Risk of stroke with typical and atypical anti-psychotics: a retrospective cohort study including unexposed subjects

Adverse effects associated with antipsychotic use in older adults

INTRODUCTION

Antipsychotic (AP) medications are extensively utilized for diverse psychiatric and non-psychiatric conditions, but they are associated with significant adverse effects in older adults. This expert opinion review provides an updated profile of adverse effects associated with AP medications in older adults.

AREAS COVERED

This review specifically examines real-world evidence for adverse events associated with AP use, including all-cause mortality, falls and fractures, diabetes, cardiovascular and cerebrovascular events, acute kidney injury, venous thromboembolism/pulmonary embolism, extrapyramidal symptoms, and infections based on real-world evidence.

EXPERT OPINION

This comprehensive safety review of AP revealed multiple adverse events in older adults. All-cause mortality, more associated with typical APs than atypicals, underscores a dose-dependent risk, urging cautious prescribing practices and avoidance of typical APs. Falls/fractures associated with atypical APs highlight the importance of judicious dosing and -close monitoring, especially after initiation. Cardiovascular risks, particularly stroke, with AP use emphasize the need for vigilant monitoring. Extrapyramidal symptoms, more linked to typical APs, also pose a significant risk in older adults. Pneumonia and pulmonary embolism/venous thromboembolism demand cautious consideration of APs, prompting the need for additional real-world studies to inform clinical practice. Conflicting evidence on diabetes and acute kidney injury necessitates ongoing studies and further research in older adults.

Stroke Risk Among Non-Elderly Users of Haloperidol or First-Generation Antipsychotics vs Second-Generation Antipsychotics: A Cohort Study from a US Health Insurance Claims Database

Background

Previous studies have reported an increased risk of stroke in patients taking antipsychotics. However, most of these studies have been conducted in the elderly population.

Objective

We estimated stroke risk in new users of any first-generation antipsychotic or haloperidol, vs second-generation antipsychotics among patients aged 18–64 years without a recent dementia diagnosis and, separately, regardless of a recent dementia diagnosis.

Methods

Data were obtained from IBM MarketScan^® Commercial Database (1 January, 2001–31 December, 2017). Among new users without a recent dementia diagnosis, stroke risk for first-generation antipsychotics (FGAw/oD cohort) or haloperidol (HALw/oD cohort) was compared with second-generation antipsychotics (SGAw/oD cohort). A similar comparison was conducted among new users regardless of dementia diagnosis: first-generation antipsychotics (FGA cohort) or haloperidol (HAL cohort) vs second-generation antipsychotics (SGA cohort). Crude incident stroke rates within each cohort were determined. For hazard ratios, three propensity score matching strategies were used: unadjusted (crude), Sentinel propensity score strategy, and large-scale regularized regression model (adapted propensity score strategy).

Results

Each cohort included ≥12,000 patients. The incident rates for stroke per 1000 person-years were 3.10 (FGAw/oD), 5.99 (HALw/oD), 0.85 (SGAw/oD), 3.14 (FGA), 6.12 (HAL), and 0.90 (SGA). Pre-planned analysis with adapted propensity score strategy matching yielded calibrated hazard ratios for stroke: FGAw/oD vs SGAw/oD: 2.05 (calibrated confidence interval 1.13–3.89); HALw/oD vs SGAw/oD: 2.47 (1.14–5.48), FGA vs SGA: 1.64 (0.94–2.97), and HAL vs SGA: 1.98 (0.99–4.00). A post-hoc sensitivity analysis to address potential bias introduced by the 2015 change from the International Classification of Diseases, Ninth Revision to the International Classification of Diseases, Tenth Revision yielded calibrated hazard ratios for FGAw/oD vs SGAw/oD: 1.59 (0.87–3.01), HALw/oD vs SGAw/oD: 2.79 (1.24–6.42), FGA vs SGA: 1.41 (0.79–2.62), and HAL vs SGA: 3.47 (1.63–7.92).

Conclusions

Among adults aged ≤64 years, without a recent dementia diagnosis, stroke risk is higher among those exposed to haloperidol compared with those exposed to second-generation antipsychotics.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40801-021-00267-2.

Stroke Risk Among Elderly Users of Haloperidol and Typical Antipsychotics Versus Atypical Antipsychotics: A Real-World Study From a US Health Insurance Claims Database

BACKGROUND

We estimated stroke risk associated with new exposure to haloperidol, or any typical antipsychotic, versus atypical antipsychotic among patients aged ≥65 years regardless of dementia status.

