July 8, 2008
Even short-term use of medications to fight agitation, aggression and disruptive behaviors may be hazardous to those with Alzheimer's disease, a new study reports. The findings add to growing debate about the use of antipsychotic drugs to help soothe and quiet those with dementia.
The potent drugs, like Zyprexa, Seroquel, and Risperdal, are commonly given to calm those in the more advanced stages of Alzheimer's. They are especially popular in nursing homes to help ease outbursts and problem behaviors in those with moderate to severe disease.
Researchers in Canada found that older adults with dementia who received short-term courses of antipsychotic medications were more likely to be hospitalized or die within 30 days than those those who did not receive such drugs. The occurrence of serious medical problems was higher regardless of whether patients were taking older antipsychotic medications or newer psychosis fighters. The findings were presented in the Archives of Internal Medicine, a medical journal from the American Medical Association.
The drugs in the study included newer antipsychotics like Zyprexa (which goes by the generic name olanzapine), Seroquel (quetiapine) and Risperdal (risperidone), which have been on the market for more than a decade. These medications, known as "atypical" antipsychotics, are commonly used to ease psychosis and hallucinations in people with serious psychiatric disorders like schizophrenia and bipolar disorder. They have largely replaced the use of older, "conventional" antipsychotic medications like Haldol (haloperidol) and loxapine. "Antipsychotic drugs are often used for short periods to treat agitation in clinical practice" for those with Alzheimer's disease, the authors of the study note. "They are frequently prescribed around the time of nursing home admission."
Indeed, about one in six people admitted to nursing homes are given antipsychotic medicines within their first 100 days. About 10 percent of receive only a single prescription. Given the widespread use of short-term prescriptions, the authors felt it was important to undertake a study to evaluate their safety.
What the Study Found
Researchers led by Dr. Paula A. Rochon of the Institute for Clinical Evaluative Sciences in Ontario studied more than 40,000 older adults with Alzheimer's and other forms dementia between 1997 and 2004. Half were living in a home setting, while the other half were being cared for in a nursing home.
In each group, the researchers identified one-third of study participants who were not receiving any antipsychotic medications; this subset served as controls. They were compared with another third who were receiving the newer "atypical" drugs and a final third who were receiving older psychosis-fighting medicines like Haldol, loxapine, or thioridazine.
It is the opinion of Fisher Center scientists that this study is interesting but has shortcomings. People who are given anti-psychotic drugs because they are agitated may be experiencing greater stress on average than those not prescribed such drugs. Increased stress may increase their risk of death or illness.
In addition, agitated behavior may have its own risks, including (falls or cardiovascular events like heart attacks). An alternative interpretation of this study's results is that it shows that Alzheimer's patients who are agitated are more likely to suffer additional illness and even death than those who are less agitated. Nevertheless, we feel that it is important for our readers to be informed about new research and, at the same time, be cautious about accepting all newsworthy stories as fact.
The researchers found that among those with Alzheimer's who were living in the community, those who received newer "atypical" drugs were three times more likely than those who weren't taking any antipsychotic medications to have a serious medical problem requiring hospital care within 30 days of starting the medicine. Hospital admissions were even more common in those taking an older antipsychotic drug, occurring four times more often compared to controls.
Among those who were being treated in nursing homes, those who were taking a newer antipsychotic were nearly two times more likely to require urgent hospital care or to die than those who weren't receiving any drugs. Those taking an older psychosis-fighter were nearly two-and-a-half times more likely to suffer a serious problem within 30-days of starting the medication. The researchers note that serious medical problems may be even more common than observed in this study, since they only followed patients for 30 days after they started taking a drug.
"Our results exploring serious adverse events likely identify only the 'tip of the iceberg'," the authors write. "Antipsychotic drugs should be prescribed with caution even for short-term therapy."
Patient advocates and some doctors question the use of such drugs to treat the agitation of Alzheimer's and urge wider use of non-drug treatments like counseling and other forms of therapy. Studies of their benefits have been mixed. Some research shows they may have a strong calming effect. Others have shown little benefit. As an alternative, antidepressant drugs like Prozac (other's include Celexa, Paxil and Zoloft) have been found to ease anxiety in Alzheimer's patients, and they may sometimes be superior to antipsychotic drugs and have fewer side effects.
Antipsychotic drugs may have side effects, such as insomnia, falling and increased confusion. Other studies have also suggested that the use of antipsychotic medications to treat aggression and agitation in people with Alzheimer's may increase the risk of dying. [See the article, "Broad Range of Psychosis Fighters Pose Risks in Seniors with Alzheimer's"]
These findings do not mean that you or a loved one with Alzheimer's should stop taking these drugs if your doctor has prescribed them. Rather, they are a reminder to everyone that potential drug benefits must be weighed against potential risks, and you should discuss these with your doctor.
Because behavioral problems may arise due to issues unrelated to Alzheimer's disease, it is also important to identify untreated or inadequately treated illnesses that may be contributing to agitation or distress in patients. In some cases, too high a dose of a medication can cause side effects like constipation or pain. Lack of engaging activities can likewise contribute to behavior problems in those with Alzheimer's.
In addition, it's important to note that Alzheimer's patients who have psychotic-like symptoms run a risk by not having their symptoms treated. If you or a loved one is taking these or other drugs, always follow directions carefully. In addition, let your doctor know if you experience any new or unusual symptoms.
Paula A. Rochon, MD, MPH, FRCPC; Sharon-Lise Normand, PhD; Tara Gomes, MHSc; et al: "Antipsychotic Therapy and Short-Term Serious Events in Older Adults With Dementia." Archives of Internal Medicine, Volume 168, Number 10, May 26, 2008, pages 1090-1096.