Doctors assail growing use of antipsychotic drugs for dementia - nytimes.com

Doctors Assail Growing Use of Antipsychotic Drugs for Dement.
http://www.nytimes.com/2008/06/24/health/24deme.html?page.
June 24, 2008
Doctors Say Medication Is Overused in DementiaBy LAURIE TARKAN Correction Appended
Ramona Lamascola thought she was losing her 88-year-old mother to dementia. Instead, shewas losing her to overmedication.
Last fall her mother, Theresa Lamascola, of the Bronx, suffering from anxiety and confusion,was put on the antipsychotic drug Risperdal. When she had trouble walking, her daughtertook her to another doctor — the younger Ms. Lamascola’s own physician — who found thatshe had unrecognized hypothyroidism, a disorder that can contribute to dementia.
Theresa Lamascola was moved to a nursing home to get these problems under control. Butthings only got worse. “My mother was screaming and out of it, drooling on herself andtwitching,” said Ms. Lamascola, a pediatric nurse. The psychiatrist in the nursing homestopped the Risperdal, which can cause twitching and vocal tics, and prescribed a sedative andtwo other antipsychotics.
“I knew the drugs were doing this to her,” her daughter said. “I told him to stop themedications and stay away from Mom.” Not until yet another doctor took Mrs. Lamascola off the drugs did she begin to improve.
The use of antipsychotic drugs to tamp down the agitation, combative behavior and outburstsof dementia patients has soared, especially in the elderly. Sales of newer antipsychotics likeRisperdal, 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 estimatethat 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’spatients found that for most patients, antipsychotics provided no significant improvementover placebos in treating aggression and delusions.
Doctors Assail Growing Use of Antipsychotic Drugs for Dement.
http://www.nytimes.com/2008/06/24/health/24deme.html?page.
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 warningon the labels of older antipsychotics.
The agency has not approved marketing of these drugs for older people with dementia, butthey are commonly prescribed to these patients “off label.” Several states are suing the topsellers of antipsychotics on charges of false and misleading marketing.
Ambre Morley, a spokeswoman for Janssen, the division of Johnson & Johnson thatmanufactures 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 forF.D.A.-approved indications.” Nevertheless, many doctors say misuse of the drugs is widespread. “These antipsychotics canbe overused and abused,” said Dr. Johnny Matson, a professor of psychology at LouisianaState University. “And there’s a lot of abuse going on in a lot of these places.” Dr. William D. Smucker, a member of the American Medical Directors Association, a group ofhealth professionals who work in nursing homes, agreed. Though the group encouragesdoctors to conduct a thorough assessment and prescribe antipsychotics only as a last resort,he said, “Many physicians are absent without leave in the nursing home and don’t take anactive role in the assessment of the patient.” Some nursing homes are trying a different approach, so-called environmental intervention.
The strategies include reducing boredom, providing intellectual and physical stimulation,exercise, calming music, bringing in pets for therapy and improving how the staff approachesand talks to dementia patients.
At the Margaret Teitz Nursing and Rehabilitation Center in Queens, social workers do lifereviews of patients to understand their interests, lifestyle and former occupations.
“I had a patient who used to be in fashion,” said Nancy Goldwasser, the director of socialservices. “So we got her fabric samples. And she’d sit and look through the books, touch thefabric, and it would calm her.” But such approaches are time consuming, they do not help all patients, they can beprohibitively expensive and they will be more difficult to provide as Alzheimer’s continues toincrease.
“Our health care system isn’t set up to address the mental, emotional and behavioralproblems of the elderly,” said Dr. Gary S. Moak, president of the American Association for Doctors Assail Growing Use of Antipsychotic Drugs for Dement.
http://www.nytimes.com/2008/06/24/health/24deme.html?page.
Nursing homes are short staffed, and insurers do not generally pay for the attentive medicalcare and hands-on psychosocial therapy that advocates recommend. It is much easier to usesedatives and antipsychotics, despite their side effects.
The first generation of antipsychotics, like Haldol, carry a significant risk of repetitivemovement disorders and sedation. Second-generation antipsychotics, also called atypicals,are more commonly prescribed because the risk of movement disorders is lower. But they,too, can cause sedation, and they contribute to weight gain and diabetes.
