question from a sharp clinical pharmacist who was able to find a fairly recent review on the topic [1].

The bottom line on the question is a moving target because it depends on factors including but not limited to the context of the diagnosis of a psychotic disorder, formulary restrictions in a particular location which may influence clinical treatment decision-making regarding a specific patient population, whether the patient in question is compliant with taking oral medication, and whether the patient has a comorbid medical condition that bears on the question, e.g., long QT syndrome.

The literature is also limited by a dearth of studies on the effects of antipsychotics on seizure thresholds in those who suffer from seizure disorders.

It’s interesting to note that epilepsy itself can lead to interictal psychoses which can persist, and which often leads to the necessity to treat with an antipsychotic drug, despite the risk for lowering the seizure threshold.

Some antipsychotics carry a higher risk for lowering seizure threshold and these include clozapine, loxapine, possibly olanzapine, and chlorpromazine. In fact, when patients receive above 600 mg a day of clozapine (some would argue the decision point should be keyed to the clozapine plasma level), we usually recommend adding an anticonvulsant in an effort to prevent seizures. And the choice of anticonvulsant in this setting can be critical. For example, carbamazepine, which is also used as a mood stabilizer in some patients who have affective psychoses, can lead to hyponatremia (low sodium) which can itself lower the seizure threshold. Carbamazepine can lower the blood level of antipsychotics by the anticonvulsant’s tendency to induce metabolic enzymes that increase the clearance of the antipsychotic.

The other important issue about carbamazepine is its synergistic interaction with clozapine, which can increase the risk for leukopenia. It’s best to avoid the combination whenever possible.

Often valproate is recommended in the  scenario above, but as Kanner points out, this drug can inhibit the metabolism of drugs like clozapine. Valproate can also rarely cause delirium through a complex metabolic pathway influenced by genetic abnormalities–valproate–associated hyperammonemic encephalopathy.

This is anything but an exhaustive review of the subject and the issue is not something that is always on the radar of psychiatric consultants. I can see how the government shutdown can get in the way of even routine patient care, when the goal is to provide the most up-to-date treatment guided by the medical literature.


1. Kanner, A. M. (2008). “The use of psychotropic drugs in epilepsy: what every neurologist should know.” Semin Neurol 28(3): 379-388.

Psychiatric disorders, such as mood, anxiety, attention deficit, and psychotic disorders, are among the most frequent comorbidities experienced by patients with epilepsy. While these psychiatric disorders have typically been considered as one of its complications, there is increasing evidence of a bidirectional relationship between the seizure disorder and mood and ADHD. Indeed, not only are patients with epilepsy at greater risk of developing these two disorders, but patients with mood and attention deficit disorders are at greater risk of developing epilepsy. Comorbid psychiatric disorders have a negative impact on the quality of life of patients with epilepsy. For patients with pharmacoresistant epilepsy, mood disorders are a stronger predictor of a worse perception of their quality of life than is their seizure frequency and severity. Thus, the use of psychotropic drugs is often necessary in patients with epilepsy, be they children or adults. Unfortunately, there are many misconceptions regarding the safety of psychotropic drugs, particularly of antidepressants and central nervous system stimulants, which are often erroneously thought of as being “proconvulsant.” Such misconceptions have resulted in the undertreatment of psychiatric comorbidities in patients with epilepsy. This article provides a practical review of the use of antidepressants, central nervous system stimulants, and antipsychotic drugs in patients with epilepsy.


New Free Online Dementia Training Resources at Iowa Geriatric Education Center

Here’s a heads-up on the Iowa Geriatric Education Center announcement about new free online dementia training resources.  The Improving Antipsychotic Appropriateness in Dementia Patients (IA-ADAPT) program provides 2 hours of free continuing education credit for nurses, physicians, and pharmacists. You can obtain free laminated guides and family information on antipsychotic use as well. The program is funded by the Agency for Healthcare Research and Quality. The link is on the blue bullet menu on my blog site or click the link

Did I mention it’s free?Iowa Geriatric Education Center

I Want The Truth…And Something Beautiful

‘Beauty is truth, truth beauty,–that is all Ye know on earth, and all ye need to know.’–John Keats

So I saw this very interesting item in AMA MorningRounds about publication bias of research studies about psychiatric drugs. Basically this is about the file drawer effect, in which negative studies regarding the efficacy of interventions, in this case antipsychotic and antidepressant medications, don’t get published. This results in psychiatrists not having all the information we need to make treatment decisions. Give me all the data, please, because I want the truth–and something beautiful. A quote from the article the news item is based on is, “instead, the negative studies were buried on the FDA website, where only a specialist with a background in statistics could understand what they meant.” You can read the story at link Hidden data show that antipsychotic drugs are less effective than advertised – The Checkup – The Washington Post. The story is based on research conducted by Erick H. Turner and colleagues [1]. The link to the paper is PLoS Medicine: Publication Bias in Antipsychotic Trials: An Analysis of Efficacy Comparing the Published Literature to the US Food and Drug Administration Database.

