Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study

Initiation and Persistence of Antipsychotic Medications at Hospital Discharge Among Community-Dwelling Veterans With Dementia

OBJECTIVES

Adults with dementia are frequently prescribed antipsychotic medications despite concerns that risks outweigh benefits. Understanding conditions where antipsychotics are initially prescribed, such as hospitalization, may offer insights into reducing inappropriate use.

DESIGN, SETTING, PARTICIPANTS

Retrospective cohort study of community-dwelling veterans with dementia aged ≥68 with VA hospitalizations in 2014, using Veterans Health Administration (VA) and Medicare data.

MEASUREMENTS

The primary outcome was new outpatient antipsychotic prescription at hospital discharge. We used generalized estimating equations to study associations between antipsychotic initiation and patient, hospitalization, and facility characteristics. Among veterans with antipsychotic initiation, we used a cumulative incidence function to evaluate discontinuation in the year following hospitalization, accounting for competing risks.

RESULTS

4,719 community-dwelling veterans with dementia had VA hospitalizations in 2014; 264 (5.6%) filled new antipsychotic prescriptions at discharge. Antipsychotic initiation was associated with discharge unit (surgical vs medical, OR 0.41, 95% CI 0.19-0.87; psychiatric vs medical, OR 6.58, 95% CI 4.48-9.67), length of stay (OR 1.03/day, 95% CI 1.02-1.05), and delirium diagnosis (OR 2.61, 95% CI 1.78-3.83), but not demographic or facility characteristics. Among veterans with antipsychotic initiation, the 1-year cumulative incidence of discontinuation was 18.2% (n = 47); 15.9% (n = 42) of those who were alive and not censored remained on antipsychotics at 1 year.

CONCLUSIONS

Antipsychotic initiation at hospital discharge was uncommon among community-dwelling veterans with dementia; however, once initiated, antipsychotic persistence at 1 year was common among those who remained community-dwelling. Hospitalization is a contributor to potentially-inappropriate medications in the community, suggesting an opportunity for medication review after hospitalization.

The incidence risk of gynecological cancer by antipsychotic use: a meta-analysis of 50,402 patients

BACKGROUND

Female gynecological cancers represent a serious public health problem, with 1,398,601 new diagnoses and 671,875 deaths per year worldwide. Antipsychotics are often used in psychiatric disorders, including schizophrenia, bipolar disorder, and major depression. It is estimated that the prescription of these drugs is linked to 1,800 deaths a year in the United States, but their association with cancer remains controversial.

METHODS

We searched PubMed, Scopus, and Web of Science databases for studies reporting the correlation in the incidence risk of gynecological cancer by antipsychotic use. We used DerSimonian and Laird random-effect models to compute logit transformed odds ratio (OR) for the primary binary endpoint with 95% confidence interval (CI). Heterogeneity was assessed through effect size width along with I-squared and Tau-squared statistics. Review Manager 5.4.1. was used for statistical analyses. A p-value of < 0.05 denoted statistically significant.

RESULTS

50,402 patients were included, of whom 778 (1,54%) took antipsychotic medication for at least 1 year. 1,086 (2,15%) with ovarian cancer and 49,316 (97,85%) with endometrial cancer. Antipsychotic use (OR 1.50; 1.06 to 2.13 95% CI; p-value 0.02), hypertension (OR 1.50; 95% CI 1.06 to 2.13; p-value < 0.01), nulliparity (OR 1.98; 95% CI 1.53 to 2.57; p-value < 0.01) and multiparity (OR 0.53; 95% CI 0.41 to 0.69; p-value < 0.01) showed significantly different distributions between groups of cancer and cancer-free patients. The primary endpoint of incidence risk of gynecological cancer by antipsychotic therapy showed a statistically significant difference (OR 1.67; 95% CI 1.02 to 2.73; p-value < 0.05) against the use of antipsychotic drugs.

CONCLUSIONS

Our meta-analysis showed that the use of antipsychotic drugs increases the risk of gynecological cancers, particularly endometrial cancer. This result should be weighed against the potential effects of treatment for a balanced prescribing decision.

Federal Enforcement of Pharmaceutical Fraud under the False Claims Act, 2006-2022

CONTEXT

The False Claims Act is the US federal government's primary tool for identifying and penalizing pharmaceutical fraud. The Department of Justice uses the False Claims Act to bring civil cases against drug manufacturers that allegedly obtain improper payment from federal programs.

METHODS

The authors searched the Department of Justice website for press releases published between 2006 and 2022 that announced fraud actions brought against drug companies. They then used the World Health Organization's Anatomical Therapeutic Classification index to identify the classes of prescription drugs implicated in fraud actions.

FINDINGS

During fiscal years 2006-2022, payments by six manufacturers amounted to more than 28% of total payments made as a result of federal False Claims Act actions. Nervous system and cardiovascular drugs were the classes of medications most commonly implicated in alleged fraud. Federal officials most frequently alleged that companies improperly promoted nervous system drugs and paid kickbacks to increase revenues from cardiovascular, antineoplastic and immunomodulating, and alimentary tract and metabolism drugs.

CONCLUSIONS

Despite frequent pharmaceutical fraud settlements and penalties, incidence of alleged fraud among drug companies remains high. Alternative methods for preventing and deterring fraud could help safeguard our health systems and promote public health, and policy makers should ensure that effective fraud enforcement complements preventive public health regulation.

Using Structured Observations to Evaluate the Effects of a Personalized Music Intervention on Agitated Behaviors and Mood in Nursing Home Residents With Dementia: Results From an Embedded, Pragmatic Randomized Controlled Trial

OBJECTIVE

The objective of this research was to determine if a personalized music intervention reduced the frequency of agitated behaviors as measured by structured observations of nursing home (NH) residents with dementia.

DESIGN

The design was a parallel, cluster-randomized, controlled trial.

SETTING

The setting was 54 NH (27 intervention, 27 control) from four geographically-diverse, multifacility NH corporations.

PARTICIPANTS

The participants were 976 NH residents (483 intervention, 493 control) with Alzheimer's disease or related dementias (66% with moderate to severe symptoms); average age 80.3 years (SD: 12.3) and 25.1% were Black.

INTERVENTION

The intervention was individuals' preferred music delivered via a personalized music device.

MEASUREMENT

The measurement tool was the Agitated Behavior Mapping Instrument, which captures the frequency of 13 agitated behaviors and five mood states during 3-minute observations.

RESULTS

The results show that no verbally agitated behaviors were reported in a higher proportion of observations among residents in NHs randomized to receive the intervention compared to similar residents in NHs randomized to usual care (marginal interaction effect (MIE): 0.061, 95% CI: 0.028-0.061). Residents in NHs randomized to receive the intervention were also more likely to be observed experiencing pleasure compared to residents in usual care NHs (MIE: 0.038; 95% CI: 0.008-0.073)). There was no significant effect of the intervention on physically agitated behaviors, anger, fear, alertness, or sadness.

CONCLUSIONS

The conclusions are that personalized music may be effective at reducing verbally-agitated behaviors. Using structured observations to measure behaviors may avoid biases of staff-reported measures.

Concomitant use of hydroxyzine and haloperidol did not worsen delirium in patients with cancer: A multicenter, retrospective, observational study

OBJECTIVES

There is concern that hydroxyzine exacerbates delirium, but a recent preliminary study suggested that the combination of haloperidol and hydroxyzine was effective against delirium. This study examined whether the concomitant use of hydroxyzine and haloperidol worsened delirium in patients with cancer.

METHODS

This retrospective, observational study was conducted at 2 general hospitals in Japan. The medical records of patients with cancer who received haloperidol for delirium from July to December 2020 were reviewed. The treatments for delirium included haloperidol alone or haloperidol combined with hydroxyzine. The primary outcome was the duration from the first day of haloperidol administration to the resolution of delirium, defined as its absence for 2 consecutive days. The time to delirium resolution was analyzed to compare the haloperidol group and hydroxyzine combination group using the log-rank test with the Kaplan-Meier method. Secondary outcomes were (1) the total dose of antipsychotic medications, including those other than haloperidol (measured in chlorpromazine-equivalent doses), and (2) the frequencies of detrimental incidents during delirium, specifically falls and self-removal of drip infusion lines. The unpaired t-test and Fisher's exact test were used to analyze secondary outcomes.

RESULTS

Of 497 patients who received haloperidol, 118 (23.7%) also received hydroxyzine. No significant difference in time to delirium resolution was found between the haloperidol group and the hydroxyzine combination group (log-rank test, P = 0.631). No significant difference between groups was found in either chlorpromazine-equivalent doses or the frequency of detrimental incidents.

