When training as a geriatric medicine fellow many, many years ago, I was always taught to be rather prudent but resolute in the use of atypical neuroleptics for the treatment of behavioral problems related to dementia-associated psychosis in the elderly. I recall the recently approved medication (at the time) risperidone was, in many respects, the agent of choice — as it was seen as a “safer” alternative to more odious preparations which had been used with abandon for years (think haloperidol). It was even gamely called “vitamin R” in our treatment circles.
Fast forward a decade or so, not only do we know that for many atypicals (especially with risperidone) the side effects are major – and dependent on dose — but we are also armed with a blanket black box warning on these drugs: elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death from all causes. We have the careful analyses of multiple placebo-controlled trials that demonstrate this.
Such uses in the community now come with quality controls and regulatory mandates that allow physicians to discuss this overall risks with patient’s families and healthcare proxies (informed consent). This is a good thing, and its implementation is as important as ever today — mainly because of new data like this.
An analysis of tens of thousands of people in nursing homes in the U.S. suggests that residents who take certain antipsychotic drugs for dementia are at about double the risk of dying compared to residents not taking those specific medications.
Amazing information, especially when the investigators in this study controlled for such disparities as age, gender, and the presence of concomitant physical illness. As more patients with or without mental illness age, the use of agents like these will drive the need for a greater understanding of how to approach the treatment of psychosis in the elderly, from whatever cause; it appears that treatment considerations will one day mirror the same considerations physicians agonize over when treating much younger patients. Yet another reason more and more elderly patients are needed for pharma trials.