In the interest of fairness, let the truth be known, though. If you read the entire article, it’s clear that the negative studies did not lead to a conclusion that the antipsychotics studied were ineffective. A quote from the article:

“When Turner added the data from the negative, unpublished studies to the positive, published studies, he found the overall effectiveness of this class of drugs in treating schizophrenia fell by a small amount, about eight percent.

‘Overall, the drugs seem to work almost as well as we thought they did,’ Turner said.”

However, Tuner’s point is well taken and I quote: “When you have cherry picking of data, weeding out of data, then you can’t discriminate between drugs that are good and drugs that aren’t good at all. You don’t know when to be confident and when to be suspicious.”

I think publication bias fuels the public perception that psychiatrists are manipulated by pharmaceutical companies, exacerbating the aura of mistrust of mental health care providers. It gives ammunition to the antipsychiatry movement, which they don’t need. In my opinion, it also tends to feed the drive to legalize marijuana for the treatment of psychiatric disorders, which is not supported by the bulk of the medical literature. See my post about this at link Let Somebody Else Bogart That Joint, My Friend « The Practical Psychosomaticist: James Amos, M.D.

In my view, I need all the data I can get to provide the safest, most effective treatment for my patients. I don’t think psychiatrists should settle for anything less. The research my colleagues conduct can be elegant, whether or not the results fit the world view I prefer. I want the truth.

1. Turner, E. H., D. Knoepflmacher, et al. (2012). “Publication Bias in Antipsychotic Trials: An Analysis of Efficacy Comparing the Published Literature to the US Food and Drug Administration Database.” PLoS Med 9(3): e1001189.

Abstract Top


Publication bias compromises the validity of evidence-based medicine, yet a growing body of research shows that this problem is widespread. Efficacy data from drug regulatory agencies, e.g., the US Food and Drug Administration (FDA), can serve as a benchmark or control against which data in journal articles can be checked. Thus one may determine whether publication bias is present and quantify the extent to which it inflates apparent drug efficacy.

Methods and Findings

FDA Drug Approval Packages for eight second-generation antipsychotics—aripiprazole, iloperidone, olanzapine, paliperidone, quetiapine, risperidone, risperidone long-acting injection (risperidone LAI), and ziprasidone—were used to identify a cohort of 24 FDA-registered premarketing trials. The results of these trials according to the FDA were compared with the results conveyed in corresponding journal articles. The relationship between study outcome and publication status was examined, and effect sizes derived from the two data sources were compared. Among the 24 FDA-registered trials, four (17%) were unpublished. Of these, three failed to show that the study drug had a statistical advantage over placebo, and one showed the study drug was statistically inferior to the active comparator. Among the 20 published trials, the five that were not positive, according to the FDA, showed some evidence of outcome reporting bias. However, the association between trial outcome and publication status did not reach statistical significance. Further, the apparent increase in the effect size point estimate due to publication bias was modest (8%) and not statistically significant. On the other hand, the effect size for unpublished trials (0.23, 95% confidence interval 0.07 to 0.39) was less than half that for the published trials (0.47, 95% confidence interval 0.40 to 0.54), a difference that was significant.


The magnitude of publication bias found for antipsychotics was less than that found previously for antidepressants, possibly because antipsychotics demonstrate superiority to placebo more consistently. Without increased access to regulatory agency data, publication bias will continue to blur distinctions between effective and ineffective drugs.

Please see later in the article for the Editors’ Summary

Antipsychotic Medication in Elderly Demented Nursing Home Residents, a video of the United States Senate Special Committee on Aging hearing about overuse of antipsychotic use in nursing home residents, the home page of the United States Senate Special Committee on Aging

One of my clinical pharmacists on the interdisciplinary team staffing the Medical-Psychiatry Unit alerted me to the recent AMA MorningRounds news announcement about the continuing overuse of antipsychotics to control agitated behavior in demented elderly persons in nursing homes. The link above takes you to the video of the United States Senate Special Committee on Aging hearing about the issue.