SIGNIFICANCE OF RESULTS

This study showed that the concomitant use of hydroxyzine and haloperidol did not worsen delirium in patients with cancer.

Overview of late-onset psychoses

BACKGROUND

Several etiologies can underlie the development of late-onset psychosis, defined by first psychotic episode after age 40 years. Late-onset psychosis is distressing to patients and caregivers, often difficult to diagnose and treat effectively, and associated with increased morbidity and mortality.

METHODS

The literature was reviewed with searches in Pubmed, MEDLINE, and the Cochrane library. Search terms included "psychosis," "delusions," hallucinations," "late onset," "secondary psychoses," "schizophrenia," bipolar disorder," "psychotic depression," "delirium," "dementia," "Alzheimer's," "Lewy body," "Parkinson's, "vascular dementia," and "frontotemporal dementia." This overview covers the epidemiology, clinical features, neurobiology, and therapeutics of late-onset psychoses.

RESULTS

Late-onset schizophrenia, delusional disorder, and psychotic depression have unique clinical characteristics. The presentation of late-onset psychosis requires investigation for underlying etiologies of "secondary" psychosis, which include neurodegenerative, metabolic, infectious, inflammatory, nutritional, endocrine, and medication toxicity. In delirium, psychosis is common but controlled evidence is lacking to support psychotropic medication use. Delusions and hallucinations are common in Alzheimer's disease, and hallucinations are common in Parkinson's disease and Lewy body dementia. Psychosis in dementia is associated with increased agitation and a poor prognosis. Although commonly used, no medications are currently approved for treating psychosis in dementia patients in the USA and nonpharmacological interventions need consideration.

CONCLUSION

The plethora of possible causes of late-onset psychosis requires accurate diagnosis, estimation of prognosis, and cautious clinical management because older adults have greater susceptibility to the adverse effects of psychotropic medications, particularly antipsychotics. Research is warranted on developing and testing efficacious and safe treatments for late-onset psychotic disorders.

Antipsychotics and Mortality in Adult and Geriatric Patients with Schizophrenia

Patients with schizophrenia have a high mortality risk, and the role of antipsychotic medications remains inconclusive. In an aging society, older patients with schizophrenia warrant increased attention. This study investigated the association of antipsychotic medication dosages with mortality in patients with schizophrenia by using data from Taiwan's National Health Insurance Research Database from 2010 to 2014. This study included 102,964 patients with schizophrenia and a subgroup of 6433 older patients in addition to an age- and sex-matched control group. The findings revealed that among patients with schizophrenia, the no antipsychotic exposure group had the highest mortality risk (3.61- and 3.37-fold higher risk for overall and cardiovascular mortality, respectively) in the age- and sex-adjusted model, followed by the high, low, and moderate exposure groups. A similar pattern was observed in the older patients with schizophrenia. High exposure to antipsychotics was associated with the highest risks of overall and cardiovascular mortality (3.01- and 2.95-fold higher risk, respectively). In conclusion, the use of antipsychotics can be beneficial for patients with schizophrenia with recommended exposure levels being low to moderate. In older patients, high antipsychotic exposure was associated with the highest mortality risk, indicating that clinicians should be cautious when administering antipsychotic medications to such patients.

Management of neuropsychiatric symptoms in dementia

PURPOSE OF REVIEW

The purpose is to review the results and clinical implications of recent studies of neuropathology in relation to neuropsychiatric symptoms (NPS) in Alzheimer's disease and related dementias, and discuss new therapeutic approaches based on evidence from clinical trials.

RECENT FINDINGS

In a large autopsy series from a national consortium, multiple neuropathologies of dementia subtypes were common and increased severity of specific NPS during life was associated with greater severity of neuropathology across diagnoses. Based on three clinical trials, brexpiprazole, which is an antipsychotic with dopamine and serotonin receptor partial agonism properties, was recently approved for the treatment of agitation in Alzheimer's dementia by the U.S. Food and Drug Administration (FDA). Its therapeutic profile indicates modest efficacy with high safety. Brexpiprazole has not been compared to other antipsychotics that are commonly prescribed to treat agitation in dementia, though none of them have been approved for this indication. Other drugs that showed positive results in Phase 2 trials are being tested in Phase 3 trials. These include cannabinoids and drug combinations that inhibit dextromethorphan metabolism peripherally, thereby increasing its bioavailability in the brain. Apathy is common in several types of dementia, and there is initial evidence that treatment with methylphenidate, a psychostimulant, may be efficacious with good tolerability.

SUMMARY

Greater understanding of the associations between NPS and dementia subtypes can improve clinical management of these disorders. In addition to the approval of brexpiprazole to treat agitation in Alzheimer's dementia, there is optimism about other medications based on ongoing clinical trials. Along with short-term improvement, altering the adverse impact on NPS on long-term prognosis remains an important challenge for the field.

A nomogram proposal for early prediction of intensive care unit admission in patients with acute antipsychotic poisoning

Background

Early identification of antipsychotic poisoned patients who may have a potential risk for intensive care unit (ICU) admission is crucial especially when resources are limited. Nomograms were previously used as a practical tool to predict prognosis and planning the treatment of some diseases including some poisoning conditions. However, they were not previously investigated in antipsychotic poisoning.

Aim

The current study aimed to construct a nomogram to predict the need for ICU admission in acute antipsychotic poisoning. Patients and methods: This 2-year study included 140 patients acutely intoxicated with antipsychotics and admitted at Tanta University Poison Control Centre throughout July 2019 to June 2021. Personal and toxicological data, findings of clinical examination and electrocardiography, as well as, results of laboratory investigations at time of admission were recorded. According to the outcome, patients were divided into ICU-admitted and ICU-not admitted groups.

Results

The results of this study provided a proposed nomogram that included five significant independent predictors for ICU admission in acute antipsychotic intoxications; the presence of seizures (OR: 31132.26[108.97-Inf]), corrected QT interval (OR: 1.04[1.01-1.09]), mean arterial blood pressure (OR: 0.83[0.70-0.92]), oxygen saturation (OR: 0.62[0.40 to 0.83)], and Glasgow Coma Scale (OR: 0.25 [0.06-0.56]).

Conclusion

It could be concluded that the developed nomogram is a promising tool for easy and rapid decision making to predict the need for ICU admission in acute antipsychotic poisoning.

Comparative Safety Analysis of Oral Antipsychotics for In-Hospital Adverse Clinical Events in Older Adults After Major Surgery : A Nationwide Cohort Study

BACKGROUND

Antipsychotics are commonly used to manage postoperative delirium. Recent studies reported that haloperidol use has declined, and atypical antipsychotic use has increased over time.

OBJECTIVE

To compare the risk for in-hospital adverse events associated with oral haloperidol, olanzapine, quetiapine, and risperidone in older patients after major surgery.

DESIGN

Retrospective cohort study.

SETTING

U.S. hospitals in the Premier Healthcare Database.

PATIENTS

17 115 patients aged 65 years and older without psychiatric disorders who were prescribed an oral antipsychotic drug after major surgery from 2009 to 2018.

INTERVENTIONS

Haloperidol (≤4 mg on the day of initiation), olanzapine (≤10 mg), quetiapine (≤150 mg), and risperidone (≤4 mg).

MEASUREMENTS

The risk ratios (RRs) for in-hospital death, cardiac arrhythmia events, pneumonia, and stroke or transient ischemic attack (TIA) were estimated after propensity score overlap weighting.

RESULTS

The weighted population had a mean age of 79.6 years, was 60.5% female, and had in-hospital death of 3.1%. Among the 4 antipsychotics, quetiapine was the most prescribed (53.0% of total exposure). There was no statistically significant difference in the risk for in-hospital death among patients treated with haloperidol (3.7%, reference group), olanzapine (2.8%; RR, 0.74 [95% CI, 0.42 to 1.27]), quetiapine (2.6%; RR, 0.70 [CI, 0.47 to 1.04]), and risperidone (3.3%; RR, 0.90 [CI, 0.53 to 1.41]). The risk for nonfatal clinical events ranged from 2.0% to 2.6% for a cardiac arrhythmia event, 4.2% to 4.6% for pneumonia, and 0.6% to 1.2% for stroke or TIA, with no statistically significant differences by treatment group.

LIMITATION

Residual confounding by delirium severity; lack of untreated group; restriction to oral low-to-moderate dose treatment.