METHODS

IBM MarketScan Medicare Supplemental Database data (January 1, 2001 to December 31, 2017) were used. Stroke risk for new users of typical antipsychotics (T1 cohort) or haloperidol (T2 cohort) was compared with new users of atypical antipsychotics (C1 cohort) aged ≥65 years. Crude incidence rate (IR) and incidence proportion of stroke were estimated within each cohort and gender subgroup. Three propensity score (PS) matching strategies were employed: Unadjusted (crude), Sentinel PS replication, and a large-scale regularized regression model (adapted PS).

RESULTS

Overall, 36,734 (T1), 24,074 (T2), and 226,990 (C1) patients were included. Crude IRs for stroke per 1000 person-years were 17.67 (T1), 23.74 (T2), and 14.17 (C1). In preplanned analyses, PS-matched calibrated hazard ratio (cHR) for stroke T1 versus C1 cohort was 1.08 (95% calibrated confidence interval [cCI] = 0.75, 1.55) with Sentinel PS strategy and 1.31 (95% cCI = 1.07, 1.60) with adapted PS strategy. The cHR for stroke in patients of T2 versus C1 was 1.69 (95% cCI = 1.08, 2.75) with Sentinel PS strategy and 1.45 (95% cCI = 1.17, 1.80) with adapted PS strategy.

CONCLUSION

Stroke risk in elderly new users of haloperidol was elevated compared to new users of atypical antipsychotics and was elevated for typical antipsychotics using the adapted PS strategy.

Mood stabilisers and risk of stroke in bipolar disorder

BACKGROUND

Research on the risk of stroke following the use of mood stabilisers specific to patients with bipolar disorder is limited.AimsIn this study, we investigated the risk of stroke following the exposure to mood stabilisers in patients with bipolar disorder.

METHOD

Data for this nationwide population-based study were derived from the Taiwan National Health Insurance Research Database. Among a retrospective cohort of patients with bipolar disorder (n = 19 433), 609 new-onset cases of stroke were identified from 1999 to 2012. A case-crossover study design utilising 14-day windows was applied to assess the acute exposure effect of individual mood stabilisers on the risk of ischaemic, haemorrhagic and other types of stroke in patients with bipolar disorder.

RESULTS

Mood stabilisers as a group were significantly associated with the increased risk of stroke in patients with bipolar disorder (adjusted risk ratio, 1.26; P = 0.041). Among individual mood stabilisers, acute exposure to carbamazepine had the highest risk of stroke (adjusted risk ratio, 1.68; P = 0.018), particularly the ischaemic type (adjusted risk ratio, 1.81; P = 0.037). In addition, acute exposure to valproic acid elevated the risk of haemorrhagic stroke (adjusted risk ratio, 1.76; P = 0.022). In contrast, acute exposure to lithium and lamotrigine did not significantly increase the risk of any type of stroke.

CONCLUSIONS

Use of carbamazepine and valproic acid, but not lithium and lamotrigine, is associated with increased risk of stroke in patients with bipolar disorder.Declaration of interestNone.

Antipsychotic drug use and risk of stroke and myocardial infarction: a systematic review and meta-analysis

BACKGROUND

The effect of antipsychotic (AP) drugs on risk of stroke and myocardial infarction (MI) remains unclear due to methodological limitations of, and inconsistencies across, existing studies. We aimed to systematically review studies reporting on the associations between AP drug use and stroke or MI risk, and to investigate whether associations differed among different sub-populations.

METHODS

We searched Medline, EMBASE, PsychINFO and Cochrane Library (from inception to May 28, 2017) for observational studies reporting on AP drug use and MI or stroke occurrence. We performed random-effects meta-analyses for each outcome, performing sub-groups analyses by study population - specifically general population (i.e. those not restricted to patients with a particular indication for AP drug use), people with dementia only and psychiatric illness only. Where feasible we performed subgroup analyses by AP drug class.

