Treat Dementia in Elderly Patients With Caution

What are the potential pitfalls of using antipsychotic drugs in older patients?

The population of elderly nursing home residents who have dementia has been steadily increasing. It is not unusual to be called early in these patients’ course, day or night, and be asked to prescribe something for agitation—triggered by strange new surroundings and people. Nearly 1 in 5 new nursing home residents receives an antipsychotic drug within 100 days of arrival.¹ Does this “typical” practice have a downside?

RISKS OF ANTIPSYCHOTIC AGENTS IN OLDER ADULTS

Recently, Rochon and coworkers² addressed the safety of antipsychotic drugs in an impressive cohort of older adults with dementia: 20,682 participants lived in the community and 20,559 lived in nursing homes. The cohort was further categorized as receiving no, only atypical, or only conventional antipsychotics. Atypical antipsychotics included olanzapine, quetiapine, and risperidone; conventional agents were haloperidol and loxapine. The control group consisted of persons who did not take antipsychotics. Outcomes were serious events within the first 30 days of antipsychotic administration.

Among 6894 community dwellers who received atypical antipsychotics, 13.9% had a serious event (140 experienced hospital admissions or falls with hip fractures) and 186 died. Compared with the control group, those treated with atypical antipsychotics were 3.2 times more likely to have a serious event. Community dwellers who received conventional antipsychotics were 3.8 times more likely than controls to have a serious event. For nursing home residents, the risk of a serious event was 2.4 times greater with conventional antipsychotics and 1.9 times greater with atypical drugs, compared with controls.
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These data are disturbing to say the least. Although it is true that the risk of a serious event is greater with conventional than with the more recently developed atypical antipsychotic drugs, both classes pose more risk than not treating agitation. The authors also observed the same patterns in previous studies that looked at similar as well as different symptom sets associated with antipsychotic drug use, such as parkinsonism, other movement disorders, hip fractures, and even death. The authors add that in Ontario, Canada, antipsychotics are prescribed for one-third of nursing home residents—and these agents are among the top 3 medications responsible for adverse events in nursing homes.

MEDICATION SAFETY: A KEY CONCERN IN ELDERLY PATIENTS

The Institute of Medicine’s To Err Is Human: Building a Safer Health System³ has been followed by multiple studies that show how a strong focus on medication safety can decrease potentially life-threatening errors. The use of antipsychotics to relieve agitation in older adults with dementia—who are easily sedated and neurologically compromised enough afterward to sustain falls, hip fractures, and even death from the effects of these medications—seems like an ideal setting to put the lessons of To Err Is Human into practice.