CONCLUSION

These results suggest that atypical antipsychotics and haloperidol have similar rates of in-hospital adverse clinical events in older patients with postoperative delirium who receive an oral low-to-moderate dose antipsychotic drug.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Evaluation of Antipsychotic Reduction Efforts in Patients With Dementia in Veterans Health Administration Nursing Homes

OBJECTIVE

The Veterans Health Administration (VHA) and the Centers for Medicare and Medicaid Services (CMS) each created initiatives to reduce off-label use of antipsychotics in patients with dementia in nursing homes. Although CMS has reported antipsychotic reductions, the impact on prescribing of antipsychotic and other CNS-active medications in the VHA remains unclear. The authors evaluated national trends in antipsychotic and other CNS-active medication prescribing for nursing home patients with dementia in the VHA.

METHODS

The study sample was all veterans with dementia residing in VHA nursing homes for more than 30 days (N=35,742). Using an interrupted time-series design, the quarterly prevalences of antipsychotic, antidepressant, antiepileptic, anxiolytic, opioid, and memory medication prescribing were evaluated from FY2009 through FY2018.

RESULTS

Antipsychotic prescribing in VHA nursing homes declined from FY2009 to FY2018 (from 33.7% to 27.5%), with similar declines in anxiolytic prescribing (from 33.5% to 27.1%). During this period, prescribing of antiepileptics, antidepressants, and opioids increased significantly (antiepileptics: from 26.8% to 43.3%; antidepressants: from 56.8% to 63.4%; opioids: from 32.6% to 41.2%). Gabapentin served as the main driver of antiepileptic increases (from 11.1% to 23.5%). Increases in antidepressant prescribing included sertraline, mirtazapine, and trazodone. From FY2009 to FY2018, the overall prescribing of non-antipsychotic psychotropic medications grew from 75.0% to 81.1%.

CONCLUSIONS

Antipsychotic and anxiolytic prescribing for VHA nursing home residents with dementia declined, although overall prescribing of other psychotropic and opioid medications increased. Policies focused primarily on reducing antipsychotic use without considering use in the context of other medications may contribute to growth in alternative medication classes with even less evidence of benefit and similar risks.

Psychotropic Drug Prescription in Nursing Homes During the COVID-19 Pandemic

Background

To limit the introduction of coronavirus disease 2019 (COVID-19) into nursing homes, restrictive measures and social distancing were implemented; however, these caused an increase in affective disorders such as depression and anxiety and an alteration of the behavioral and psychological symptoms of dementia. Therefore, it is expected that prescription trends of psychotropic drugs in nursing homes during the pandemic may have changed significantly.

Objective

This study aims to compare patterns of prescribing psychotropic drugs in nursing homes during the COVID-19 pandemic to those of the pre-pandemic period.

Methods

This cross-sectional multicenter study was conducted in geriatric units and psychogeriatric units in seven nursing homes in Gipuzkoa, Spain. On 1 March, 2020, data regarding 511 residents in geriatric units and 163 in psychogeriatric units were recorded. This study examined utilization percentages for psychotropic drugs before the pandemic (April 2018–March 2020) and during the pandemic (April 2020–March 2021) in light of projected usage based on previous years. Following the Anatomical, Therapeutic, Chemical Classification System, four therapeutic groups were analyzed: antipsychotics (N05A), benzodiazepines (N05B and N05C), antidepressants (N06A), and antiepileptic drugs (N03A).

Results

In the case of geriatric units, a downward trend of prescription was reversed for antipsychotics (−0.41; 95% confidence interval [CI] −1.41, 0.60). Benzodiazepine use also decreased less than expected (−2.00; 95% CI −3.00, −1.00). Antidepressant use increased more than predicted (0.02; 95% CI −0.97, 1.01), as did antiepileptic drug use (2.93; 95% CI 2.27, 3.60). In the psychogeriatric units, the drop in antipsychotic utilization was less than expected (−2.31; 95% CI −3.68, −0.93). Although it was expected that the prescription of benzodiazepines would decrease, usage remained roughly the same (−0.28; 95% CI −2.40, 2.34). Utilization of antidepressants (8.57; 95% CI 6.89, 10.24) and antiepileptic drugs (6.10; 95% CI 3.20, 9.00) increased significantly, which was expected, based on the forecast.

Conclusions

For all categories, usage of psychotropic drugs was higher than anticipated based on the forecast; this increase might be related to the worsening of emotional and behavioral disorders caused by the restrictive measures of the COVID-19 pandemic.

A retrospective comparison of haloperidol and hydroxyzine combination therapy with haloperidol alone in the treatment of overactive delirium

BACKGROUND

For the treatment of delirium, antipsychotics such as haloperidol are used as standard treatments. However, haloperidol has a little sedative effect and may not be sufficiently effective in controlling overactive delirium. Hydroxyzine, an antihistamine, may be used in combination with haloperidol to supplement its sedative effect. The aim of this study was to investigate the effect of haloperidol alone or in combination with hydroxyzine on the improvement of overactive delirium retrospectively.

METHOD

Delirium was assessed from medical records using the Intensive Care Delirium Screening Checklist (ICDSC). The number of patients and days with an ICDSC score of < 4, indicating an absence of delirium after haloperidol alone or haloperidol and hydroxyzine was surveyed for 6 days.

RESULTS

A total of 157 patients were diagnosed with delirium from April 2019 to July 2021, of which 18 patients received haloperidol alone, and 21 patients received the combination of haloperidol and hydroxyzine for overactive delirium. The number of patients with a mean ICDSC score of < 4 on days 1-6 was two patients (11%) in the haloperidol groups and two patients (10%) in the combination of haloperidol and hydroxyzine group (P = 0.999). The days within < 4 of the ICDSC score on days 1-6 were 0.8 (1.3) and 0.8 (1.5), respectively (P = 0.848).

CONCLUSION

Haloperidol alone and haloperidol plus hydroxyzine are both effective in the treatment of overactive delirium. However, the concomitant use of hydroxyzine with haloperidol may not improve the efficacy of treatment of overactive delirium compared to haloperidol alone.

Increased risk of death compared to other antipsychotics in elderly clozapine users in Poland

Clozapine can cause severe adverse effects. Few epidemiologic studies have considered the effect of clozapine use in elderly patients. The aim of this study was to assess mortality in elderly patients treated with clozapine in comparison to patients treated with first- or second-generation antipsychotics. We conducted a retrospective cohort study involving 26 639 patients who were 65 years of age or older and were receiving antipsychotic medication between 2008 and 2012. Cox proportional-hazards models were used to compare the risk of death between different groups of antipsychotics after controlling for age, sex, concomitant treatment with cardiovascular or metabolic medications. The use of antipsychotic medications other than clozapine was associated with a lower adjusted risk of death [hazard ratio, 0.89; 95% confidence interval (95% CI), 0.79-0.99]. The use of cardiac and antilipemic but not antidiabetic drugs was associated with a significantly lower risk of death in this population (hazard ratio, 0.88; 95% CI, 0.83-0.93; hazard ratio, 0.66; 95% CI, 0.58-0.75 and hazarad ratio, 1.09; 95% CI, 0.96-1.24, respectively). These results suggest that clozapine is associated with an increased risk of death in the elderly. Although the study was based on administrative records linkage, its results suggest that attention should be paid to patients taking antipsychotics.

Medicare claims analysis of agents used to manage dementia-related psychosis: a treatment pattern study

Currently, no agents are approved in the USA to treat dementia-related psychosis. After failure of a nonpharmacologic approach to treatment, antipsychotics or divalproex is often prescribed. We characterized existing treatment patterns in patients with dementia-related psychosis. Medicare claims data from 2008 to 2016 were used to identify patients with dementia-related psychosis. The agents and associated dosages prescribed, time to first use, and patterns of use were evaluated for agents prescribed to treat dementia-related psychosis. In total, 49 509 patients were identified as having dementia-related psychosis. Over three-quarters (76.8%) received an antipsychotic or divalproex. The most prescribed first-line agents were quetiapine (30.5%), risperidone (19.5%), and divalproex (11.2%). More than 80% of patients received a low dose of an agent, and 65.5% switched or discontinued their first-line treatment during a mean follow-up period of 1.8 years. In the absence of US FDA-approved therapies to treat dementia-related psychosis, treatment after behavioral intervention involves frequent use of low-dose antipsychotics or divalproex. The high rate of treatment switching or discontinuation is consistent with current treatment guidelines and suggests a need for an improved, standardized pharmacological approach to treat dementia-related psychosis.

