Managing dementia: Risks of using vs. not using atypical antipsychotics
Don’t let medicolegal concerns dictate dementia treatment, these five experts advise. Here’s what they recommend to protect patients and yourself.
A typical antipsychotics may increase mortality in older patients, as the FDA warns. Yet no proven alternatives exist to manage dementia’s behavior problems, say geriatricians interviewed by Current Psychiatry.
“I’ve had calls from psychiatrists in nursing home practices and primary care physicians,” says Sumer Verma, MD, associate professor of psychiatry, Boston University School of Medicine. “They ask, ‘Should I take everyone off atypicals?’ ‘Should I try benzodiazepines or cholinesterase inhibitors?’”
To answer these and other questions, we interviewed Dr. Verma and:
- Murray Raskind, MD, director, Alzheimer’s Disease Research Center, University of Washington, Seattle
- Pierre Tariot, MD, professor of psychiatry, University of Rochester (NY) Medical Center
- Bruce Pollock, MD, head of the division of geriatric psychiatry, University of Toronto
- Patricia Recupero, JD, MD, clinical professor of psychiatry, Brown University, Providence, RI.
This report summarizes their insights on whether to change atypical antipsychotic prescribing patterns, when to use medication to control dementia-related behaviors, and how to balance the medical risks against the benefits of controlling or preventing violent behavior.
To address prescribers’ fears about possible malpractice claims, these experts also offer advice on explaining antipsychotics’ risks to patients’ families and documenting these discussions.
Take everyone off atypicals?
In April, the Food and Drug Administration (FDA) ordered a black box on the labels of atypical antipsychotics and olanzapine-fluoxetine combination tablets stating that these agents may increase the risk of death from stroke, heart attack, or other causes in older patients (“When ‘agitation’ spells a medical problem,” Current Psychiatry, February 2005.]
Also check whether a drug the patient is taking for a medical condition—such as warfarin or digoxin—is causing anticholinergic effects. To justify using an atypical antipsychotic, “you need to be clear that behavior is a direct result of the psychosis, that the patient is acting on delusions or hallucinations,” Dr. Pollock adds.
Eliminate environmental stressors. An older patient’s difficulties with vision, hearing, and/or speech can increase his or her frustration and trigger behavior problems, Dr. Verma says.
“If I cannot hear or see well and I vaguely see lips moving but hear no sound, I assume that you are whispering about me,” Dr. Verma says. “That’s where paranoia begins. It is treated with a hearing aid, not an antipsychotic.”
Dr. Verma warns against prescribing a psychotropic to eliminate behaviors that are problematic but not dangerous. “Inappropriate voiding, being foul-mouthed, etc., can be controlled a lot of other ways than using medication.” He suggests, for example, posting large signs to help incontinent patients find the bathroom.
More-frequent visits from family members and increased attention from staff can help the patient adjust to a nursing home and decrease the risk of inappropriate behaviors, Dr. Pollock notes.
Dr. Verma urges clinicians to continue environmental manipulation after medication is started: “You still must make sure that there are no cords or rugs to trip over, the patient’s surroundings are brightly colored, and sound is appropriately modulated because of the patient’s poor hearing.”
Educating patients, families
Family members—who often make treatment decisions on an older patient’s behalf—need to understand atypical antipsychotics’ risks and benefits. Dr. Recupero recommends giving them handouts describing the medication’s action, side effects, and contraindications during the risk/benefit discussion. Document the family’s comments and apprehensions in the chart.
“A signed consent form is not a substitute for an informed consent discussion,” Dr. Recupero warns. “It is better to record that you had a comprehensive discussion and top it off with a signed consent.”
If the patient or proxy agrees to an atypical antipsychotic after the risk/benefit discussion, Dr. Recupero suggests keeping the patient on the atypical if anticipated clinical gains are realized.
If new evidence arises about risks of medications the patient is taking, be sure to discuss these risks with the patient or proxy as appropriate. “Informed consent is a process, not an event,” Dr. Recupero says.
Dosing atypicals in older patients
When prescribing antipsychotics to older patients, Dr. Verma says the adage “start low and go slow” cannot be overemphasized.
“I could be a lot more aggressive when treating a 30-year-old person with schizophrenia who is in much better metabolic health,” Dr. Verma says. “By contrast, an older person’s adaptive reserve is diminished.” Table 2 lists suggested first-line dosing strategies for managing dementia’s behavioral and psychotic symptoms, based on Dr. Verma’s clinical experience.
Dr. Verma recommends titrating more quickly for patients who are significantly distressed but more gradually for someone who is moderately stressed or agitated. “You’ve got to monitor the situation,” he says “There’s no formula for titration.” If the patient still does not respond or cannot tolerate the medication, he says, “I might switch to another atypical antipsychotic.”
Before switching, Dr. Raskind says, find out if an underlying medical condition or other medication is thwarting the antipsychotic’s efficacy. Again, check for and modify environmental triggers.
Dr. Pollock would avoid giving an atypical to a patient who recently had a heart attack or stroke but would not rule out “a small dose of an atypical” if the behavior were life-threatening.
Recommended atypical antipsychotic dosing for older patients
Most-common side effects
2.5 to 5 mg/d, depending on the patient’s body mass and frailty
2.5 mg every 2 to 3 days to 15 to 20 mg/d or therapeutic effect
Weight gain, orthostasis, sedation
25 mg every 2 to 3 days to 350 mg/d or therapeutic effect
Sedation, weight gain
0.25 mg bid
0.25 mg every 2 to 3 days to 2 to 3 mg bid or therapeutic effect
Extrapyramidal symptoms, orthostasis
* Recommended for patients with Lewy body dementia or parkinsonian movement problems.
Source: Sumer Verma, MD
Reassessing need. Dr. Pollock suggests re-evaluating the prescription every 4 months. Assess response to the medication, risk factors, and consequences of recurrent behavior problems. Consider reducing the dosage or discontinuing the atypical if the patient is stable, then monitor for relapse.
Dr. Verma, however, advocates continuing the atypical at the lowest possible dosage to maintain therapeutic effect and prevent recurrence of problem behaviors. After prescribing the atypical, he suggests waiting at least 4 weeks before reducing the dosage in patients with a history of rapid decompensation, unpredictable behavior, and extremely aggressive and dangerous episodes. Wait 1 to 3 weeks before reducing the dosage for patients who were stable before the episode. Bring the dosage back up if behavior problems resurface.
- Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia. A review of the evidence. JAMA 2005;293:596-608.
- Straus SM, Bleumink GS, Dieleman JP, et al. Antipsychotics and the risk of sudden cardiac death. Arch Intern Med 2004;164:1293-7.
- U.S. Food and Drug Administration, Center for Drug Evaluation and Research. Atypical antipsychotic drugs information. www.fda.gov/cder/drug/infopage/antipsychotics/default.htm.
Drug Brand Names
- Aripiprazole • Abilify
- Carbamazepine • Tegretol
- Citalopram • Celexa
- Divalproex • Depakote
- Eszopiclone • Lunesta
- Galantamine • Reminyl, Razadyne
- Haloperidol • Haldol
- Memantine • Namenda
- Olanzapine • Zyprexa
- Olanzapine-fluoxetine • Symbyax
- Quetiapine • Seroquel
- Risperidone • Risperdal
- Valproate • Depakene
- Zaleplon • Sonata
- Ziprasidone • Geodon
- Zolpidem • Ambien
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