There was a very sad article in the NYTimes about the regular practice in some long-term care facilities of treating demented patients with anti-psychotic medications like Risperdal, Seroquel and Zyprexa:
The use of antipsychotic drugs to tamp down the agitation, combative behavior and outbursts of dementia patients has soared, especially in the elderly. Sales of newer antipsychotics like Risperdal, Seroquel and Zyprexa totaled $13.1 billion in 2007, up from $4 billion in 2000, according to IMS Health, a health care information company.
Part of this increase can be traced to prescriptions in nursing homes. Researchers estimate that about a third of all nursing home patients have been given antipsychotic drugs.
The increases continue despite a drumbeat of bad publicity. A 2006 study of Alzheimer’s patients found that for most patients, antipsychotics provided no significant improvement over placebos in treating aggression and delusions.
In 2005, the Food and Drug Administration ordered that the newer drugs carry a “black box” label warning of an increased risk of death. Last week, the F.D.A. required a similar warning on the labels of older antipsychotics.
The agency has not approved marketing of these drugs for older people with dementia, but they are commonly prescribed to these patients “off label.” Several states are suing the top sellers of antipsychotics on charges of false and misleading marketing.
Ambre Morley, a spokeswoman for Janssen, the division of Johnson & Johnson that manufactures Risperdal, would not comment on the suits, but said: “As with any medication, the prescribing of a medication is up to a physician. We only promote our products for F.D.A.-approved indications.”
Nevertheless, many doctors say misuse of the drugs is widespread. “These antipsychotics can be overused and abused,” said Dr. Johnny Matson, a professor of psychology at Louisiana State University. “And there’s a lot of abuse going on in a lot of these places.”
The ostensible reason for treating demented patients — often with end-stage Alzheimer’s disease — with antipsychotics is to limit agitation and outbursts, but honestly this is sort of like treating a childhood temper-tantrum with thorazine. It is treating a soluble problem without drugs with a medicinal sledgehammer.
Now I would certainly admit that anti-psychotic medications have a place in in-patient care, particularly for patients that are paranoid or violent. However, I get the impression that for a lot of these patients whether they are paranoid or violent has not even be assessed by a physician. They are acting out, so they get hit with the heavy sedation. These drugs also have very serious side effects including movement disorders and diabetes. If these drugs are being used, it needs to be when they are addressing specific symptoms — not as an all-purpose solution.
The real problem here is that the alternative to sedating demented patients requires heavy supervision by the staff and hence large quantities of money. You can make them less agitated when you put them in more familiar environments and give them lots of quality time interacting with them, but that level of care isn’t cheap.
These drugs are being used to paper over our failure to adequate treat these patients through the end of life. I don’t have a good answer to where we are going to find the money to do a better job, but I do know that this is not a solution to that problem. You can’t just warehouse sedated old people and call it the standard of care.
As an aside, they mention used other anti-dementia drugs in the article such as Aricept, Exelon and Namenda. These drugs are cholinesterase inhibitors, and they do show positive therapeutic effects with patients who have Alzheimer’s. The article suggests that these drugs may be under-utilized. That is all fine and good, but it is important to remember that these drugs provide temporary symptomatic relief without changing the disease course. In the end, you are still going to have to deal with a patient who is very severely demented, so these drugs do not provide a long-term solution either.