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Antipsychotics Pose New Risks for People With Dementia

Drugs are overused in nursing homes where staffing is limited, says new study

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The use of antipsychotic medications for people with dementia has gone up in recent years, even amid warnings. A new study suggests that these drugs — developed for conditions like bipolar disorder and schizophrenia, but sometimes prescribed for dementia — pose more risks to people with dementia than previously known.

In people ages 50 and older with dementia, taking antipsychotics more than doubled the risk of pneumonia, the most common cause of death in people with dementia. And along with the known threat of stroke, the drugs increased the risk of acute kidney injury, blood clots, bone fracture, heart attack and heart failure.

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Risks are greatest in the first week after patients started antipsychotic medications, according to the study, reported by U.K. researchers in BMJ on April 17. The team analyzed health records of nearly 174,000 people in the United Kingdom diagnosed with dementia from January 1998 to May 2018. About two-thirds were women, and their average age at diagnosis was 82.

The drugs risperidone, haloperidol, quetiapine and olanzapine accounted for close to 80 percent of the antipsychotic prescriptions in the study.

About 4.5 percent of people with dementia developed pneumonia during the first 90 days of antipsychotic use, and 10 percent developed pneumonia within the first year. Those rates were two to three times higher than in similar patients not prescribed antipsychotics.

Prescriptions on the rise

Researchers and regulators have been concerned about the risks of antipsychotic medication in dementia patients for decades, particularly after studies found that antipsychotic drugs increase the risk of death.

Antipsychotics increased risk in people with dementia

  • Pneumonia: 219%
  • Kidney damage: 72%
  • Blood clots: 62%
  • Stroke: 61%
  • Bone fracture: 43%
  • Heart attack: 28%
  • Heart failure: 27%

Source: The BMJ

Use of the drugs for people with dementia dipped after the Food and Drug Administration issued multiple “black box” warnings — its strictest safety warning — about antipsychotics because of the increased risk of stroke and death. But their use crept up during the early phase of the COVID-19 pandemic, when lockdowns disrupted daily routines and many people with dementia, including those in nursing homes, were unable to see loved ones.

Use of these drugs is especially high in nursing homes in neighborhoods with high poverty where staff levels are low, according to a study reported on April 24 in JAMA Network Open. Nursing homes in low-income areas with staffing levels that meet government guidelines for staffing showed no significant difference in the level of antipsychotic use as higher-income areas. “Addressing staffing deficiencies, particularly in nursing homes in disadvantaged neighborhoods, will be critical for reducing the overuse of antipsychotics,” study author Jasmine Travers, assistant professor at NYU Rory Meyers College of Nursing said in a news release.

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Antipsychotic medications were developed for people with schizophrenia and other serious mental illness, but doctors may prescribe them for people with dementia “who exhibit severe behavioral and psychological symptoms that could pose a risk to themselves or others” such as patients who are aggressive or violent or who experience hallucinations or delusions, says Raya Elfadel Kheirbek, M.D., chief of gerontology, geriatrics and palliative medicine at the University of Maryland School of Medicine, who cowrote an editorial accompanying the new study. 

Patients with dementia sometimes “become paranoid, which is a way of filling in for missing information,” Gary Small, M.D., chair of psychiatry at Hackensack University Medical Center, wrote in an email. “If the patient is constantly forgetting where they put things, they may start believing that others are stealing their things.”

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While antipsychotics can sometimes reduce these symptoms, “they should be used with extreme caution,” Small says. “When antipsychotics are used, it is best to use the minimal dose for short periods.”

Doctors should closely monitor people with dementia taking antipsychotics and watch for signs of pneumonia, particularly in older patients and those who smoke and those who have chronic respiratory disease, a history of stroke and trouble swallowing, said Kheirbek. Small listed additional underlying conditions that would rule out a person with dementia from taking antipsychotics. These include liver or kidney disease, cardiovascular disease, diabetes, Parkinson’s disease, epilepsy or stroke.


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Other options for treating agitation

Doctors should look for the underlying source of a patient’s psychological or behavioral problems, Manisha Parulekar, M.D., codirector of the Center for Memory Loss & Brain Health at Hackensack University Medical Center, wrote in an email. Behavior changes in older people can be caused by dehydration, infection, hospitalization, moving to a new residence or drug interactions. People with dementia are at greater risk of hallucinations and agitation when they’re hungry, thirsty, or in pain, if they have sleep disturbances or if they feel too hot or too cold, research shows.

People with dementia are less likely to feel agitated if they’re in a familiar environment with family and trusted caregivers, if they have a personalized care plan and if their caregivers receive support. Simple but important things like making sure that people have their eyeglasses and hearing aids can help prevent agitation.

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