Be forewarned, the video is almost 2 hours long, It’s not similar in any way to the fun and comical music videos I generally attach to my posts. It’s a sobering and sometimes painful video document of the problems we have providing safe and high quality care for older persons in this country. It’s a call to action toward creating a sea change in the culture of how we care for the elderly. Sometimes the tenor of the testimony gave me the impression that the concern about overprescribing of antipsychotics for the management of problematic behaviors in the demented elderly is focused on just the economic burden imposed on our national and state economies.

But because I’m a blogger and pay a fair amount of attention to words, I gradually got a sense of one of the major issues in this crisis, which is that the “culture” of medical care contributes to the problem in a major way. You’ll notice that a number of physician leaders give testimony, among them geriatricians. No geriatric psychiatrist was asked to testify, and I’m not sure why–but by the end of the 114 minute video, I decided that the panel did an extraordinarily thorough job of describing the problem and outlining potential solutions.

And there was a very important reminder that the problem of trying to fix behavioral problems with drugs is often a mistake. Challenging behavior in elderly demented persons (substitute “grandfather”, “uncle”, “brother”, “sister” and so on) is frequently an attempt by them to communicate with us, when the skill of language is lost during the course of dementia. One common problem (among many) they might be trying to communicate with us about is untreated or inadequately treated pain. Research and clinical best practice guidance for years now have counseled health care professionals to try nonpharmacologic behavioral methods first–exhaustively before resorting to psychotropic medications of any kind, not just antipsychotics.

The panel rightly identified that the overprescribing of antipsychotics doesn’t just occur in nursing homes, but is common in hospitals and other types of long-term care facilities and assisted living facilities.

As a psychiatric consultant in the general hospital and co-attending staff physician on the Medical-Psychiatry Unit, my colleagues in medicine and surgery and I are faced with difficult decisions every day about how to cope with challenging and sometimes dangerous behaviors in patients who had cognitive impairment of various kinds including dementia (one of the main risk factors for delirium) who get delirious resulting from medical problems. My colleagues occasionally have an issue with my usual number one recommendation, couched in the usual terms: “Delirium is not a psychiatric problem per se, but a medical emergency; please try finding and resolving the inciting medical problems causing delirium first.” And again, some have an issue with my other oft-expressed opinion, “Haldol is not the treatment for delirium; the treatment for delirium is diagnosing and treating the underlying medical causes.”

Sadly, when behavioral management methods don’t work to control dangerous behavior, we’re compelled to use antipsychotics to maintain safety for patients and caregivers. It’s imperative, though, to have a careful informed consent discussion with families about the risks and benefits of a drug-assisted management approach that will hopefully be temporary. This is the “off label” prescribing mentioned in the video, which physicians legally can and sometimes must do. What is illegal is the “off label marketing” of antipsychotics done by pharmaceutical companies who have settled multimillion dollar lawsuits over this practice. What families need to know is that research repeatedly shows that there are many risks for harm from antipsychotics (including increased risk for death) and little to no benefit when used in an effort to manage challenging behaviors that are not dangerous but which may interfere with providing care.

By far, though, the preferred way to manage challenging behaviors in the demented elderly is through non-pharmacologic interventions. I learned from a recent newsletter from the Mayo Clinic about what Dr. Glenn E. Smith, PhD, LP and colleagues at Mayo Clinic are doing to help caregivers managed disruptive behavior using the Dementia-Behavioral Assessment and Response Team (D-BART, see link at [1]. The D-BART intervention has been helping professional care providers and family members since 1995 and the method reduces the frequency and severity of negative behaviors and improves quality of life and mood for patients with dementia. D-BART can include a licensed neuropsychologist, a psychiatrist, and a dementia education specialist. The patient-centered and team-based approach follows the notion that aggression and agitation are influenced by medical, environmental, psychological, and social factors. The view is what is explicitly commented on in the video, which is that behavior is a form of communication. According to Dr. Smith, “Behavior is a form of communication. As caregivers, it’s our job to detect what the behavior is trying to say and work from that knowledge.” The D-BART approach helps caregivers recognize and capitalize on the understanding that they can adapt a lot easier than the demented person.

