Antipsychotics were discovered as an effective treatment for schizophrenia in the 1950s, but their use was expanded despite lack of supporting evidence, to treat other patient groups. This included treating aggression, agitation and other behavioural and psychological symptoms of dementia (BPSD).
There is evidence that these distressing symptoms can often be prevented or managed without medication. However, people with dementia are frequently prescribed antipsychotic drugs for BPSD as a first resort and it has been estimated that around two thirds of these prescriptions are inappropriate (Alzheimer’s Society).
Numerous warnings from both manufacturers and regulatory agencies about these drugs when used to treat BPSD were raised as early as 2002. There is only one antipsychotic drug, Risperidone, which is licensed for use in this vulnerable patient group, although other types are routinely prescribed “off-label”. Guidelines including those issued by NICE state that antipsychotic drugs should only be used as a last resort – when non-drug treatments have been unsuccessful, and for a maximum of 12 weeks.
A Cochrane systematic review (Ballard, 2006) which analysed the results of high-quality (aka randomised) trials further indicated that antipsychotic treatment has limited efficacy as well as increasing the risk of cardiovascular events, weight gain, or death, particularly if taken for longer than the recommended period.
It is interesting to note that the high-quality trials included in the Cochrane review look almost exclusively at narrow efficacy outcomes. So, basically, does the drug get rid of the symptoms and make everyone’s life easier? If the answer is “yes…somewhat…well it’s statistically significant anyway”, as long as the warnings about those pesky side-effects are made clear, the guidelines cover all that, then what is the incentive to delve any deeper? Absolutely none for drug manufacturers of course!
More important patient-relevant outcomes such as long-term side-effects, quality of life, are not routinely measured in trials on antipsychotics, let alone reported. Questions such as why they work for some people and not others, direct comparisons between antipsychotic treatment and alternative drug or non-drug treatments, what happens when you withdraw antipsychotics and so on are also much less well researched. Happily the situation is changing, albeit slowly. But at the moment there is simply less good-quality evidence available for non-drug treatments. What evidence there is, however, is positive, as covered in several Mental Elf blogs on the subject, most recently Non-drug treatments delivered by family carers can improve neuropsychiatric symptoms in people with dementia.
A recent interesting study by Puyat et al, published in the Canadian Journal of Psychiatry looked at administrative data on essential use of antipsychotics to treat schizophrenia and also the potentially inappropriate use of antipsychotics in people with dementia across income groups.
A summary of the study relating specifically to the dementia cohort (Evidence-Based Mental Health, Feb 2013) concluded that potentially inappropriate antipsychotic use is more prevalent in nursing homes, and in lower-income households.
This study looked retrospectively at the de-identified administrative records of a patient population in British Columbia, Canada. It analysed the relationship between potentially inappropriate antipsychotic use and household income.
The dementia study cohort comprised 33,633 adults over 65 living who had been given a diagnosis of dementia in 2004 or 2005. 23% of these people were living in long-term care facilities. The observation period for prescription drug use was the calendar year 2005.
Income-related differences in antipsychotic use was assessed using logistic regression, controlling for health and sociodemographic characteristics known to influence medicine use.
23% (7,736) of this cohort had been prescribed antipsychotics for up to 90 days which defined potentially inappropriate use. Of these, 14% (1,083) were likely to have been prescribed antipsychotics for longer than the recommended 12 weeks.
The prevalence of antipsychotic use was higher in care homes (56%) than in the community (13%). In the community setting the incidence of antipsychotic use was higher in older people from lower-income households.
The authors concluded that:
[there is] …some evidence for the potentially inappropriate use of antipsychotics which affects mostly seniors in long-term care and some seniors from low-income households
Of course, having only administrative rather than clinical data to go on, the authors can only say that the antipsychotic use was “potentially inappropriate”. But the upside of using administrative data is having it for over 33,000 people rather than the significantly smaller numbers which can be analysed in clinical studies.
Rather naughtily (well I am an Elf, after all) I applied the estimate given on the Alzheimer’s Society website that two thirds of all antipsychotic prescriptions for BPSD are inappropriate. This gives a staggering figure of over 5,000 people from this cohort alone who should probably not have been prescribed antipsychotics at all.
This study is important because until now there has been very little data linking potential levels of inappropriate medication use with income, and it gives a clear indication where inappropriate prescription of antipsychotics is more likely to be happening.
If you’re feeling optimistic, you can argue that this study will help equip patient advocates, professional and informal caregivers, clinicians and organisers of care services to make more targeted efforts to reduce inappropriate use of these drugs. But the challenge of changing prescribing culture in nursing homes and poorer communities is not an easy one when the training and support for prevention and for providing non-drug treatments is currently very limited, and even more so in care settings serving poorer communities.
Puyat JH, Law MR, Wong ST, et al. The essential and potentially inappropriate use of antipsychotics across income groups: an analysis of linked administrative data. Can J Psychiatry 2012;57:488–95. [PubMed abstract]
Drugs used to relieve behavioural and psychological symptoms in dementia. Alzheimer’s Society website, Factsheet 408 (Last reviewed: Jan 2012).
Ballard CG, Waite J, Birks J. Atypical antipsychotics for aggression and psychosis in Alzheimer’s disease. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD003476. DOI: 10.1002/14651858.CD003476.pub2.
Potentially inappropriate use of antipsychotics in community dwelling adults with dementia more common in those with low income: Evidence-Based Mental Health Online First, published on February 16, 2013 doi:10.1136/eb-2012-101180 [Abstract]