Regular readers may recall previous blogs where I have written about the dangers associated with antipsychotic drugs in elderly patients. Many of you have responded simply and emotionally on Twitter by saying: “Stop prescribing these drugs!” Others have recognised that the issue is far from clear cut as a fair proportion of patients do have a need for drug treatment and so the clinical decision is all about weighing up the benefits and harms of this powerful medication.
Systematic reviews and randomised trials would normally be the publication types us elves would scurry away to collect when we’re looking to investigate the comparative safety of individual drugs, but unfortunately those are thin on the ground in this subject area.
However, a new population based cohort study has recently been published in the BMJ that will be of interest to clinicians responsible for prescribing antipsychotics to elderly people. It involved 75,445 new users of various antipsychotics drugs (haloperidol, aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone), all living in US nursing homes, all aged ≥65.
The authors note that almost a third of elderly nursing home patients are given antipsychotic drugs. They set out to investigate the risk of overall and cause-specific mortality, to see if it was equal across all antipsychotics or whether there are particular drugs with safety advantages that should be prescribed preferentially in older residents of nursing homes.
Here’s what they found:
- Compared with risperidone (the antipsychotic most widely prescribed for patients with dementia):
- Haloperidol had an increased risk of mortality (hazard ratio 2.07, 95% confidence interval 1.89 to 2.26)
- Quetiapine had a decreased risk of mortality (0.81, 0.75 to 0.88)
- The effects were strongest shortly after the start of treatment, remained after adjustment for dose, and were seen for all causes of death examined
- No significant differences were observed for the other drugs
- There was a dose-response relation for all drugs except quetiapine
The researchers concluded:
Though these findings cannot prove causality, and we cannot rule out the possibility of residual confounding, they provide more evidence of the risk of using these drugs in older patients, reinforcing the concept that they should not be used in the absence of clear need. The data suggest that the risk of mortality with these drugs is generally increased with higher doses and seems to be highest for haloperidol and least for quetiapine.
So why are doctors continuing to prescribe antipsychotics to people with behavioural problems and dementia?
A small study by Wood-Mitchell et al left readers with a number of questions to consider:
- How should I respond to this distressed patient and their family and carers?
- What are the alternative non-drug treatments?
- Are the resources available to implement these approaches locally?
- Are local care homes and community care services adequate?
- Are local guidelines helpful given these real-life dilemmas?
Huybrechts, K.F. et al Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. BMJ 2012;344:e977
Wood-Mitchell A, James IA, Waterworth A, Swann A, Ballard C. Factors influencing the prescribing of medications by old age psychiatrists for behavioural and psychological symptoms of dementia: a qualitative study. Age Ageing 2008;37:547-52.
My mother was given haloperidol in one nursing home. I saw her change from a feisty angry old lady into a ‘typical’ demented individual. She hated being in a home and felt abandoned by her family who lived hundreds of miles away. She only had monthly visits from one or other of her children. After being medicated the care home discovered that they could ‘occupy’ her by giving her huge mail order catalogues which she would systematically work her way through tearing out a page at a time. She stood while doing this, rocking to and fro and focusing intently on the task in hand. Ignoring those visiting her.
After being moved to a home nearer to me, and only a few months before she died, she came off medication. She was briefly able to feed herself for the first time in many months. About six weeks before she died I visited her and she was being aggressive. She pulled my hair and was clearly angry with the world. As she hadn’t really spoken for a very long time and her dementia was very advanced I doubted if I could get through to her but I gave it a try. I said I wondered if she was angry. Maybe she was disappointed that I had not visited her on her birthday, two days earlier, but reminded her I was at work and my husband had been to see her. The family were coming at the weekend and she and I would share a birthday cake as it would be my birthday too in a few days. To my amazement to she immediately calmed down and repeated ‘angry’.
I have no idea what part of my communication effected her. Perhaps just a recognition of her state of mind – angry. But I felt empowered and she became her old self again.
It is hard, and painful, to imagine some one with dementia still having intact reasoning. If we could hold this idea as a possibility, and treat them as such, perhaps there would be less need for the use of anti-psychotic medication.
There’s a good summary of this paper and some links to relevant resources on the National Prescribing Centre website:
The Mental Elf