D-BART can offer virtual access to those in need by virtual consultations using Skype (for explanation of what Skype is and how it works, see link The team provides a laptop or downloadable survey software to facilities that use Skype technology. They review teh survey and the patients electronic medical record prior to the interview of the patient. A group session amongst the team and caregivers results in practical recommendations. A study in 2010 showed D-BART outcomes following consultation indicating that 79% of caregivers reported improvement in the patient’s target behaviors, although it’s not perfect as 7% showed worsening behaviors and 14% showed no change. And the idea is to teach caregivers how to help one patient and they can share what they learn with others–an inductive teaching model which can help spread knowledge and skills faster.

The way to change the course of this crisis in health care treatment of the demented elderly will involve education in nonpharmacologic behavior management techniques, new and stiffer penalties, closer oversight by regulatory agencies, and an increased emphasis on collaboration amongst many stakeholders in our system. The last involves cultivating greater awareness of how the culture of care can create both crises and opportunities.

1. Mayo Clinic PsychUpdate, Psychiatry and Psychology News From Mayo Clinic, Vol. 3, No. 2, 2011.

Preventing Delirium

Try responding to the poll above after reading this post. Have fun!

Preventing delirium is the hot topic and research on what’s the best way to do it is growing. The newest study I could find has results that contrast sharply with what I posted only a short while ago (see short link This one actually used a strategy I haven’t used in a long time as a psychiatric consultant because of the perceived and actual risks and it’s the intravenous bolus followed by continuous infusion (IV) of Haloperidol [1]. In this study, though, they used much lower doses than we did back in the day, on the order of 10 times lower, in fact. Haloperidol at 0.5 mg IV as a one time bolus dose was followed by continuous infusion at a rate of 0.1 mg/hr for 12 hours.

We used to use a 10 mg bolus dose, and if agitation from delirium was still an issue after eight of those (that’s right, I said “eight”), then a continuous infusion of 10 mg/hr was started and that could go for a while, sometimes involving very large doses in the hundreds of milligrams range. Extrapyramidal side effects were said to be rare with this administration, but I’ve seen them. Because of the risk for incurring prolonged cardiac conduction sometimes complicated by the development of cardiac arrhythmias, continuous infusions of IV Haloperidol were done only in the critical care units where cardiac monitoring by telemetry was available. Guidance on implementation came from the relevant literature available at the time, Riker’s paper being the most explicit [2].

There was also a placebo arm in the Wang et al study. the primary endpoint was the incidence of delirium within the first 7 days following noncardiac surgery. This intervention was well-tolerated and reduced the incidence of postoperative delirium. However, the incidence of delirium was still 15% in the Haloperidol group, and the differences in length of stay in the intensive care unit and the time to onset of delirium were statistically significant, though small.

The jury remains out on pharmacologic prevention of delirium, but study goes on regarding prevention because of the dire consequences of delirium. Don’t forget the nonpharmacologic methods for preventing delirium (see short link

And then there’s melatonin for the prevention of delirium. It’s not really a drug per se. Review the blog post at short link

As a reminder for why delirium research is so vital, review the data from the American Delirium Society website:

  • More than 7 million hospitalized Americans suffer from delirium each year.
  • Among hospitalized patients who survived their delirium episode, the rates of persistent delirium at discharge, 1, 3 and 6 months are 45%, 33%, 26%, and 21% respectively.
  • More than 60% of patients with delirium are not recognized by the health care system.
  • Compared to hospitalized patients with no delirium and after adjusting for age, gender, race, and comorbidity, delirious patients suffer from:
  • Higher mortality rates at one month (14% vs. 5%), at six months (22% vs. 11%), and 23 months (38% vs. 28%);
  • Hospital stay is longer 21 days vs. 9 days); receive more care in long-term care settings at discharge (47% vs. 18%), at 6 months (43% vs. 8%), and at 15 months (33% vs. 11%);
  • Have higher probability of developing dementia at 48 months (63% vs. 8%).