Dopamine Neuron Challenge Test for early detection of Parkinson's disease

Diagnosing Parkinson's disease (PD) before the clinical onset proves difficult because the hallmark PD symptoms do not manifest until more than 60% of dopamine neurons in the substantia nigra pars compacta have been lost. Here we show that, by evoking a transient dopamine release and subsequently measuring the levels of dopamine metabolites in the cerebrospinal fluid and plasma, a hypodopaminergic state can be revealed when less than 30% of dopamine neurons are lost in mouse PD models. These findings may lead to sensitive and practical screening and diagnostic tests for detecting early PD in the high-risk population.

A Novel Approach to the Treatment and Prevention of Alzheimer's Disease Based on the Pathology and Microbiology

Utilizing the pathology and microbiology found in tissue from patients with documented Alzheimer's disease (AD), the pathogenesis of this fateful disorder has been made clear. Borrelia burgdorferi and Treponema denticola spirochetes enter the brain, mostly via neuronal pathways and the entorhinal circulation. These organisms easily pass through the blood-brain barrier and have an affinity for neural tissue. Once in the brain, the spirochetes make intra- and extracellular biofilms, and it is the biofilms that create the pathology. Specifically, it is the intracellular biofilms that are ultimately responsible for neurofibrillary tangles and dendritic disintegration. The extracellular biofilms are responsible for the inflammation that initially is generated by the first responder, Toll-like receptor 2. The hypothesis that arises from this work is two-pronged: one is related to prevention; the other to treatment. Regarding prevention, it is very likely possible that AD could be prevented by periodic administration of penicillin (PCN), which would kill the spirochetes before they made biofilms; this would prevent the disease and would not allow any of the above deleterious changes generated by the biofilms to occur. As regards treatment, it may be possible to slow or prevent further decline in early AD by administration of PCN together with a biofilm disperser. The disperser would disrupt the biofilm coating and enable the PCN to kill the spirochetes. This protocol could be administered in a trial with the control arm utilizing the current treatment. The progress of the treatment could be evaluated by one of the current blood tests that is semi-quantitative. The specific protocols are listed.

Mortality Risk of Antipsychotic Augmentation for Adult Depression

(Reprinted with permission from PLOS ONE 2020).

Multidisciplinary pharmacotherapy collaboration for home-based older adults with dementia: a study focusing on physicians, pharmacists, and nursing professionals

BACKGROUND

It is imperative that a team consisting of a physician, pharmacist, and nursing professional provides pharmacotherapy support to achieve the optimal effect of pharmacotherapy for older adults with dementia. This study reviewed Japanese publications on the process of pharmacotherapy support practised by various professionals for home-based older adults with dementia and investigated healthcare professionals' perceived importance and practice of pharmacotherapy support.

METHODS

This study aimed to shed light on basic pharmacotherapy support for behavioural and psychological symptoms among home-based older adults with dementia using multidisciplinary collaboration, through a literature review of Japanese publications. Based on the literature review, 13 items pertaining to basic pharmacotherapy support for home-based older adults with dementia were extracted. A mail-based, self-administered, anonymous questionnaire survey was conducted with professionals including physicians, pharmacists, and nursing professionals who provide pharmacotherapy support to home-based older adults with dementia. Participants rated 13 items on their perceived importance and practice of basic pharmacotherapy support using a four-point Likert scale.

RESULTS

The results indicated that participants recognised the importance of all 13 items. At least 80% of all professionals indicated that they practised seven out of 13 items. Less than 80% of all professionals indicated they practised the other six items that should be provided after the commencement of pharmacotherapy. A relatively high proportion of nursing professionals (70%) indicated they practised the remaining six items. The 13 items were indeed deemed important for characterising pharmacotherapy support. However, in Japan, suboptimal support is provided following the commencement of medication. This may be because appropriate modifications to dementia care are not made as the patient's condition progresses.

CONCLUSIONS

It is suggested that multidisciplinary collaboration focusing on the progression of dementia and the process of pharmacotherapy, especially after the commencement of pharmacotherapy, may help provide effective, continuous pharmacotherapy.

Greater than the Sum: Applying Daily-Dose Equivalents to Antipsychotic Prescription Claims to Study Real-World Effects

Traditional methods to standardize exposures in pharmacoepidemiologic studies, like defined daily-doses, may be inadequate to capture drug class effects when there are many in-class medications, formulations, and administration routes. Antipsychotic medications are one example of a drug class with these complexities. Direct dose conversion methods are pharmacologically-based but often overlooked, potentially for lack of real-world guidance and examples of their implementation. The purpose of this article is to describe a method to implement dose conversion, using an example study that quantifies antipsychotic use among a cohort of older adults with dementia. We identified 45,442 older adults (aged ≥66 years) with dementia initiating antipsychotic therapy between January 1, 2009 and December 31, 2012 in Ontario, Canada using linked administrative healthcare databases. We developed and applied a data cleaning and dose conversion algorithm to quantify antipsychotic exposure in chlorpromazine dose equivalents at initiation, month 6, and month 12 of therapy. Results were stratified by route of administration. At initiation, 14% of patients received multiple antipsychotic prescriptions simultaneously. Patients initiating regular injectable and multiple administration routes received the highest median chlorpromazine equivalent daily-doses. Data cleaning changed 3, 16, 36, and 42% of total equivalent daily-doses in patients initiating oral, regular injectable, long-acting injectable, and multiple administration routes, respectively. Dose conversion of prescription claims data was a feasible method to quantify and present antipsychotic drug exposures. Dose conversion methods can be considered for drug effects studies of antipsychotic therapies and other medication classes with complex use.

Effects of a novel M4 muscarinic positive allosteric modulator on behavior and cognitive deficits relevant to Alzheimer's disease and schizophrenia in rhesus monkey

Alzheimer's disease (AD) is a profoundly debilitating neurodegenerative disorder characterized most notably by progressive cognitive decline, but also agitation and behavioral disturbances that are extremely disruptive to patient and caregiver. Current pharmacological treatments for these symptoms have limited efficacy and significant side effects. We have recently reported the discovery of Compound 24, an M4 positive allosteric modulator (PAM) that is potent, highly selective, and devoid of cholinergic-like side effects in rats. In order to further evaluate the translatability of the effects of compound 24 in primates, here we describe the effect of Compound 24 on three behavioral and cognition assays in rhesus monkeys, the stimulant induced motor activity (SIMA) assay, the object retrieval detour task (ORD), and the visuo-spatial paired-associates learning (vsPAL) task. As far as we know, this is the first such characterization of an M4 PAM in non-human primate. Compound 24 and the clinical standard olanzapine attenuated amphetamine induced hyperactivity to a similar degree. In addition, Compound 24 demonstrated procognitive effects in scopolamine-impaired ORD and vsPAL, and these effects were of similar magnitude to donepezil. These findings suggest that M4 PAMs may be beneficial to diseases such as Alzheimer's disease and schizophrenia, which are marked by behavioral disturbances as well as deficits in cognitive function.

Non-ketotic Hyperglycemia Chorea-Ballismus and Intracerebral Hemorrhage: A Case Report and Literature Review

Non-ketotic hyperglycemia chorea-ballismus (NKH-CB) is a rare metabolical syndrome secondary to the hyperglycemic condition, which is characterized by a triad of acute or subacute hemichorea-hemiballismus, hyperglycemic state, and unique abnormalities limited to the striatum on neuroimaging. Several related case studies on this disorder have been reported previously, but NKH-CB had never been associated with intracerebral hemorrhage (ICH). Herein, we report an uncommon case of NKH-CB and ICH that occurred simultaneously in one patient, which provides a challenge for clinicians in making a correct diagnosis. An 88-year-old woman with a long-term history of poor-controlled type 2 diabetes mellitus and hypertension, who presented with a sudden-onset headache, restlessness, severe bilateral choreiform and ballistic movements, elevated levels of glucose and osmolality in the serum, an increased white blood cell count, and two-type hyperdense signs on CT imaging, was finally diagnosed with NKH-CB and ICH. Despite administrated active treatments, the patient's clinical status did not improve and ultimately passed away. This case is reported to remind clinicians to consider the possibility of NKH-CB when patients present sudden-onset choreiform and ballistic movements. It is also the first entity with two-type hyperdense signs on CT imaging simultaneously, which helps us distinguish NKH-CB from ICH more intuitively.

Discharge from hospital with newly administered antipsychotics after intensive care unit delirium - Incidence and contributing factors

PURPOSE

Delirium in the intensive care unit (ICU) is often treated with haloperidol or atypical antipsychotics. Antipsychotic treatment can lead to severe adverse effects and excess mortality. After initiation in the ICU, patients are at risk of having their antipsychotics continued unnecessarily at ICU and hospital discharge. This study aims to determine the incidence of, and risk factors for antipsychotic continuation at hospital discharge after ICU delirium.

