With respect to the gender differences, a study of patients with Alzheimer's disease cared for in nursing homes found that men were more likely than women to show behavioral problems such as wandering or socially inappropriate behavior (Ott et al., 2000). Although psychotic symptoms were equally prevalent in men and women, men were more likely to receive antipsychotic drugs and less likely to receive antidepressants. Similar disparities have been documented in patients with Parkinson's disease (PD) and associated cognitive impairment. Thus, Fernandez et al. (2000) studied the management of behavioral problems of patients with PD living in nursing homes. Once again, psychotic symptoms (e.g., hallucinations, delusions) were equally prevalent in men and women; nevertheless, men were more likely to receive antipsychotic drugs and less likely to receive antidepressants compared to women. The gender disparity was greatest in the patients with more severe dementia.
Gender issues. Gender differences may inappropriately affect the management of behavioral problems associated with dementia. Thus, clinicians treating patients with dementia should scrutinize their prescribing practices with respect to gender. Because gender disparities in treatment may be greatest in patients with more severe dementia, prescribing patterns in this subgroup should be evaluated very carefully.
Age, race and ethnicity. Age, race and ethnicity may also influence prescribing patterns in the long-term care of the elderly. Quilliam and Lapane (2001) studied the use of drug prevention strategies among nursing home residents with a history of stroke. Those residents over the age of 85, as well as African-American residents, were less likely to be prescribed secondary drug prevention than were younger white residents. African-American residents were 20% less likely to have been treated with anti-platelet or anticoagulant therapy, despite an elevated risk of stroke in African-Americans.
The take-home message regarding elderly care and race. Long-term care of the elderly may be inappropriately influenced by ethnicity or race. Clinicians should be especially vigilant in evaluating prescribing practices for African-American patients with dementia because this group may be under-treated.
Finally, medication should not be considered a remedy of first resort in managing the behavioral disturbances of dementia (Kasckow et al., 2004). After medical causes (Table 2) have been ruled out, psychosocial treatment is considered the first-line intervention. For an agitated patient, for example, ensuring a quiet, consistent environment with good orienting cues may be helpful (Jacobson et al., 2002).
Whether considering schizophrenia, BD or dementia, special populations often present special challenges. Women, children and adolescents, elderly people, and various ethnic and racial minorities may receive suboptimal treatment unless the clinician is attuned to their particular needs. This means attending to pharmacodynamic, pharmacokinetic and psychosocial issues that may affect these groups in unique ways.