Used correctly, the drugs do have a role in treating some seriously demented patients, whomay be incapacitated by paranoia or are self-destructive or violent. Taking the edge off thebehavior can keep them safe and living at home, rather than in a nursing home.
If patients are prescribed an antipsychotic, it should be a very low dose for the shortest periodnecessary, said Dr. Dillip V. Jeste, a professor of psychiatry and neuroscience at the Universityof California, San Diego.
It may take a few weeks or months to control behavior. In many cases, the patient can then beweaned off of the drugs or kept at a very low dose.
Some experts say another group of medications — antidementia drugs like Aricept, Exelonand Namenda — are underused. Research shows that 10 to 20 percent of Alzheimer’s patientshad noticeable positive responses to the drugs, and 40 percent more showed some cognitiveimprovement, even if it was not noticeable to an observer.
“Sometimes, it’s enough to take the edge off the behavioral problems, so the family andpatient can live with it and you don’t expose people to much risk,” said Dr. Gary J. Kennedy,director of geriatric psychiatry at the Montefiore Medical Center in the Bronx.
Other experts cite a lack of research backing these drugs for behavioral problems.
If patients begin showing behavioral symptoms of dementia, doctors said, they should havecomplete medical and psychiatric workups first, especially if symptoms develop suddenly.
“Just because someone is 95 does not mean one should not do a workup, especially if she’sbeen healthy,” Dr. Kennedy said.
Common causes of the symptoms include ministrokes, reparable brain hemorrhage from amild bump on the head, hypothyroidism, dehydration, malnourishment, depression and sleepdisorders.
Doctors Assail Growing Use of Antipsychotic Drugs for Dement.
http://www.nytimes.com/2008/06/24/health/24deme.html?page.
Some doctors point out that simply paying attention to a nursing home patient can easedementia symptoms. They note that in randomized trials of antipsychotic drugs for dementia,30 to 60 percent of patients in the placebo groups improved.
“That’s mind boggling,” Dr. Jeste said. “These severely demented patients are not respondingto the power of suggestion. They’re responding to the attention they get when they participatein a clinical trial.
“They receive both T.L.C. and good general medical and humane care, which they did notreceive until now. That’s a sad commentary on the way we treat dementia patients.” To family members looking at a nursing home for an aging parent, experts recommendseeking out homes with low staff turnover, a high ratio of staff members to patients, andprograms with psychosocial components.
The Medicare Web site has basic information on individual homes atwww.medicare.gov/NHcompare. The National Citizens’ Coalition for Nursing Home Reform,at www.nccnhr.org, offers a consumer guide to choosing a nursing home.
If medications are necessary, a family member should communicate with the prescribingdoctor, learn the goal of each medication and be involved in making the decision.
Dr. Moak, of the psychiatry association, emphasized seeking out the doctor. Family members,he said, “often speak through the nursing staff, and that’s a huge mistake.” Family members who are not convinced that a relative is receiving the best care should get asecond opinion, as Ramona Lamascola did.
The physician she consulted, Dr. Kennedy of Montefiore, stopped her mother’s antipsychoticsand sedatives and prescribed Aricept.
“It’s not clear whether it was getting her hypothyroid and other medical issues finally undercontrol or getting rid of the offending medications,” he said. “But she had a miraculousturnaround.” Theresa Lamascola still has dementia, but she went from confinement in a wheelchair —unable to sit still and screaming out in fear — to being able to walk with help, sit peacefully,have some memory and ability to communicate, understand subtleties of conversations andeven make jokes.
Or, as her daughter put it, “I got my mother back.” Doctors Assail Growing Use of Antipsychotic Drugs for Dement.
http://www.nytimes.com/2008/06/24/health/24deme.html?page.
This article has been revised to reflect the following correction: Correction: June 25, 2008
An article on Tuesday about the use of antipsychotic drugs in dementia patients misspelled
the names of two drugs in a different class, sometimes used to treat the symptoms of
Alzheimer’s and Parkinson’s diseases. They are Exelon and Namenda, not Exalon and
Menamda.
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