METHODS

This retrospective observational study was performed in a tertiary care center. Adult patients who received antipsychotics for ICU delirium during 2016 were included. Data was extracted from patient records. After univariate testing, a multivariate binary logistic regression model was used to identify independent risk factors for antipsychotic continuation.

RESULTS

A total of 196 patients were included, of which 104 (53.1%) and 41 (20.9%) had their antipsychotics continued at ICU and hospital discharge respectively. Medical ICU admission (odds ratio [95% confidence interval] 2.97 [1.37-6.41]) and quetiapine treatment (5.81 [1.63-20.83]) were independently associated with antipsychotic continuation at hospital discharge.

CONCLUSIONS

Approximately one in five patients were discharged from the hospital with continued antipsychotics. Hospital policies should implement strategies for systematic antipsychotic tapering and better follow-up of antipsychotics at transitions of care.

Oral quetiapine treatment results in time-dependent alterations of recognition memory and brain-derived neurotrophic factor-related signaling molecules in the hippocampus of rats

Antipsychotic drugs (APDs) have a variety of important therapeutic applications for neuropsychiatric disorders. However, they are routinely prescribed off-label across all age categories, a controversial practice given their potential for producing metabolic and extrapyramidal side effects. Evidence also suggests that chronic treatment with some APDs may lead to impairments in cognition and decreases in brain volume, although these findings are controversial. The purpose of the studies described here was to evaluate one of the most commonly prescribed APDs, quetiapine, for chronic effects on recognition memory, brain-derived neurotrophic factor (BDNF), its precursor proBDNF, as well as relevant downstream signaling molecules that are known to influence neuronal plasticity and cognition. Multiple cohorts of adult rats were treated with quetiapine (25.0 mg/kg/day) for 30 or 90 days in their drinking water then evaluated for drug effects on motor function in a catalepsy assessment, recognition memory in a spontaneous novel object recognition (NOR) task, and BDNF-related signaling molecules in the post mortem hippocampus via Western Blot. The results indicated that oral quetiapine at a dose that did not induce catalepsy, led to time-dependent impairments in NOR performance, increases in the proBDNF/BDNF ratio, and decreases in Akt and CREB phosphorylation in the hippocampus. These results indicate that chronic treatment with quetiapine has the potential to adversely affect recognition memory and neurotrophin-related signaling molecules that support synaptic plasticity and cognitive function. Given the widespread use this APD across multiple conditions and patient populations, such long-term effects observed in animals should be considered.

The systemic inflammatory response syndrome in acute antipsychotic poisoning

The purpose of this study was to investigate the mutual effect of systemic inflammatory response syndrome (SIRS) accompanied with fibrinolysis, endotoxemia, and coagulation in severe cases of antipsychotic poisoning. A total of 199 patients were examined, of which 71 were men and 128 were women. The age of the patients was from 22 to 63 years, (45.3 ± 6.1 years on average). According to the results of the course of therapy, the patients were divided into two groups. In the blood plasma, the content of C-reactive protein, fibrinogen and its proteolysis products (oligopeptides, D-dimers), interleukin-6 were determined. In the first 1 to 3 days, in group 1, the level of interleukin-6 decreased and approached the normal level (P ≤ .05). The opposite trend continued throughout the observation of patients from group 2-their levels of interleukin-6 increased day by day (P ≤ .05). The concentration of D-dimer already in 1 day after admission to intensive care in patients from group 2 exceeded the norm by 14 times (P ≤ .05). The level of D-dimer correlated with the level of oligopeptides in blood plasma upon admission, as well as for 3 and 5 days after admission to intensive care: 0.36, 0.76 at P ≤ .05, 0.94 at P ≤ .01, respectively. Similar correlations were obtained for the content of oligopeptides in urine and the level of D-dimer: 0.55, 0.85 at P ≤ .05, 0.93 at P ≤ .01. In this regard, the most pronounced correlation is that between the SIRS score, plasma D-dimer level, and the plasma level of the D-dimer derivatives, oligopeptides.

Mortality risk of antipsychotic augmentation for adult depression

Importance

Randomized controlled trials have demonstrated increased all-cause mortality in elderly patients with dementia treated with newer antipsychotics. It is unknown whether this risk generalizes to non-elderly adults using newer antipsychotics as augmentation treatment for depression.

Objective

This study examined all-cause mortality risk of newer antipsychotic augmentation for adult depression.

Design

Population-based new-user/active comparator cohort study.

Setting

National healthcare claims data from the US Medicaid program from 2001–2010 linked to the National Death Index.

Participants

Non-elderly adults (25–64 years) diagnosed with depression who after ≥3 months of antidepressant monotherapy initiated either augmentation with a newer antipsychotic or with a second antidepressant. Patients with alternative indications for antipsychotic medications, such as schizophrenia, psychotic depression, or bipolar disorder, were excluded.

Exposure

Augmentation treatment for depression with a newer antipsychotic or with a second antidepressant.

Main outcome

All-cause mortality during study follow-up ascertained from the National Death Index.

Results

The analytic cohort included 39,582 patients (female = 78.5%, mean age = 44.5 years) who initiated augmentation with a newer antipsychotic (n = 22,410; 40% = quetiapine, 21% = risperidone, 17% = aripiprazole, 16% = olanzapine) or with a second antidepressant (n = 17,172). The median chlorpromazine equivalent starting dose for all newer antipsychotics was 68mg/d, increasing to 100 mg/d during follow-up. Altogether, 153 patients died during 13,328 person-years of follow-up (newer antipsychotic augmentation: n = 105, follow-up = 7,601 person-years, mortality rate = 138.1/10,000 person-years; antidepressant augmentation: n = 48, follow-up = 5,727 person-years, mortality rate = 83.8/10,000 person-years). An adjusted hazard ratio of 1.45 (95% confidence interval, 1.02 to 2.06) indicated increased all-cause mortality risk for newer antipsychotic augmentation compared to antidepressant augmentation (risk difference = 37.7 (95%CI, 1.7 to 88.8) per 10,000 person-years). Results were robust across several sensitivity analyses.

Conclusion

Augmentation with newer antipsychotics in non-elderly patients with depression was associated with increased mortality risk compared with adding a second antidepressant. Though these findings require replication and cannot prove causality, physicians managing adults with depression should be aware of this potential for increased mortality associated with newer antipsychotic augmentation.

Trends in Antipsychotic and Mood Stabilizer Prescribing in Long-Term Care in the U.S.: 2011-2014

OBJECTIVE

The Centers for Medicare and Medicaid Services' National Partnership to Improve Dementia Care in Nursing Homes focuses on but is not limited to long-term care (LTC) residents with dementia; the potential impact on residents with other diagnoses is unclear. We sought to determine whether resident subpopulations experienced changes in antipsychotic and mood stabilizer prescribing.

DESIGN

Repeated cross-sectional analysis of a 20% Medicare sample, 2011-2014.

SETTING AND PARTICIPANT

Fee-for-service Medicare beneficiaries with Part D coverage in LTC (n = 562,485) and a secondary analysis limited to persons with depression or bipolar disorder (n = 139,071).

METHODS

Main outcome was quarterly predicted probability of treatment with an antipsychotic or mood stabilizer.

RESULTS

From 2011 to 2014, the adjusted predicted probability (APP) of antipsychotic treatment fell from 0.120 [95% confidence interval (CI) 0.119-0.121] to 0.100 (95% CI 0.099-0.101; P < .001). Use decreased for all age, sex, and racial/ethnic groups; the decline was larger for persons with dementia (P < .001). The APP of mood stabilizer use grew from 0.140 (95% CI 0.139-0.141) to 0.185 (95% CI 0.184-0.186), growth slightly larger among persons without dementia (P < .001). Among persons with depression or bipolar disorder, the APP of antipsychotic treatment increased from 0.081 (95% CI 0.079-0.082) to 0.087 (95% CI 0.085-0.088; P < .001); APP of mood stabilizer treatment grew more, from 0.193 (95% CI 0.190-0.196) to 0.251 (0.248-0.253; P < .001). Quetiapine was the most commonly prescribed antipsychotic. The most widely prescribed mood stabilizer was gabapentin, prescribed to 70.5% of those who received a mood stabilizer by the end of 2014.

CONCLUSIONS AND IMPLICATIONS

The likelihood of antipsychotic and mood stabilizer treatment did not decline for residents with depression or bipolar disorder, for whom such prescribing may be appropriate but who were not excluded from the Partnership's antipsychotic quality measure. Growth in mood stabilizer use was widespread, and largely driven by growth in gabapentin prescribing.

