(RxWiki News) Treating and caring for patients with dementia is often difficult, and medications are seen as a way to help manage behavior. What happens when those medications may also pose health risks?
A new study from the University of Michigan Health System found that medications for dementia may increase patients' health risks. Also, the risk increased with the dose in some of these medications.
The authors of this study said doctors should be cautious in prescribing these medications to people with dementia and try other methods first.
In an interview with dailyRx News, Cindy D. Marshall, MD, medical director of the Baylor Memory Center in Dallas, detailed some of the risks of these medications.
"The FDA issued a 2005 black block warning on the use of antipsychotics in dementia patients due to mounting evidence showing increased mortality," Dr. Marshall said. "The mechanism of death is not specifically defined in the data, but typically includes cerebrovascular events (such as stroke), cardiovascular events (such as heart attack) and infections (such as pneumonia)."
Psychiatrist and study author Donovan T. Maust, MD, said in a press release, “The harms associated with using these drugs in dementia patients are clear, yet clinicians continue to use them. That’s likely because the symptoms are so distressing. These results should raise the threshold for prescribing further.”
Antidepressants, mood stabilizers and antipsychotics are often used in patients who have Alzheimer’s disease or other neurological problems. Antipsychotics are typically given to reduce hallucinations, agitation and aggressive behavior.
Some of these behaviors can be dangerous to patients and caregivers, and they can be distressing for all concerned.
This study looked at over 90,000 US veterans over the age of 65 who had dementia. Each patient was compared to a similar patient who was not taking any of these medications.
The US Food and Drug Administration had previously warned that antipsychotic medications increase the risk of heart disease and death.
This study and a recent literature review by one of the study’s authors — Helen C. Kales, MD — found that the risk of death was higher than previously thought. Dr. Kales is the head of the U-M Program for Positive Aging and Geriatric Psychiatry at the University of Michigan Health System.
Other psychiatric medications like the mood stabilizer valproic acid (brand names Depakene, Depacon, Depakote, Stavzor) also had higher risks and less benefit, according to Dr. Maust and team. With the newer and more commonly used antipsychotics, the risk increased with higher doses.
Other options are available to help manage patients who have dementia, Dr. Maust and team noted.
Dr. Kales and colleagues previously suggested using DICE: describe, investigate, create and evaluate. Caregivers describe the behavior, the doctor looks at possible causes or triggers and both work together to develop a plan to improve the situation.
Although this approach can help manage patients without the use of medications, it is more time-consuming.
"The utility of the DICE model is the collaboration between patients, caregivers and physicians," Dr. Marshall said. "The patient and caregivers collect real time information in the home or long term care setting looking for triggers or patterns of behavior. For example, the problem behaviors occur in the evening or when a patient gets out of his/her normal routine. Physicians collect this information for medical problems on a regular basis. For example if a patient complains of chest pain, the physician will ask when it started, how long it lasted, was it triggered by exertion, etc. So we’re applying the same principles to behavior."
Dr. Marshall continued, "So it’s not about using DICE instead of medications but to include environmental intervention in the treatment plan. For physicians who lack expertise in the area of environmental and behavioral interventions, collaboration with a care and support specialist at the Alzheimer’s Association may be beneficial."
Dr. Kales noted that the current health care system is not designed to pay for interventions like DICE.
“In other words, non-pharmacologic approaches will only succeed if we as a society agree to pay front-line providers for the time needed to ‘do the right thing,'” Dr. Kales said in a press release.
This study was published March 18 in JAMA Psychiatry.
Funding for this study was supplied by a National Institute of Mental Health grant and the Beeson Career Development Award Program. The National Institute on Aging, the American Federation for Aging Research, the John A. Hartford Foundation and the Atlantic Philanthropies also funded this research.
Study authors received funds from sources like Eli Lilly, Novartis, the National Institute on Aging and the Department of Veterans Affairs.
