A US study has found that when faced with symptoms like aggression and psychosis in patients with Alzheimer’s and similar conditions, doctors sometimes prescribe anti-psychotic medications – which, they warn, can increase the risk of cardiac problems and even death.
Alzheimer’s and other neurodegenerative conditions aren’t just diseases of the memory, but diseases of the whole mind. They lead to personality and behavioural changes that, as they progress, prove ever more challenging for caregivers.
Yet while doctors sometimes turn to anti-psychotic medications, researchers involved in the recent study – of older patients in New York – said these serious psychiatric drugs are over-prescribed and used inappropriately for off-label dementia management, reports TIME.
The data revealed that among homebound elderly patients receiving home healthcare services, those with Alzheimer’s and related dementias (ADRD) were more than twice as likely to be taking anti-psychotic medications than other elderly homecare patients, a difference the study authors say indicates over-prescription.
Anti-psychotic drugs should be last resort
Most anti-psychotic medications, including all that were included in the study, aren’t approved by the US Food and Drug Administration to treat dementia, but many physicians continue to use them anyway, making it a common off-label use of the drugs.
According to the best practices set forth by the Alzheimer’s Association, off-label antipsychotic drugs should be a last resort for the behavioural and psychological symptoms of dementia, collectively referred to as BPSD.
Caregivers and physicians are asked to first exhaust non-drug options of behavioural management, which include strategies like avoiding confrontation and ensuring that a patient gets sufficient rest.
Even then, prescribing common anti-psychotic drugs requires a careful calculation, as their use is associated with an increased risk of both heart attacks and death more broadly.
The researchers said the rate of prescriptions given to patients in their study was much higher than previously identified rates in similar cases.
More than 6 600 Medicare patients across the state of New York were included in the study, published in the Journal of the American Geriatrics Society.
The cohort included 889 subjects with Alzheimer’s and related dementias. Information recorded by nurses during home visits in 2019 revealed that 17.2% of patients diagnosed with ADRD were prescribed at least one anti-psychotic medication – despite not being diagnosed for psychosis – compared with 6.6% of non-ADRD patients.
“These medications are sometimes prescribed inappropriately for patients with dementia who are experiencing agitation or restlessness without underlying psychosis,” said the authors, led by University of Rochester Assistant Professor Jianjiao Wang.
The study isn’t the first to raise concerns about mis-prescribing anti-psychotics.
There remains a debate among geriatric psychiatrists about how these drugs can ethically be used to treat dementia patients, and whether prescribing them is “a necessary evil”, as one British researcher has written, or if they are used as chemical restraints and sedatives simply for the ease of caregivers.
It is, however, the first US specific study in more than a decade to collect real-life prescription data from a large cohort, although similar suspected over-prescription rates have been recorded in both the UK and Australia.
It is also one of the few to focus exclusively on “community-dwelling” older adults, or those living outside nursing homes – what the researchers called an “under-studied” setting for over-prescription.
Few good options for caregivers
Caring for dementia patients requires a balancing act every day: minimising the risk that an agitated patient will cause harm to themselves or others can be at odds with enabling them to still feel themselves and live independently in calmer moments.
According to the New York study, dementia patients living with ADRD who take anti-psychotics are less likely to regain the ability to engage in daily activities – known to slow the progression of such diseases – after a health event, compared to those who don’t.
Fixing the issue of over-prescription is difficult because so much of it “comes from a real sense of desperation by both clinicians and family/caregivers”, Wang and co-authors say.
“We have not had a lot of options for medications specifically to treat troublesome symptoms in dementia. The struggles experienced by family caregivers are real.”
Study details
Antipsychotic use among older patients with dementia receiving home health care services: Prevalence, predictors, and outcomes
Jinjiao Wang, Jenny. Shen, Yeates Conwell, Fang Yu, Kobi Nathan, Kathi Heffner, Yue Li, Thomas Caprio.
Published in Journal of the American Geriatrics Society on 6 September 2023
Abstract
Background
Anti-psychotic use is a safety concern among older patients in home health care (HHC), particularly for those with Alzheimer's disease and related dementias (ADRD). The objective of this study was to examine the prevalence and predictors of anti-psychotic use among older adults with and without ADRD who received HHC, and the association of antipsychotic use with outcomes among patients living with ADRD.
Methods
In this secondary analysis of adults ≥65 years receiving care from an HHC agency in New York in 2019 (N = 6684), we used data from the Outcome and Assessment Information Set, Medicare HHC claims, and home medication review results in the electronic HHC records during a 60-day HHC episode. ADRD was identified by diagnostic codes. Functional outcome was the change in the composite activities of daily living (ADL) score from HHC admission to HHC discharge (measured in 5833 patients), where a positive score means improvement and a negative score means decline. Data were analysed using logistic (predictors) and linear regression (association with outcome) analyses.
Results
The point prevalence of antipsychotic use was 17.2% and 6.6% among patients with and without ADRD, respectively. Among patients living with ADRD, predictors of antipsychotic use included having greater ADL limitations (odds ratio [OR] = 1.30, p = 0.01), taking more medications (OR = 1.04, p = 0.02), having behavioural and psychological symptoms (OR = 5.26, p = 0.002), and living alone (OR = 0.52, p = 0.06). Among patients living with ADRD, anti-psychotic use was associated with having less ADL improvement at HHC discharge (β = −0.70, p < 0.001).
Conclusions
HHC patients living with ADRD were more likely to use anti-psychotics and to experience worse functional outcomes when using anti-psychotics. Anti-psychotics should be systematically reviewed and, if contraindicated or unnecessary, de-prescribed. Efforts are needed to improve HHC patients' access to non-pharmacological interventions and to provide education for caregivers regarding behavioural approaches to manage symptoms in ADRD.
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Debate on long-term psychiatric drug use