Mohammed T. Abou-Saleh

244 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYwas a cross-over study with 6 weeks in the drug or placebo arm.Of 194 residents who were taking regular medication at the startof the study, only 58 (30%) participated, but only 16 (8%) caseswere excluded for reasons that potentially related to theirbehaviour. Thirty-five (60%) completed the study. Dropoutsdue to emergence of BPSD were not more significantly likely tooccur in the withdrawal phase (six cases) than the continuationphase (three cases). After correction for multiple comparisons,BPSD were not more likely to re-emerge following drug withdrawalthan with continuation. There was also a slightimprovement in cognitive function. At face value, this studysuggests that a trial without medication at 6 weeks is indicated.However, the difficulty of sustaining non-pharmacologicalapproaches to the management of BPSD in nursing homes wasshown by the fact that, during the 22 weeks followingdiscontinuation of the original drug, less than one-third of casesremained free of psychotropic medication. The mean time untilreceiving another psychotropic drug was 21 days.SUMMARYOld age psychiatrists are often called for advice when psychosocialinterventions have been tried and have failed, or the resources ofthe staff to try such interventions are limited. Careful judgement isneeded in these circumstances, since a decision not to prescribecan make a precarious situation worse. Drug treatment canprovide a breathing space during which ‘‘something’’ has beenseen to be done, as well as having a useful ‘‘real’’ impact in the75% of cases in which the behaviour persists. The relatively highplacebo effect (often 30–40%) can be useful, as long as the maxim‘primum non nocere’’ is borne in mind. It is important not to leavepatients on medication without having a trial of drug withdrawal.Recent demonstrations of the efficacy of atypicals, carbamazepine,antidepressants and cholinomimetics are important evidencethat this most neglected area of psychiatry need not be dominatedby therapeutic nihilism. Brief programmes of behaviouralmanagement are probably only effective briefly, if at all.Continuing support and training are required for successfulpsychosocial interventions.REFERENCES1. Finkel SI. Behavioral and psychological signs and symptoms ofdementia: implications for research and treatment. Int Psychogeriat1996; 8(suppl 3): 501–52.2. De Deyn PP, Wirshing WC. Scales to assess efficacy and safety ofpharmacologic agents in the treatment of behavioral and psychologicalsymptoms of dementia. J Clin Psychiat 2001; 62 (suppl 21): 19–22.3. McShane RH. 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