1. Wang, W., H. L. Li, et al. (2011). “Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery: A randomized controlled trial.” Critical care medicine.
OBJECTIVES:: To evaluate the efficacy and safety of short-term low-dose intravenous haloperidol for delirium prevention in critically ill elderly patients after noncardiac surgery. DESIGN:: Prospective, randomized, double-blind, and placebo-controlled trial in two centers. SETTING:: Intensive care units of two large tertiary teaching hospitals. PATIENTS:: Four hundred fifty-seven patients 65 yrs or older who were admitted to the intensive care unit after noncardiac surgery. INTERVENTION:: Haloperidol (0.5 mg intravenous bolus injection followed by continuous infusion at a rate of 0.1 mg/h for 12 hrs; n = 229) or placebo (n = 228) was randomly administered from intensive care unit admission. MEASURES:: The primary end point was the incidence of delirium within the first 7 days after surgery. Secondary end points included time to onset of delirium, number of delirium-free days, length of intensive care unit stay, all-cause 28-day mortality, and adverse events. Delirium was assessed using the confusion assessment method for the intensive care unit. RESULTS:: The incidence of delirium during the first 7 days after surgery was 15.3% (35/229) in the haloperidol group and 23.2% (53/228) in the control group (p = .031). The mean time to onset of delirium and the mean number of delirium-free days were significantly longer (6.2 days [95% confidence interval, 5.9-6.4] vs. 5.7 days [95% confidence interval, 5.4-6.0]; p = .021; and 6.8 +/- 0.5 days vs. 6.7 +/- 0.8 days; p = .027, respectively), whereas the median length of intensive care unit stay was significantly shorter (21.3 hrs [95% confidence interval, 20.3-22.2] vs. 23.0 hrs [95% confidence interval, 20.9-25.1]; p = .024) in the haloperidol group than in the control group. There was no significant difference with regard to all-cause 28-day mortality between the two groups (0.9% [2/229] vs. 2.6% [6/228]; p = .175). No drug-related side effects were documented. CONCLUSIONS:: For elderly patients admitted to intensive care unit after noncardiac surgery, short-term prophylactic administration of low-dose intravenous haloperidol significantly decreased the incidence of postoperative delirium. The therapy was well-tolerated.

2. Riker, R. R., G. L. Fraser, et al. (1994). “Continuous infusion of haloperidol controls agitation in critically ill patients.” Critical care medicine 22(3): 433-440.
OBJECTIVE: To evaluate the safety and efficacy of continuous infusion of haloperidol in treating agitated critically ill adult patients. DESIGN: Case series of patients treated with continuous infusion of haloperidol and followed to hospital discharge, during a 6-month period. SETTING: A 34-bed multidisciplinary intensive care unit (ICU) in a 598-bed nonuniversity, tertiary care teaching hospital. PATIENTS: Consecutive sample of eight patients requiring mechanical ventilation who had severe agitation which was refractory to intermittent bolus treatment with benzodiazepines, narcotics, and haloperidol. INTERVENTIONS: Continuous infusions of haloperidol (range 3 to 25 mg/hr) were supplemented, as required, to maintain adequate sedation. MEASUREMENTS AND MAIN RESULTS: The four men and four women averaged 47 yrs of age, and the average length of hospitalization was 33 days, with 25 days spent in the ICU. On the day continuous infusion of haloperidol was initiated, the average Acute Physiology and Chronic Health Evaluation (APACHE) II and Therapeutic Intervention Scoring System (TISS) scores were 24 and 47, respectively. The Sedation-Agitation Scale score averaged +2.4 (maximum agitation score being +3) before continuous infusion of haloperidol decreasing to +1.8 after 1 day (p = .38) and to +0.8 after 2 days (p = .06) of continuous infusion of haloperidol. The average daily haloperidol dose increased from 68 mg before continuous infusion of haloperidol to 269 mg (p < .008) after 1 day. The daily total of nonhaloperidol sedatives decreased from 18.3 to 10.9 sedation-equivalent units (p = .15) and the daily number of bolus administrations of sedatives decreased from 23 to 7 (p = .01) after 1 day of continuous infusion of haloperidol. Estimated nursing time to prepare, administer, and monitor these bolus medications decreased from 320 to 96 mins per 24 hrs (p = .01). Of the five patients discharged alive (37.5% mortality rate), four were successfully weaned from assisted ventilation during continuous infusion of haloperidol. Two of these four patients were difficult to wean because of agitation and oversedation. Four possible complications were noted: minor tremors (n = 2), atrial dysrhythmias with intermittent third-degree atrioventricular block and QT interval prolongation (n = 1), and ventricular tachycardia (n = 1). CONCLUSIONS: Continuous infusion of haloperidol effectively controls severe agitation in critically ill patients, reduces requirements for bolus administration of sedatives and nursing time lost to that task, and may facilitate ventilator weaning. Parenteral administration of haloperidol was associated with few complications in > 1,340 patient-hours of continuous administration.

