Pure Pedantry

Sedating the Demented

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.

Comments

  1. #1 Daniel Haszard
    June 25, 2008

    Comment spam deleted.

  2. #2 Mom77
    June 25, 2008

    Zyprexa Use by Children Zyprexa, as well as the other atypical antipsychotics, is being prescribed for children, even though this is an unapproved, off-label use.
    Eli Lilly has been charged in allegedly pushing the drug for children in more than one state. Recently a parent wrote to us about her two sons.

    She received pressure to place them on ADHD drugs as early as Head Start.Over the years, they were on a cocktail of various psychotropic drugs. At one time, they were place on Zyprexa and according to the mother more than doubled their body weight.
    A report by Dr. Cooper at Vanderbilt University states that 2.5 million children are now taking atypical antipsychotics. Over half are being given them for Attention Deficit Hyperactivity Disorder. Perhaps it is statistics like these that caused the FDA to finally require warnings on the labels of the ADHD drugs.
    The use of atypical antipsychotics for children should be banned

  3. #3 JT Young
    June 25, 2008

    The real reason that this over-sedation occurs is that nursing homes have skeleton staffs, especially at night. They want every one asleep because they don’t have the staff to deal with issues. This can also occur on weekends at poorer nusring facilities. There is a very real problem of over-sedation. I see this in my practice 2-3 times a week in the ER masked as “altered mental status”. The nurses make their rounds in the morning and can’t wake someone up and thus a visit to the ER ensues. All in the name of quiet and peace for the employees, who are over worked, uncer-staffed and underpaid.

  4. #4 themadlolscientist
    June 25, 2008

    Shades of the Thorazine Zombies in the old mental hospitals. Scary – and dangerous when you consider that elderly people can easily be overmedicated even on “normal” dosages simply because their bodies don’t eliminate the drugs as well as they did when they were younger.

    Several years ago I saw what overmedication did to my grandmother. She had been taking a dozen different meds for various physical ailments and always felt terrible. When she moved in with my parents, Mom took her to her own doctor, who nearly had a heart attack himself when he saw how much stuff Grandma was taling. He took her off all but three, and she felt better than she had in years.

  5. #5 Sandra
    June 25, 2008

    In the absence of non-medicinal therapies, what do you think about using other, less harmful sedatives like benzodiazepines? I know that they too have their risks, but considering the higher risk of tardive dyskinesia in the elderly I’m curious as to why nursing homes don’t use benzos. Any idea?

  6. #6 Don Moyer
    June 25, 2008

    Not only is this harmful, just paying attention to persons gets better results.

    Guess what: �paying attention to persons with dementia� won�t generate any campaign contributions!

  7. #7 Don Moyer
    June 25, 2008

    Not only is this harmful, just paying attention to persons gets better results.

    Guess what: “paying attention to persons with dementia” won’t generate any campaign contributions!

  8. #8 LMM
    June 25, 2008

    The use of atypical antipsychotics for children should be banned

    Hell, no. I’m an Aspie. I went on Risperdal (a *very* low dosage — a fraction of what’s given to people in psych wards) when I was sixteen, and it was the best thing that’s ever happened to me.

    I only wish I had been given it a decade sooner.

  9. #9 Raveen Shenoi
    June 25, 2008

    Not sure if you’ve already read this article but I think its something right up your alley

    http://www.newyorker.com/reporting/2008/06/30/080630fa_fact_gawande?currentPage=all

  10. #10 yogi-one
    June 26, 2008

    The problem is the blind belief in the marketplace. For some reason we have a system which assumes that the simple desire to turn a profit will cure all of societies problems.

    But it doesn’t. Having EVERYTHING, including how you care for your parents, be profit-driven, doesn’t work.

    There’s a place or markets for sure. But we have seen, contrary to the claims of the Friedman fanatics, that markets don’t self-police or clean up after themselves, that it is not inherent in markets to protect human rights or even preserve social structures such as the family, and that when turning a profit is at odds with compassion, profit wins, and human lives get thrown by the wayside.

    Having the drive for profits dominate all aspects of our lives, including our closest family relations is not good.

    We have to restructure our society in a way that reflects our actual priorities. Caring for your parents is not the same as the buying and selling of products.

  11. #11 Sarah
    April 21, 2010

    My father is temporarily in a nursing home in another state, although he normally lives here. He has been there only a week, and I can only understand 10% of what he says on the phone. He is on Seroquel 25mg, and Ativan 1mg. He normally takes NO medication, and is healthy, but was confused and up at night…so they “sedated him”.

    I told him I will get him home soon, and all he can say which is comprehensible was, “Please” and “I am NOT happy.”
    His speech is very very slow, and he is scared. So am I!!
    Help anyone.
    Any advice???