Use of Antipsychotic Drugs by Elderly Primary Care Patients and the Effects of Medication Reviews: A Cross-Sectional Study in Sweden

Medications causing potential cognitive impairment are common in nursing home dementia units – A cross-sectional study

Background

With advancing age the brain becomes more sensitive to centrally acting drugs thus increasing the risk of cognitive side-effects. The Swedish National Board of Health and Welfare developed indicators to measure and follow quality in older people's drug therapy, one being “Potentially Inappropriate Medications risking Cognitive impairment (PIMcogn)”. Associations between anticholinergics and cognitive impairment are described, especially in persons with Alzheimer's disease or Lewy Body Dementia/Parkinson's disease dementia, due to degenerated cholinergic pathways.

Objectives

To examine the prevalence of PIMcogn and if it differed between nursing home residents with and without a dementia diagnosis and between residents with different dementia aetiologias.

Methods

Descriptive cross-sectional study, based on residents ≥65 years in nursing home dementia units in Malmö, Sweden, in 2012–2013 (N = 574).

Results

The study population consisted of 76% women, the mean age was 86 years and a dementia diagnosis was registered in 92%. A total of 74% were prescribed at least one PIMcogn. Benzodiazepines were prevalent in 59%, opioids in 27%, antipsychotics in 20% and anticholinergics in 13%. Opioids used regularly and antiepileptics were more common in residents without a dementia diagnosis. The lowest proportion of anticholinergics was seen in the oldest age group, 11.0%. There was no difference seen in anticholinergics between dementia types with considerable cholinergic deficit and other dementia diagnoses.

Conclusions

Treatment with at least one PIMcogn was common. Usage of benzodiazepines and antipsychotics was, despite the knowledge of alarming side-effects, high.

An awareness of the inappropriateness in prescribing anticholinergics to the oldest old seems to be apparent, but not to persons with cholinergic deficit.

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Benzodiazepine use was alarmingly high, despite the knowledge of increased risk of sedation, cognitive impairment, delirium and fall in older people.

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Antipsychotics were common in residents with dementia. This is worrying since alarming side-effects are seen in these persons and treatment effects of antipsychotics are modest in BPSD.

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An awareness of the inappropriateness in prescribing anticholinergics to the oldest old seem to be apparent, but not to persons with cholinergic deficit due to Alzheimer's disease or LBD/PDD.

Epigenetic Alterations Impact on Antipsychotic Treatment in Elderly Patients

PURPOSE OF THE REVIEW

Antipsychotics are commonly prescribed for the treatment of psychosis as well as behavioral and psychological symptoms of dementia (BPSD) in elderly patients. However, elderly patients often experience decreased antipsychotic efficacy and increased side effects, though the mechanisms underlying these changes with age are not clear.

RECENT FINDINGS

Although aging can affect drug metabolism and clearance through changes in renal and hepatic function, additional pharmacokinetic and pharmacodynamic changes due to aging-induced epigenetic alterations also impact processes important for antipsychotic function. Epigenetic mechanisms account for some of the altered efficacy and increased side effects seen in elderly patients.

SUMMARY

Both clinical and animal studies from our group and others have demonstrated a plausible epigenetic mechanism involving histone modifications that can adversely affect the efficacy of antipsychotics and increase their side effects in elderly patients. Hopefully, further investigation of this mechanism will benefit elderly patients who need treatment for psychosis and BPSD.