[Psychiatrists' decision making and monitoring of antipsychotic prescription for elderly schizophrenia patients]

Identification of a Set of Patient-Related Features to Foster Safe Prescribing of Specific Antipsychotics in the Elderly With Dementia

Background: Antipsychotics (APs) are widely used to manage behavioral and psychiatric symptoms in dementia, although with a variety of adverse drug reactions. Therefore, it is important to know which patient-related features should be considered to foster a safe prescribing of these medications. Objectives: To compile and validate a set of patient-related features (PRFs) to foster safe prescribing of specific APs in the elderly with dementia; and to evaluate the feasibility of using them in clinical practice by analyzing the exhaustiveness of medical records. Method: A rapid literature review was the starting point, where PRFs were identified through a search in PubMed combined with information from the Summary of Product Characteristics (SmPCs). In the next step, a two-round e-Delphi survey was undertaken, where a total of 450 participants were invited by e-mail, including prescribers and specialists in benefit-risk assessment. Finally, a cross-sectional study was undertaken, where 100 patients were randomly extracted from the psychiatric hospital database. Outcomes were defined as the assessment of the clinical relevance and feasibility of the PRFs, and the level of exhaustiveness of these features in medical records. Data analysis was performed using univariate statistics (IBM SPSS v.23.0). Results: A total of 92 experts participated in the e-Delphi. Forty-seven PRFs obtained consensus, where 12 were applicable to haloperidol, 14 to olanzapine/risperidone, 13 to quetiapine, and 8 to aripiprazole. Age, comorbidities, and co-medications were rated as important features regardless of the prescribed drug. All PRFs were rated as always or frequently available and, if not, they were easy or partially easy to obtain. Age, comorbidities, and co-medications were always available in the medical records, whereas cognitive status (between 41.4 and 78.8%) or hepatic function (between 17.2 and 30.4%) presented a low-level of exhaustiveness. Conclusions: Even though a high number of PRFs were rated as clinically relevant, some of them were identified as frequently missing from medical records. This may suggest that medical records should be complemented with other sources (e.g., nursing and pharmacy records) to ensure a safe prescribing of APs.

The impact of antipsychotics as a risk factor for thromboembolism

Patients with schizophrenia are predisposed toward developing cardiovascular disease. Although neuroleptics affect the cardiovascular system, it is also important to consider the consequences of the disease itself such as lower physical activity due to living on disability pension, inadequate nutrition, and/or nicotine addiction, being more common among patients with schizophrenia versus the general population. All these factors combined lead to an increased risk of death caused by cardiovascular conditions in schizophrenic patients. Individuals receiving typical antipsychotic drugs have been reported to have elevated concentrations of antiphospholipid antibodies, including anticoagulants and anticardiolipin antibodies. The presence of both antibodies is associated with an increased risk for thromboembolism. It is also likely that mental illness is accompanied by increased procoagulant activity. Patients with acute psychosis have been shown to have a statistically significant increase in the concentrations of D-dimer, P-selectin, and in the expression of platelet glycoprotein IIb/IIIa receptors. Learning about causes and mechanisms of venous thromboembolism could help to reduce or neutralize the adverse effects of antipsychotic treatment and facilitate the identification of appropriate markers necessary to monitor changes and provide preventive care against hazardous and potentially fatal complications such as deep venous thrombosis and pulmonary embolism. Before atypical neuroleptic treatment is administered to hospitalized patients, all possible risk factors for thromboembolism should be considered to allow the application of lower risk drugs. Also, other preventive measures should be taken into account, including hydration, compression stockings, regular exercise of lower extremities, and low-molecular-weight heparin injections.