Association Between Antipsychotics and All-Cause Mortality Among Community-Dwelling Older Adults

BACKGROUND

Antipsychotics are prescribed to treat various symptoms in older adults, however, their safety in this context has not been fully evaluated. The objective was to evaluate mortality risks associated with off-label use of antipsychotics among older adults with no preexisting mental illness or dementia relative to those with diagnosis of dementia.

METHODS

Data (2007-2015) were derived from Department of Veterans Affairs registries for 730,226 patients (≥65 years) with no baseline serious mental illness, dementia). We estimated the cumulative incidence of antipsychotics prescription and 10-year all-cause mortality. The extended Cox models were used to estimate Hazard Ratios (HRs) associated with antipsychotics prescription, adjusted for time-varying covariates, dementia diagnosis, comorbidity index score, and age at time of first exposure to antipsychotics.

RESULTS

The study included 98% males, 13% African Americans, and 81% Caucasian. Patients with dementia and antipsychotics had the highest risk of mortality (78.0%), followed by (73.0%) for patients with dementia alone and compared with patients without dementia or antipsychotics exposure who had the lowest mortality risk (42.0%). Exposure to typical antipsychotics was associated with (HR: 2.1, confidence interval [CI] 2.0-2.2) compared with atypical antipsychotics (HR: 1.5, CI 1.4-1.5, p = <.0001).

CONCLUSION

In a large cohort of older adults, antipsychotics were associated with an increased risk of all-cause mortality. While significant increase in mortality was attributable to the diagnosis of dementia, the addition of antipsychotics resulted in added mortality risk among all patients. Antipsychotic medications should be used cautiously in all older adults, not only those with dementia.

A Canadian Cohort Study to Evaluate the Outcomes Associated with a Multicenter Initiative to Reduce Antipsychotic Use in Long-Term Care Homes

OBJECTIVES

To evaluate the impact of a multicenter intervention to reduce potentially inappropriate antipsychotic use in Canadian nursing homes at the individual and facility levels.

DESIGN

Longitudinal, population-based cohort study to evaluate the Canadian Foundation for Healthcare Improvement's Spreading Healthcare Innovations Initiative to reduce potentially inappropriate antipsychotic use in 6 provinces/territories.

SETTING AND PARTICIPANTS

Adults in nursing homes in 6 provinces/territories in Canada between 2014 and 2016. The sample involved 4927 residents in 45 intervention homes and 122,570 residents in 1193 control homes in the first quarter of the study.

MEASURES

Assessment data based on the Resident Assessment Instrument 2.0 were used in both settings to track antipsychotic use and to obtain risk-adjusters for a quality indicator on potentially inappropriate use.

INTERVENTION

Quality improvement teams in participating organizations were provided with education, training, and support to implement localized strategies intended to reduce antipsychotic medication use in residents without diagnosis of psychosis.

RESULTS

At the resident level, we found that the odds of remaining on potentially inappropriate antipsychotics were 0.75 in intervention compared with control homes after adjusting for age, sex, aggressive behavior, and cognition. These findings were evident within the pooled Canadian data as well as within provinces. At the facility level, the intervention homes had greater improvements in risk-adjusted quality indicator performance than the control homes, and this was true for the worst, median, and best-performing homes at baseline. There was no major change in the quality indicator for worsening of behavior symptoms.

CONCLUSIONS/IMPLICATIONS

The Canadian Foundation for Healthcare Improvement intervention was associated with a reduction in potentially inappropriate antipsychotic use at both the individual and facility levels of analysis. This improvement in performance was independent of secular trends toward reduced antipsychotic use in participating provinces. This suggests that substantial improvements in medication use may be achieved through targeted, collaborative quality improvement initiatives in long-term care.

Psychotropic drug use in residents with dementia living in small-scaled special care facilities; a longitudinal study

Objectives: Over the past decade, a trend has been noticed in the Netherlands to replace large-scaled special care units (SCUs) caring for 20-30 residents with dementia by small-scaled SCUs caring for up to 8 residents. Systematic evaluations, however, have yielded a differentiated picture of the effects. As the impact on psychotropic drug use has hardly been addressed thus far, we examined the (potential) impact of psychotropic drug use when moving residents with dementia from large-scaled to small-scaled SCUs.Methods: We conducted a non-randomized, controlled study with a six-month follow-up. Among 145 residents with dementia living a large-scaled SCUs for dementia caring for 20-30 residents per unit, a total of 77 residents were moved to small-scaled SCUs caring for up to 8 residents per unit. Psychotropic drug use, classified according to the Anatomical Therapeutic Chemical Classification (ATC) system was monitored at 2 months before replacement, as well as at 3 and 6 months thereafter. Repeated measures ANOVAs were conducted for the mean Defined Daily Doses (DDDs) of both groups.Results: No significant differences between both groups in psychotropic medication use were found over a period of 8 months.Conclusion: Prescription of psychotropic drugs does not change after a transfer from a large-scaled SCU to a small-scaled SCU of patients with moderate to severe dementia.Current Controlled Trials: ISRCTN11151241.

Drug use and torsades de pointes cardiac arrhythmias in Sweden: a nationwide register-based cohort study

OBJECTIVE

To study the occurrence of torsades de pointes (TdP) ventricular tachycardia in relation to use of drugs labelled with TdP risk, using two nationwide Swedish registers.

DESIGN

Prospective register-based cohort study.

SETTING

Entire Sweden.

PARTICIPANTS

Persons aged ≥18 years prescribed and dispensed any drug classified with TdP risk during 2006-2017, according to CredibleMeds. Persons with a registered TdP diagnosis during the study period, using drugs labelled with known (TdP 1), possible (TdP 2) or conditional (TdP 3) risk at the incident of TdP were examined.

PRIMARY OUTCOME MEASURES

Occurrence of TdP in relation to exposure rates for individual drugs with TdP risk.

SECONDARY OUTCOME MEASURES

Concurrent use of more than one TdP-labelled drug in a person with a TdP diagnosis.

RESULTS

During the study period, 410 TdP cases using drugs with TdP risk labels at the incident were registered; 205 women and 205 men, mean age 74.0 and 71.5 years, respectively. Antidepressants dominated (129/410, 30%), followed by antiarrhythmics (17%). Diuretics and gastric acid-secretion inhibitors, with TdP risk related to induction of hypokalaemia or hypomagnesaemia, were used in 56% and 32% of the 410 TdP cases, respectively. Among the most used antidepressants, citalopram with known TdP 1 risk was associated with both a higher absolute number and incidence of TdP per 100 000 users (two to four times), compared with mirtazapine with possible (TdP 2), and sertraline with conditional (TdP 3) risk. Multiple risk factors, including advanced age, cardiovascular disease and treatment with more than one TdP-classified drug, were frequently observed.

CONCLUSIONS

Antidepressants followed by antiarrhythmics dominated among TdP risk drugs used by adults with TdP diagnosis, the majority being ≥65 years. TdP risk class and concomitant medication should be considered when prescribing antidepressants to older patients.

Pimavanserin: A Novel Antipsychotic With Potentials to Address an Unmet Need of Older Adults With Dementia-Related Psychosis

Dementia affects more than 40 million people worldwide. When it is accompanied by psychosis, symptom management is especially challenging. Although no drug has been approved by the US Food and Drug Administration (FDA) for psychosis in patients with dementia, atypical antipsychotics are used off-label in severe cases in patients who do not respond to non-pharmacological interventions. However, antipsychotic use in elderly patients with dementia-related psychosis (DRP) is associated with adverse reactions including motor function disorders, cognitive impairment, cerebrovascular events, and increased risk of death. In 2017, the US FDA granted breakthrough therapy designation to the new antipsychotic pimavanserin for the treatment of DRP. Topline result of the pivotal phase III HARMONY (NCT03325556) trial suggests that pimavanserin reduces the relapse of psychosis by 2.8-folds compared to placebo. This favorable result may open path for the potential approval of pimavanserin in DRP. In this review, we discuss the pharmacological activity, clinical efficacy and safety of pimavanserin as a novel atypical antipsychotic with potentials to address the unmet needs of older adults with DRP.

Effectiveness of confidential reports to physicians on their prescribing of antipsychotic medications in nursing homes

BACKGROUND

Antipsychotic medication use in nursing homes is associated with potential for harms. In Ontario, Canada, an agency of the provincial government offers nursing home physicians quarterly audit and feedback on their antipsychotic prescribing. We compared the characteristics of physicians who did and did not engage with the intervention, and assessed early changes in prescribing.