Delirium Risk Screening and Haldol Prophylaxis

Something new in the medical literature will probably temper enthusiasm for trying to prevent delirium with antipsychotic. A recently published study in The Netherlands used a delirium risk screening tool called the Risk Model for Delirium (RD score) to identify high risk hip fracture patients and treated them with prophylactic low-dose Haloperidol [1]. This is line with much of the up and down literature on the efficacy of antipsychotics in preventing delirium. We simply don’t have enough data yet to recommend routine antipsychotic prophylaxis against delirium in any population yet. It deserves and will get further study.

1. Vochteloo, A., S. Moerman, et al. (2011). “Delirium risk screening and haloperidol prophylaxis program in hip fracture patients is a helpful tool in identifying high-risk patients, but does not reduce the incidence of delirium.” BMC Geriatrics 11(1): 39.
BACKGROUND:Delirium in patients with hip fractures lead to higher morbidity and mortality. Prevention in high-risk patients by prescribing low dose haloperidol is currently under investigation.METHODS:This prospective cohort surveillance assessed hip fracture patients for risk of developing a delirium with the Risk Model for Delirium (RD) score. High-risk patients (score [greater than or equal to] 5 points) were treated with a prophylactic low-dose of haloperidol according to hospital protocol. Primary outcome was delirium incidence. Secondary outcomes were differences between high- and low-risk patients in delirium, length of stay (LOS), return to pre-fracture living situation and mortality. Logistic regression analysis was performed with age, ASA-classification, known dementia, having a partner, type of fracture, institutional residence and psychotropic drug use as possible confounders.RESULTS:445 hip fracture patients aged 65 years and older were admitted from January 2008 to December 2009. The RD-score was completed in 378 patients, 173 (45.8%) high-risk patients were treated with prophylactic medication. Sensitivity was 71.6%, specificity 63.8% and the negative predictive value (NPV) of a score < 5 was 85.9%.Delirium incidence (27.0%) was not significantly different compared to 2007 (27.8%) 2006 (23.9%) and 2005 (29.0%) prior to implementation of the RD- protocol.Logistic regression analysis showed that high-risk patients did have a significant higher delirium incidence (42.2% vs. 14.1%, OR 4.1, CI 2.43-7.02). They were more likely to be residing at an alternative living situation after 3 months (62.3% vs. 17.0%, OR 6.57, CI 3.23-13.37) and less likely to be discharged from hospital before 10 days (34.9% vs. 55.9%, OR 1.63, CI 1.03-2.59). Significant independent risk factors for a delirium were a RD-score [greater than or equal to] 5 (OR 4.13, CI 2.43-7.02), male gender (OR 1.93, CI 0.99-1.07) and age (OR 1.03, CI 0.99-1.07).CONCLUSIONS:Introducing the delirium prevention protocol did not reduce delirium incidence.The RD-score did identify patients with a high risk to develop a delirium. This high-risk group had a longer LOS and returned to pre-fracture living situation less often.The NPV of a score < 5 was high, as it should be for a screening instrument. Concluding, the RD-score is a useful tool to identify patients with poorer outcome.

Educational Module on Neuroleptic Malignant Syndrome from the NMS Information Service

The link above takes you to the Neuroleptic Malignant Syndrome Information Service (NMSIS) web site at As a general hospital psychiatrist, I occasionally get called to evaluate suspected cases of neuroleptic malignant syndrome (NMS). It’s a rare condition, occurring perhaps in 1 in 5,000 cases of exposure to anti-dopaminergic agents. In order to diagnose NMS, there must have been an exposure to antipsychotic, a similar dopamine antagonist like Reglan or Compazine, or even abrupt withdrawal of anti-Parkinson drugs like Sinemet. It’s marked mainly by fever and muscle rigidity and early signs could be mental status changes or muscle rigidity, sometimes after increases in doses of offending drugs, perhaps in the setting of dehydration or other medical stressors. However, these can also be signs for a wide variety of other medical conditions; NMS is a diagnosis of exclusion.

The NMSIS is a very useful service, especially when you see what kind of misinformation is out there by just surfing the web. The presentation is a little on the dry side and is likely to be of interest mainly to physicians, but is also accessible to informed laypersons.