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Behavioral and psychological symptoms of dementia can occur in 60-80% of patients with Alzheimer's disease or other dementing illnesses, and are important in that they are a source of significant caregiver stress and often precipitate nursing home placement. These symptoms, namely, aggression, delusions, hallucinations, apathy, anxiety, and depression, are clinically managed with a variety of psychotropic drugs such as antipsychotics, antidepressants, antiepileptic drugs, and benzodiazepines. Various advances in the neuropathophysiology and pharmacotherapy must be considered in the optimal design of regimens for patients with these symptoms.

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OBJECTIVE: To report a case of the successful use of donepezil for treatment of cognitive and noncognitive symptoms in a patient with dementia with Lewy bodies. CASE SUMARY: An 86-year-old white woman with dementia was experiencing early-onset significant fluctuation of her cognitive status, functional impairment, visual hallucinations, aggression, and parkinsonism. She was intially diagnosed with Alzheimer disease and Parkinsons disease and prescribed donepezil 5 mg/d and benztropine 1 mg twice daily. On reexamination of the case by a neurologist, the diagnoses were revised to dementia with Lewy bodies. The benztropine was discontinued, and donepezil was increased to 10 mg/d. The patient's cognitive and functional status significantly improved, as did her visual hallucinations. DISCUSSION: This case supports previous reports of the marked responsiveness of patients with dementia with Lewy bodies to acetylcholinesterase inhibitors. This may be explained by the marked cholinergic deficit observed in patients with dementia with Lewy bodies and the evidence linking cognitive as well as noncognitive symptoms to this deficit. CONCLUSIONS: The present case suggests that patients with dementia with Lewy bodies respond well to acetylcholinesterase inhibitors. Controlled trials are necessary to further define the role of these drugs for this disease.

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Because benzodiazepines can cause significant morbidity and data of their use in elderly people in Canada are scarce, the patterns of benzodiazepine use by Nova Scotia's seniors were studied with the use of administrative, population-based data. The prevalence of benzodiazepine use in the fiscal years 1993/94 to 1995/96 was explored, the types of benzodiazepines used and the extent of use for periods exceeding 30 days were examined, and an attempt was made to examine the average daily doses used. Benzodiazepine use decreased from 28.74% in 1993/94 to 24.69% in 1995/96 (P<0.001). Long elimination half-life benzodiazepines accounted for 23% of benzodiazepines in 1995/96. The proportion of benzodiazepines filled for periods exceeding 30 days increased from 65% in 1993/94 to 68% in 1995/96 (P<0.001). Variability in the estimated daily doses of the benzodiazepines was such that comparison with recommended dose maxima could not be made with confidence, even though the averages of these estimated daily doses appeared to exceed recommended maxima, except for users of alprazolam, lorazepam, oxazepam or bromazepam. Although benzodiazepine use decreased, the observed patterns of use may place seniors at unnecessary risk for adverse health outcomes and increased health resource utilization.

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Alzheimer's disease accounts for 50-60% of dementia cases in older people. Dementia with Lewy bodies is now recognized as the second most common type of dementia. It is different from Alzheimer's disease and has important pharmacotherapeutic implications. Key features include early-onset, persistent, well-formed, visual hallucinations and motor features of parkinsonism. Pharmacologic management of neurobehavioral symptoms is complicated by an exaggerated response to neuroleptics, which causes excessive morbidity and mortality. Patients with dementia with Lewy bodies may be particularly responsive to cholinesterase inhibitors. When neurobehavioral symptoms are severe enough to require pharmacologic intervention, it is recommended that agents such as trazodone or cholinesterase inhibitors be considered first-line therapy. If these fail, neuroleptics may be prescribed with caution.

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OBJECTIVE: To determine current patterns of acetylsalicylic acid (ASA) use in Nova Scotia for individuals with self-reported myocardial infarction, stroke or ischemic heart disease. DESIGN: Descriptive, cross-sectional, population-based study using data from the 1995 Nova Scotia Health Survey (NSHS). The NSHS was based on a probability sample and was representative of the Nova Scotia adult population by age, sex and region. Survey data were obtained by standardized home interviews conducted by trained public health nurses. SETTING: The province of Nova Scotia in 1995. PARTICIPANTS: Survey respondents who reported having a myocardial infarction, stroke or ischemic heart disease were assessed. RESULTS: Among those who reported a history of myocardial infarction, stroke or ischemic heart disease, 55% (95% CI 47% to 63%), 49% (95% CI 38% to 61%) and 54% (95% CI 39% to 68%), respectively, reported using ASA at the time of the survey. Overall, only 53% of those with cardiovascular disease were using ASA. Exclusion of persons with potential contraindications to ASA did not significantly increase these proportions. CONCLUSIONS: ASA appears to be underused in those at high risk for future vascular events. Further research is required to investigate determinants of ASA use and to increase appropriate use of ASA.

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