METHODS

This population-level, retrospective cohort study used linked administrative databases to track prescribing practices in nursing homes pre-intervention (baseline), immediately post-initiative (3 months), and at follow-up (6 months). Exposure variables identified whether a physician signed up to participate (or not) or viewed the feedback following sign up (or not). Differences in the proportion of days that residents received antipsychotic medications at 6 months compared to baseline by exposure(s) were assessed using a linear mixed effects regression analysis to adjust for a range of resident, physician, and nursing home factors. Benzodiazepine and statin prescribing were assessed as a balance and tracer measures, respectively.

RESULTS

Of 944 eligible physicians, 210 (22.3%) signed up to recieve the feedback report and 132 (13.9%) viewed their feedback. Physicians who signed up for feedback were more likely to have graduated from a Canadian medical school, work in urban nursing homes, and care for a larger number of residents. The clinical and functional characteristics of residents were similar across physician exposure groups. At 6 months, antipsychotic prescribing had decreased in all exposure groups. Those who viewed their feedback report had a signicantly greater reduction in antipsychotic prescribing than those who did not sign up (0.94% patient-days exposed; 95% CI 0.35 to 1.54%, p = 0.002). Trends in prescribing patterns across exposure groups for benzodiazepines and statins were not statistically significant.

INTERPRETATION

Almost a quarter of eligible physicians engaged early in a voluntary audit and feedback intervention related to antipsychotic prescribing in nursing homes. Those who viewed their feedback achieved a small but statistically significant change in prescribing, equivalent to approximately 14,000 fewer days that nursing home residents received antipsychotic medications over 6 months. This study adds to the literature regarding the role of audit and feedback interventions to improve quality of care.

Framework of treating Alzheimer’s dementia

Current treatment paradigm in Alzheimer’s disease (AD) involves multiple approaches combining pharmacological and nonpharmacological intervention to mitigate the clinical symptoms, slow the progressive loss of cognitive and functional abilities, or modify the disease course. So far, beyond anti-cholinesterase inhibitors (AChEIs), donepezil, rivastigmine, galantamine, and antagonist of N-methyl-D-aspartic acid (NMDA) receptor, there are no newly approved medicines to treat AD. Under pharmacological treatment, the personal characteristic and the intra-individual therapeutic evaluations to examine various cognitive domains, behavioral and psychological problems, and global function should be considered when choosing any of AChEIs. The use of optimal dosage referring to the expected clinical outcomes and currently reported deficits from patient with AD has become an important issue in clinical treatment. Establishing and maintaining a strong therapeutic alliance to physician, patient, and caregiver is crucial and central to the comprehensive care in AD.

"The Lesser of Two Evils" Versus "Medicines not Smarties": Constructing Antipsychotics in Dementia

BACKGROUND AND OBJECTIVES

Because antipsychotics are associated with an increased risk of morbidity and mortality, they should only be prescribed in dementia in limited circumstances. But antipsychotics are prescribed to a large proportion of residents in formal care settings despite guidance and warnings to the contrary, justifying a study into how professionals define and in turn create realities about antipsychotic usage in dementia.

RESEARCH DESIGN AND METHODS

Twenty-eight professionals with a role in the care and management of patients with dementia in care homes were recruited and interviewed in this qualitative study. A gap in the literature about the social construction of antipsychotics in dementia prompted the use of critical discourse analysis methodology.

RESULTS

Antipsychotics were portrayed in 2 distinct ways; as "the lesser of two evils' they were conceptualized as the less harmful or unpleasant of 2 bad choices and as "medicines not Smarties" (a brand of sweets/candy) they were conceptualized as prescribed too frequently and indiscriminately. The first resource could be used to defend the prescribing of antipsychotics and uphold the prescribers' privilege to do so whereas the second enabled the speaker to reject their own wilful involvement in overprescribing.

DISCUSSION AND IMPLICATIONS

When prescribers draw on "the lesser of two evils" paradigm to sanction the overprescribing of antipsychotics, implicit assumptions about these medications as being the best of bad choices should be recognized and challenged. Future studies should target specific normative beliefs about antipsychotic prescribing consequences, to change the lexicon of common knowledge which perpetuates bad practice.

Impact of Social Isolation on the Behavioral, Functional Profiles, and Hippocampal Atrophy Asymmetry in Dementia in Times of Coronavirus Pandemic (COVID-19): A Translational Neuroscience Approach

The impact of COVID-19 on the elderly is devastating, and nursing homes are struggling to provide the best care to the most fragile. The urgency and severity of the pandemic forces the use of segregation in restricted areas and confinement in individual rooms as desperate strategies to avoid the spread of disease and the worst-case scenario of becoming a deadly trap. The conceptualization of the post-COVID-19 era implies strong efforts to redesign all living conditions, care/rehabilitation interventions, and management of loneliness forced by social distance measures. Recently, a study of gender differences in COVID-19 found that men are more likely to suffer more severe effects of the disease and are over twice as likely to die. It is well-known that dementia is associated with increased mortality, and males have worse survival and deranged neuro-immuno-endocrine systems than females. The present study examines the impact of long-term isolation in male 3xTg-AD mice modeling advanced stages of Alzheimer's disease (AD) and as compared to age-matched counterparts with normal aging. We used a battery of ethological and unconditioned tests resembling several areas in nursing homes. The main findings refer to an exacerbated (two-fold increase) hyperactivity and emergence of bizarre behaviors in isolated 3xTg-AD mice, worrisome results since agitation is a challenge in the clinical management of dementia and an important cause of caregiver burden. This increase was consistently shown in gross (activity in most of the tests) and fine (thermoregulatory nesting) motor functions. Isolated animals also exhibited re-structured anxiety-like patterns and coping-with-stress strategies. Bodyweight and kidney weight loss were found in AD-phenotypes and increased by isolation. Spleen weight loss was isolation dependent. Hippocampal tau pathology was not modified, but asymmetric atrophy of the hippocampus, recently described in human patients with dementia and modeled here for the first time in an animal model of AD, was found to increase with isolation. Overall, the results show awareness of the impact of isolation in elderly patients with dementia, offering some guidance from translational neuroscience in these times of coronavirus and post-COVID-19 pandemic. They also highlight the relevance of personalized-based interventions tailored to the heterogeneous and complex clinical profile of the individuals with dementia and to consider the implications on caregiver burden.

Barriers and facilitators to accessing psychological therapies for severe mental health difficulties in later life

Background:

The number of people growing older with severe mental illness (SMI) is rising, reflecting societal trends towards an ageing population. Evidence suggests that older people are less likely to seek help, be referred for and receive psychological therapy compared with younger people, but past research has focused on those with mild to moderate mental health needs.

Aims:

This research aims to identify the specific barriers faced by older people with SMI.

Method:

We interviewed 53 participants (22 service users with SMI aged over 50 years, 11 carers of people with SMI, and 20 health care professionals) about their views and experiences of accessing therapy for SMI in later life.

Results:

Thematic analysis revealed five themes: organizational and resource issues; myths about therapy and attitudinal barriers; stigma; encouraging access to therapy; and meeting age-specific needs.

Conclusions:

Barriers faced by older people with SMI are not only age-related, but also reflect specific issues associated with having a SMI over many years. Improving awareness of the benefits of psychological therapies is important not only for older people with SMI themselves, but also for their carers and staff who work with them.

Impact of Chronic Risperidone Use on Behavior and Survival of 3xTg-AD Mice Model of Alzheimer's Disease and Mice With Normal Aging

Psychosis and/or aggression are common problems in dementia, and when severe or persistent, cause considerable patient distress and disability, caregiver stress, and early institutionalization. In 2005, the Food and Drug Administration (FDA) determined that atypical antipsychotics were associated with a significantly greater mortality risk compared to placebo, which prompted the addition of an FDA black-box warning. The American College of Neuropsychopharmacology (ACNP) White Paper, 2008, reviewed this issue and made clinical and research recommendations regarding the use of antipsychotics in dementia patients with psychosis and/or agitation. Increased mortality risk has also been described in cerebrovascular adverse events in elderly users of antipsychotics. In the present work, at the translational level, we used male 3xTg-AD mice (PS1M146V, APPSwe, tauP301L) at advanced stages of the disease reported to have worse survival than females, to study the behavioral effects of a low chronic dose of risperidone (0.1 mg/kg, s.c., 90 days, from 13 to 16 months of age) and its impact on long-term survival, as compared to mice with normal aging. Animals were behaviorally assessed for cognitive and BPSD (behavioral and psychological symptoms of dementia)-like symptoms in naturalistic and experimental conditions (open-field test, T-maze, social interaction, Morris water maze, and marble test) before and after treatment. Weight, basal glucose levels, and IPGTT (i.p. glucose tolerance test) were also recorded. Neophobia in the corner test was used for behavioral monitoring. Survival curves were recorded throughout the experiment until natural death. The benefits of risperidone were limited, both at cognitive and BPSD-like level, and mostly restricted to burying, agitation/vibrating tail, and other social behaviors. However, the work warns about a clear early mortality risk window during the treatment and long-lasting impact on survival. Reduced life expectancy and life span were observed in the 3xTg-AD mice, but total lifespan (36 months) recorded in C57BL/6 × 129Sv counterparts with normal aging was also truncated to 28 months in those with treatment. Sarcopenia at time of death was found in all groups, but was more severe in wild-type animals treated with risperidone. Therefore, the 3xTg-AD mice and their non-transgenic counterparts can be useful to delimitate critical time windows and for studying the physio-pathogenic factors and underlying causal events involved in this topic of considerable public health significance.

