Should We be Giving Antipsychotic Drugs to the Elderly?

Recently there has been an increase in giving antipsychotic drugs to the elderly. In fact, statistics show that one quarter of Medicare beneficiaries in nursing homes are prescribed antipsychotic medications. In spite of the fact that antipsychotics should not be used to treat dementia in the absence of a psychotic disorder, only one quarter of elderly patients on antipsychotics actually have a psychotic disorder. In other words, the majority of antipsychotic prescriptions are inappropriate for elderly patients without an indication for an antipsychotic, namely hallucinations or delusion. In addition, the risk of side effects like diabetes and lipid elevations is greater in older patients using these powerful drugs. The FDA recently warned that the use of atypical antipsychotic medication doubles the risk of death in the elderly.

Some times Alzheimer's patients can experience symptoms of aggression, hallucinations, delusions, disorganized thoughts, and bizarre behavior. These symptoms may be treatable with antipsychotic medications. Antipsychotic medications should only be used in Alzheimer's patients who are psychotic. That doesn't stop them from being used, however, to try and calm down or in other ways control the Alzheimer's patient or other elderly person with a dementia condition.

The typical antipsychotic medications block the dopamine-2 receptor in the brain, which is felt to be involved in the symptoms of psychosis. Probably more importantly, antipsychotics (previously known as "major tranquilizers") are very sedating, which leads to their use in Alzheimer's patients who have agitated behavior.

The antipsychotic drugs developed for schizophrenia are actually used just as much or more in elderly patients with dementia. One study looked at all of the studies of antipsychotics for the treatment of behavioral problems in demented patients. They found data on 3353 patients randomized to antipsychotic and 1757 randomized to placebo. There was a 1.2% absolute increase in death in patients on antipsychotics. The authors concluded that antipsychotic treatment of demented patients may be associated with an increased risk of death.

The first generation of antipsychotic medications included thorazine, haloperidol, mellaril, and trilafon. These medications, however, were associated with troubling extra-pyramidal side effects, including twitching, jerking movements, and lip smacking. They also have anticholinergic side effects and may interfere with memory in the elderly.

The second generation of atypical antipsychotic meds block a range of different dopamine receptors, in addition to other receptors like the serotonin receptors. It is thought that this is the reason they are not associated with extra pyramidal side effects. The first atypical, clozaril, is associated in rare cases with agranulocytosis, a condition where the body stops making blood cells and immune cells, which is fatal. For this reason, patients on clozaril have to have their blood checked frequently, which is very inconvenient. Other atypicals include Zyprexa (olanzepine), Risperdol (risperidal), and Seroquel (quetiapine). These medications have fewer neurological side effects. These medications have not, however, been without their own problems. They can interfere with glucose metabolism, increasing the tendency to develop adult onset (Type 2) diabetes, and rarely ketoacidosis (Newcomer 2004). They also increase lipids, and cause weight gain. All of these can increase the risk of heart disease in patients on atypical antipsychotics. Increased diabetes has been seen with olanzepine (Sernyak et al 2002) and clozepine (Sernyak et al 2002) with less risk with risperidone (Sernyak et al 2002) and the typical antipsychotics. There are conflicting results for quetiapine (Sernyak et al 2002).

The risk of death when using typical antipsychotics was even higher than the risk of death with atypical antipsychotics. Risperidone and quetiapine were associated with a two-fold increase in stroke in patients with dementia. Moreover, neither quetiapine nor rivastigmine were effective for treatment of agitation in elderly demented patients, and quetiapine was associated with a more rapid cognitive decline over time compared to placebo. As I mentioned above, antipsychotic drugs should not be used to control the behavior of elderly people unless they are really suffering from psychosis (e.g. seeing or hearing things that aren't there). They have not been shown to be helpful, and they increase the risk of death.

The increased risk of stroke in elderly patients with dementia with olanzapine prompted a letter to doctors in Canada from the Canadian Drug Regulatory authorities, but no such letter was produced in the US from the FDA. Many American doctors are unaware of the risks and the recommendation not to use atypical antipsychotics for behavioral symptoms in demented elderly patients. I recommend that patients with Alzheimer's or other forms of dementia should not be given antipsychotic drugs unless they have clear forms of psychosis that meet the criteria for psychosis (e.g. seeing or hearing things that are not there, or having frank delusions, or incorrect beliefs) as outlined in the Diagnostic and Statistical Manual of Mental Disorders.

Newcomer JW (2004): Abnormalities of glucose metabolism associated with atypical antipsychotic drugs. Journal of Clinical Psychiatry 18:36-46.

Sernyak MJ, Leslie DL, Alarcon RD, Losonczy MF, Rosenheck R (2002): Association of diabetes mellitus with use of atypical neuroleptics in the treatment of schizophrenia. American Journal of Psychiatry 159:561-566.

Learn more about alternatives to medications and hidden risks of prescription medications in 'Before You Take That Pill: Why the Drug Industry May be Bad for Your Health: Risks and Side Effects You Won't Find on the Label of Commonly Prescribed Drugs, Vitamins and Supplements', by researcher and physician J. Douglas Bremner, MD.