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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 6 of 6. This is the beginning of the thread.
Posted by jamestheyonger on December 3, 2005, at 0:15:09
http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/tb/2243?pfc=101&spc=230
BOSTON, Nov. 30 - For elderly patients, so-called conventional antipsychotic medications are more likely to cause death than the newer atypical drugs, researchers here say.
The finding comes in the wake of a "black box" warning from the FDA earlier this year that the atypical agents -- such as Zyprexa (olanzapine) and Risperdal (risperidone) -- were associated with increased mortality in elderly patients with dementia
Clinicians, Dr. Wang said in an interview, should not think that "lack of warning means lack of risk" and immediately begin switching patients off the atypical medications.
"Don't assume that either medication class is safe," he said.
In fact, the FDA's announcement of the black box warning said the agency was considering a similar warning for the older drugs, but adds the data are limited
Posted by ed_uk on December 3, 2005, at 14:51:13
In reply to Older Antipsychotic Drugs Called Risky, posted by jamestheyonger on December 3, 2005, at 0:15:09
Conventional antipsychotics as likely as atypicals to increase risk of death in elderly, study suggests
Conventional antipsychotic drugs are at least as likely as atypical antipsychotics to increase the risk of death among elderly people, according to the authors of a study published in The New England Journal of Medicine this week (2005;353:2335).The US Food and Drug Administration issued a public health advisory in April that warned that, compared with placebo, the use of atypical antipsychotics almost doubled the risk of death in elderly patients with dementia.
Philip Wang, department of psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts, and colleagues conducted an observational study with the aim of defining the risk of death among elderly patients starting treatment with conventional antipsychotics compared with those starting atypicals. They analysed data from 22,890 patients aged 65 years and over who had begun receiving a conventional or an atypical antipsychotic drug and compared risk of death within 180 days, less than 40 days, 40 to 79 days and 80 to 180 days of initiation of therapy.
Analyses that adjusted for a number of confounders showed that conventional anti-psychotics were associated with a higher risk of death than atypical antipsychotics at all intervals (<=180 days: relative risk 1.37, 95 per cent confidence interval 1.27–1.49; <40 days: RR 1.56, 1.37–1.78; 40–79 days: RR 1.37, 1.19–1.59; 80 to 180 days: RR 1.27, 1.14–1.41). The greatest increase in risk occurred with higher doses and during the first 40 days after initiation of therapy, say the researchers.
They also looked at subgroups of patients, defined by the presence or absence of dementia and residency in a nursing home, and found that the risk of death within 180 days was higher with conventional antipsychotics in all subgroups.
“On average, for every 100 patients treated with a conventional antipsychotic drug instead of an atypical agent, there would be seven additional deaths,” they say. “If confirmed, our results suggest that conventional antipsychotic medications may not be safer than atypical agents and should not simply replace atypical drugs that are stopped in response to recent FDA warnings, as may be happening.” They suggest that well defined studies specifically involving the elderly are needed to define optimal care.
Posted by med_empowered on December 3, 2005, at 16:43:03
In reply to Older Antipsychotic Drugs Called Risky, posted by jamestheyonger on December 3, 2005, at 0:15:09
I think it is usually inappropriate to "treat" elderly people with antipsychotics. Such "treatment" usually serves to make life easier for the people looking after them--not the patient themselves.
Besides, despite the bad rap benzos are given these days, they're actually pretty helpful with senile agitation and the like. Small doses of xanax, valium, klonopin, etc. can make life easier for everyone while producing fewer side effects (and less dangerous side effects, also) than the antipsychotics (both old and new). I read a disturbing anti-benzo page once that called for the use of small doses of Mellaril in the elderly instead of benzos, which apparently were created in the deepest, darkest nether-regions of Hell. Ugh. It just makes me so upset..the idea that someone could lead a useful life, raise kids, have a job, etc. and then, when you're old, some people decide you're too difficult to deal with and they load you up on antipsychotics (chemical straight jakcets) to make you more docile. Its unfair, and its immoral.
Posted by Phillipa on December 3, 2005, at 22:57:53
In reply to Re: Older Antipsychotic Drugs Called Risky, posted by med_empowered on December 3, 2005, at 16:43:03
Amen. I hated seeing haldol given to the elderly. They kept giving it to them until they could not wake up for days. Fondly, Phillipa
Posted by ed_uk on December 5, 2005, at 15:21:29
In reply to Re: Older Antipsychotic Drugs Called Risky, posted by med_empowered on December 3, 2005, at 16:43:03
In healthy elderly people, 'generalised anxiety' can be treated with SSRIs such as citalopram. Low dose of benzodiazepines can be used as a short-term treatment for severe anxiety and insomnia associated with physical disease, hospital admission etc. Short-acting benzos such as oxazepam and temazepam may be safer for elderly people - they are less likely to accumulate and to be associated with falls and confusion.
In elderly patients who suffer from dementia, paranoid delusions and severe agitation are common. Very low doses of risperidone can sometimes provide symptomatic relief eg. 0.25mg to 1.5mg/day in divided doses.
Risperidone appears to be the most appropriate pharmacological treatment for paranoid delusions and hallucinations in patients with dementia. Benzodiazepines tend to worsen confusion, frequently inducing delirium. Haloperidol was commonly used in the past eg. 0.5mg every 12 hours prn. Risperidone appears to be more effective and better tolerated than haloperidol.
Antipsychotics should never be used to control 'challenging behavior' in elderly people. In patients with demential, APs should only be used to treat distressing hallucinations, delusions and severe agitation.
Ed
Posted by med_empowered on December 7, 2005, at 2:52:31
In reply to Re: Older Antipsychotic Drugs Called Risky » med_empowered, posted by ed_uk on December 5, 2005, at 15:21:29
here in the US, there's a pretty long history of misuse/overuse of antipsychotic drugs. It isn't limited to nursing homes; recently, it was found that in Florida, lots of the foster kids and other kids under state care were on psychotropic drugs, with many of them on multi-drug combos that could prove problematic (mother jones did an interesting article on one case of this..the kid was put on haldol, zyprexa, depakote, and ativan..she was 13.)
With the emergence of the atypicals, its more acceptable to use them "off-label"...there is some use for ADHD in the US. This is troubling since lower-class children are more likely to be diagnosed as ADHD and more likely to be given only drug (not combo) treatment. I imagine low-dose Risperdal and other atyicals would be a pretty good option for elderly dementia, especially compared to haloperidol or similar old-school drugs. The problem for me is that there's a pretty ugly history of using the neuroleptics to control and subdue people, even the non-psychotic/non-mentally ill. I'm concerned that with atypicals, we could see this happening again--only since there will be less TD and less obvious EPS, it won't raise as much conern (a chemical straight jacket is still a chemical straight jacket--even if it is a more comfortable one).
This is the end of the thread.
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