Antipsychotics In Older Adults With Dementia Associated With Serious Adverse Events And Death

Short term courses of antipsychotic medications, when given to older
adults with dimentia, are associated with a greater risk of
hospitalization and death, according to a report released on May 26,
2008 in the Archives of Internal Medicine, one of
the JAMA/Archives journals.



Antipsychotic drugs are used to treat various psychotic disorders --
some conventional examples include haloperidol or loxaprine. The
authors point out that a new generation of these drugs has been
released, but the effects of short term prescription have not yet been
ascertained. "Newer antipsychotic drugs (olanzapine, quetiapine
fumarate and
risperidone) have been on the market for more than a decade and are
commonly used to treat the behavioral and psychological symptoms of
dementia," they say. "Antipsychotic drugs are often used for short
periods to treat agitation
in clinical practice. They are frequently prescribed around the time of
nursing home admission." Approximately 17% of nursing home admission
begin a regimen of antipsychotic medications, with only 10% on a single
prescription. Given this information, they say, it is important to
evaluate the effects of short term regimens on patients.



To investigate this issue, Paula A. Rochon, M.D., M.P.H., F.R.C.P.C.,
of the Institute for Clinical Evaluative Sciences (ICES), Ontario, and
colleagues examined older adults living with dementia in the community
and in nursing homes between 1997 and 2004. In each setting, three
separate groups of equal size were identified, each differing only in
their exposure to antipsychotic medications. One group had not received
antipsychcotics, one group had been prescribed atypical or newer
antipsychotics, and the last group was prescribed conventional
psychotics. For older adults in the community, 6,894 were in each group
for a total or 20,682 patients. In the older adults with dementia
living in nursing homes, each group had 6,853 for a total of 20,559
subjects.



The medical records of each participant were examined, and hospital
admissions and death within 30 days of the initiation of therapy were
noted as serious adverse events. The team found that, in the general
community, those prescribed with nonconventional antipsychotic drugs
were more likely to experience adverse events, while those on
conventional antipsychotic drugs were even more likely. "Relative to
community-dwelling older adults with dementia who did not
receive a prescription for antipsychotic drugs, similar older adults
who did receive atypical antipsychotic drugs were three times more
likely and those who received a conventional antipsychotic drug were
almost four times more likely to experience a serious adverse event
within 30 days of starting therapy." The authors continue, noting a
similar but less pronounced trend in the nursing room group: "Relative
to nursing home residents in the control group, individuals in
the conventional antipsychotic therapy group were 2.4 times more likely
to experience a serious adverse event leading to an acute care hospital
admission or death. Those in the atypical antipsychotic group were 1.9
times more likely to experience a serious adverse event during 30 days
of follow-up."



The precise number of adverse events may be underestimated in this
study, because the length of follow-up was so short, according to the
authors. Also, often, the serious events experienced by nursing home
residents are taken care of within the facility, without hospital
admission. Additionally, when physicians notice signs of a problem
early, they may take patients off of antipsychotics. This could avoid
more serious consequences. The authors indicate that this only cements
the need for further research to this end. "Our results exploring
serious adverse events likely identify only the 'tip of the iceberg',"
they say. "Antipsychotic drugs should be prescribed with caution even
for short-term therapy."



Antipsychotic Therapy and Short-term Serious Events in Older Adults
With Dementia

Paula A. Rochon; Sharon-Lise Normand; Tara Gomes; Sudeep S. Gill;
Geoffrey M. Anderson; Magda Melo; Kathy Sykora; Lorraine Lipscombe;
Chaim M. Bell; Jerry H. Gurwitz

Arch Intern Med. 2008;168(10):1090-1096.

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Written by Anna Sophia McKenney