You talk to him, too, about the importance of weight control and note that if his BMI increases by ≥1 point you will refer him to a nutritionist and recommend a structured exercise program. Finally, you schedule an appointment in 3 months.
Risks associated with older age and dementia
In 2010, there were 84,842 visits to US emergency departments (EDs) due to adverse drug events involving antipsychotic agents—a 110% increase since 2005. Nearly 30% of these ED visits involved patients 65 years or older.20
Among patients with dementia, use of antipsychotics has been found to dramatically increase the risk of stroke (rate ratio, 3.26 for FGAs and 5.86 for SGAs).21 The risk was greatest in the first 35 days of treatment, but persisted throughout the 175-day study period.
The rate of MI also was elevated in dementia patients (hazard ratio of 2.19 for the first 30 days of treatment, then falling to 1.15 for the first year).22 The risk of pulmonary embolism and deep vein thrombosis also rose for patients who had been on antipsychotics during the previous 24 months (odds ratio=1.32), with the highest risk within the first 90 days of treatment.23
Risk of death varies with agent and dose. Multiple studies have shown that the mortality risk associated with antipsychotics varies greatly among individual drugs, with haloperidol carrying the highest risk and quetiapine the lowest.24-26 The hazard ratio for death within the first 30 days was 3.2 for haloperidol, 1.6 for risperidone, and 1.5 for olanzapine; quetiapine had no statistically significant increase. The increased mortality risk was statistically significant only at higher doses.24
The FDA weighs in
Evidence of the elevated risk of death led the FDA to require black-box warnings on SGAs (in 2005)27 and FGAs (in 2008),28 stating that “antipsychotics are not indicated for the treatment of dementia-related psychosis.”28 More recently (in 2012), the American Geriatrics Society (AGS) published a guide on the management of NPS in patients with dementia.29 In it, the AGS acknowledges that despite FDA warnings, antipsychotics may be necessary for the treatment of NPS.
The AGS stresses the importance of nonpharmacologic interventions (eg, positive reinforcement, orientation to time and place, music, light exercise, pet therapy) as a first-line approach. If these measures fail and antipsychotics are necessary, the AGS calls for obtaining informed consent from a family member, using the lowest effective dose, and regularly attempting to wean the patient off the antipsychotic as the standard of care.28
CASE 2 › New or worsening aggressive behavior in an elderly patient with dementia requires a prompt assessment. You start with a complete medical evaluation of Ms. F, ruling out common causes of agitation such as infection, pain, constipation, and an adverse reaction to medication.
You also ask about the incidents of aggression: Does the same aide dress Ms. F daily? Does the aide introduce herself and explain what she’s about to do before attempting to dress the patient?
Next, you recommend nonpharmacologic therapies, such as calming music, participation in group activities, and pet therapy. You tell the floor nurse that if these measures fail and Ms. F’s threatening behavior continues, an antipsychotic may be considered.
Guard against abuse of antipsychotics
As antipsychotic use increases, so, too, does misuse and abuse, particularly of quetiapine. The drug has a reported street value of $3 to $8 for a 25- to 100-mg dose and is known as “quell,” “Susie-Q,” “and “baby heroin”; “Q-ball” is the name used for a combination of cocaine and quetiapine.30,31
The Drug Abuse Warning Network reported a 115% increase in ED visits related to the misuse or abuse of pharmaceuticals between 2004 and 2010.32 In 2010, 57,199 drug abuse cases—including 28,618 suicide attempts—were linked to antipsychotics.20
To optimize the benefit of antipsychotics and minimize the likelihood of abuse, ensure that every patient taking them has a clearly documented indication for an antipsychotic and a single responsible prescriber of the antipsychotic, often a psychiatrist. Your responsibilities: Schedule visits for monitoring, do a medication review to identify potential drug-drug interactions, and assess efficacy, all on a regular basis.
CASE 1 › At Mr. B’s next visit, you retest his fasting glucose (which is now 105 mg/dL) and recheck his BMI, which has climbed to 30. You tell him you will speak with his psychiatrist about his weight gain and your concern about the development of insulin resistance.
Meanwhile, you refer the patient to a nutritionist and encourage a healthy lifestyle. Because the medication has been effective, you schedule a follow-up visit in 6 weeks to see if the lifestyle interventions have been successful before consulting with the patient’s psychiatrist about a change in medication.