The Impact of Antipsychotic Drugs on Long-term Care, Nursing Home Admission, and Death in Dementia Patients

Background

Behavioral and psychological symptoms of dementia are commonly treated with antipsychotic drugs (APDs), which have been associated with adverse health effects. We examine the effect of APDs on long-term care (LTC), nursing home (NH) admission, and death of dementia patients.

Methods

We used health claims data of the largest German health insurer from 2004 to 2010 and followed newly-diagnosed dementia patients aged 60 years and older into LTC, NH, and until death. Cox proportional hazards models were estimated to explore whether the risk of these outcomes differed between patients receiving haloperidol, melperone, risperidone, or quetiapine.

Results

In a cohort of 6,930 dementia patients who were initially free of LTC dependency, APD users generally faced a twofold increased risk of LTC relative to nonusers. Quetiapine was the exception, showing a comparatively lower risk (HR = 1.64; CI = 1.35–1.98). Among 9,950 dementia patients initially living in private homes, the risk of moving into a NH was generally increased by about 50% among APD users relative to nonusers. Risk of death (N = 10,921) was significantly higher for haloperidol-, melperone-, and risperidone- but not for quetiapine users (HR = 0.91; CI = 0.78–1.08). The excess mortality associated with haloperidol and melperone was greater among patients living in private households.

Conclusions

In our study, APDs appeared to accelerate adverse health outcomes in German dementia patients. Differentiating between the effect of antipsychotic drug use among dementia patients residing in private households and in NHs, we found that excess mortality for haloperidol and melperone users was higher in private settings.

Cardiovascular effects of psychotic illnesses and antipsychotic therapy

Mortality from cardiovascular disease is increased in people with mental health disorders in general and schizophrenia in particular. The causes are multifactorial, but it is known that antipsychotic medication can cause cardiac side-effects beyond the traditional coronary risk factors. Schizophrenia itself is a contributor to an increased risk of cardiovascular mortality via cardiac autonomic dysfunction and a higher prevalence of metabolic syndrome, both contributing to a reduced life expectancy. The pro-arrhythmic impact of traditional antipsychotics, especially via the hERG-potassium channel, has been known for several years. Newer antipsychotics have a reduced pro-arrhythmic profile but might contribute to higher cardiac death rates by worsening the metabolic profile. Clozapine-induced cardiomyopathy, which is dose independent, is a further concern and continuous monitoring of these patients is required. Prophylaxis with angiotensin-converting enzyme inhibitors is currently under review. Overall, management of cardiovascular risk within this population group must be multifaceted and nuanced to allow the most effective treatment of serious mental illness to be conducted within acceptable parameters of cardiovascular risk; some practical measures are presented for the clinical cardiologist.

Intermittent antipsychotic medication and mortality in institutionalized older adults: A scoping review

OBJECTIVE/BACKGROUND

Antipsychotic use appears to increase mortality risk among older adults with dementia. Whether this risk is similar for regular or intermittent use is unknown. This scoping review aims to explore the temporal association between antipsychotic use and mortality risk for older institutionalized adults.

METHOD

We conducted a scoping review using Medline (PubMed), EMBASE, CINAHL, and the Cochrane libraries between October 2018 and January 2019.

RESULTS

Twenty-eight articles met review criteria. We found that different antipsychotic medications present different safety profiles. The risk of mortality was highest with conventional antipsychotic use and within 40 days of antipsychotic initiation.

CONCLUSIONS

Conventional antipsychotic use increases mortality for older institutionalized adults. The evidence for atypical antipsychotics is less clear. Mortality risk appears highest within 30 to 40 days of initiating antipsychotic treatment. This temporal association suggests increased mortality may actually be the result of some previously unrecognized illness, comorbidity, change in health status, or increased frailty, rather than an idiosyncrasy of the antipsychotic itself.

Antipsychotic drug use and favourable natures of emotional functions in patients with dementia

AIM

To characterise the effects of antipsychotics on brain functions of patients with behavioural psychological symptoms of dementia (BPSD).

METHODS

Studies were performed during 6 weeks of intervention with either a nonantipsychotic drug (group A, n = 38) or an antipsychotic drug (group B, n = 10).

RESULTS

Neuropsychiatric Inventory scores were significantly decreased in both groups. Scores on the Mini-Mental State Examination did not change with intervention. By contrast, favourable natures of emotional functions, scored using the Delightful Emotional Index of 10 items, were significantly lower in the antipsychotic drug treatment group B relative to scores in the nonantipsychotic drug treatment group A.

CONCLUSIONS

Antipsychotics reduce favourite emotions as well as BPSD, and this should be considered in prescribing medications for patients with dementia.

Effects of haloperidol on cognitive function and behavioural flexibility in the IntelliCage social home cage environment

This study examined the effects of chronic administration of haloperidol in female C57BL/6 mice. As patients with schizophrenia often show perseverant behaviours and lack of behavioural flexibility, it is important to know whether the effect of haloperidol makes these traits worse. This study, therefore, was designed to evaluate the effects of haloperidol on the learning performance of mice using an automated home cage environment, the IntelliCage. Behavioural shuttling in the IntelliCage enabled us to assess learning in tasks including place discrimination learning and reversal place learning. In reversal place learning, spatial patterns of rewarded and non-rewarded places that mice had learned to discriminate were reversed, and the adaptability of mice to change the previously acquired place learning was measured. Haloperidol (1 mg/kg/day) reduced locomotor activity and water intake. Haloperidol impaired the cognitive flexibility of mice during reversal place learning rewarded by access to water but enhanced the rapid acquisition of behavioural flexibility when airpuff punishment was applied.

Psychosis symptoms in nursing home residents with and without dementia-Cross-sectional analyses from the COSMOS study

OBJECTIVE

To investigate the characteristics of nursing home residents with psychosis and the association with potential underlying factors, such as pain, sleep disturbances, and antipsychotic medication.

METHOD

Five hundred forty-five residents with and without dementia from 67 Norwegian nursing home units were included in the cross-sectional analyses. Psychosis was the main outcome measure in our study; other outcome measures include quality of life (QoL), activities of daily living (ADL) function, cognitive function, pain, and antipsychotic medication.

RESULTS

One hundred twelve residents had one or more symptoms of psychosis, and compared with residents without psychosis, they had lower QoL (p < 0.001), ADL function (p = 0.003), and cognitive functioning (p = 0.001). Adjusted logistic regression analyses showed that psychosis was associated with the prevalence of pain (OR: 3.19; 95% CI, 1.94-5.24), sleep disturbances (OR: 4.51; 95% CI, 2.91-6.99), and total number of medication (OR: 1.10; 95% CI, 1.03-1.17). Residents with psychosis but without antipsychotic medication had better QoL (p = 0.005) compared with residents receiving any antipsychotics.

CONCLUSION

Psychosis in NH residents is associated with pain, sleep disturbances, and number of medications. Residents with psychosis have poor QoL, although better QoL was observed among those who did not use antipsychotic medication.

[Antipsychotics: features of undesirable adverse reactions in elderly and senile age]

This review summarizes and systematizes currently available literature on antipsychotics as one of the most frequently prescribed group of psychotropic drugs. Based on published data from clinical studies and meta-analyzes, the authors consider unwanted adverse reactions in patients taking antipsychotic medications. Mechanisms of development of undesirable drug reactions are discussed. Special attention is paid to those adverse reactions of antipsychotics that most often occur in old and very old age (increased risk of adverse cardiovascular and cerebrovascular events, sudden death, prolonged QTc interval, falls, fractures, orthostatic hypotension, extrapyramidal disorders, pneumonia, urinary tract infections, etc.).