RESULTS

From 7008 articles, we included 29 relevant observational studies, 19 on stroke and 10 on MI. Results of cohort studies that included a general population indicated a more than two-fold increased risk of stroke, albeit with substantial heterogeneity (pooled HR 2.31, 95% CI 1.13, 4.74, I² = 83.2%). However, the risk among patients with dementia was much lower, with no heterogeneity (pooled HR 1.16, 95% CI 1.00, 1.33, I² = 0%) and there was no clear association among studies of psychiatric populations (pooled HR 1.44, 95% CI 0.90, 2.30; substantial heterogeneity [I² = 78.8])). Associations generally persisted when stratifying by AP class, but few studies reported on first generation AP drugs. We found no association between AP drug use and MI risk (pooled HR for cohort studies: 1.29, 95% CI 0.88, 1.90 and case-control studies: 1.07, 95% CI 0.94, 1.23), but substantial methodological and statistical heterogeneity among a relatively small number of studies limits firm conclusions.

CONCLUSIONS

AP drug use may be associated with an increased risk of stroke, but there is no clear evidence that this risk is further elevated in patients with dementia. Further studies are need to clarify the effect of AP drug use on MI and stroke risk in different sub-populations and should control for confounding by indication and stratify by AP drug class.

All-cause mortality and antipsychotic use among elderly persons with high baseline cardiovascular and cerebrovascular risk: a multi-center retrospective cohort study in Italy

BACKGROUND

Little is known about the comparative risk of death with atypical or conventional antipsychotics (APs) among persons with cardiovascular or cerebrovascular disease (CCD).

RESEARCH DESIGN AND METHODS

A cohort study was conducted using five Italian claims databases. New atypical AP users with CCD aged ≥65 (reference) were matched to new conventional AP users. Mortality per 100 person-years (PYs) and hazard ratios (HR), estimated using Cox models, were reported. Incidence and risk of death were estimated for persons having drug-drug interactions. Outcome occurrence was evaluated 180 days after AP initiation.

RESULTS

Overall 24,711 and 27,051 elderly new conventional and atypical AP users were identified. The mortality rate was 51.3 and 38.5 deaths per 100 PYs for conventional and atypical AP users. Mortality risk was 1.33 (95%CI: 1.27-1.39) for conventional APs. There was no increased mortality risk with single drug-drug interactions (DDIs) vs. no DDI. AP users with ≥1 DDI had a 29% higher mortality risk compared to no DDI in the first 90 days of treatment (HR: 1.29 (95% CI: 1.00-1.67)).

CONCLUSIONS

Conventional APs had a higher risk of death than atypical APs among elderly persons with CCD. Having ≥1 DDI was associated with an increased risk of death.

Relationship Between Antipsychotic Medications and Cerebrovascular Disease in Patients With Serious Mental Illness

INTRODUCTION AND OBJECTIVES

Cerebrovascular disease (CVD), especially in its asymptomatic forms, is relatively common in patients with serious mental illness (SMI). Nevertheless, the literature on this topic is scarce and sometimes contradictory. Antipsychotic medications, especially atypical agents, play an important role in the overall cardiovascular health of these patients. The goal of this study was to analyze the frequency of CVD in patients with and without SMI.

PATIENTS AND METHODS

This retrospective cohort study compared the frequency of CVD, including silent forms, in a group of patients without mental illness and without a history of taking antipsychotic medication, with another group of patients diagnosed with SMI who had received antipsychotic treatment. The 2 groups were matched for age and sex, and the mean age of the subjects in the 2 groups was 63 years.

RESULTS

The frequency of CVD was the same in both groups and it was not modified by the use of antipsychotic medications. A nonsignificant trend toward an association between CVD and prolonged use of antipsychotic polypharmacy was found.

CONCLUSIONS

In this study, in contrast to previous reports, use of antipsychotic medications and the presence of SMI were not associated with an increased risk of CVD.

Review of treatment for late-life depression

Depressive disorder in those over the age of 60 has many clinical similarities to depression in younger adults, but biological changes related to ageing may necessitate a different approach to treatment. We present an evidence-based review of treatment for late-life depression, focusing on pharmacological approaches, including monotherapy, combination and augmentation strategies. Selective serotonin reuptake inhibitors such as sertraline and citalopram are well tolerated, have the advantage of a favourable side-effect profile, and are good options for first-line treatment. Second-line treatment options include combination therapy with a second antidepressant, or treatment augmentation with an antipsychotic or lithium. We also consider evidence for nonpharmacological treatment strategies, including psychological therapy and neurostimulation. Finally, we summarise evidence for treatment of depression in patients in dementia.

Meet the relatives: a reintroduction to the clinical pharmacology of ‘typical’ antipsychotics (Part 2)

This second of two articles on the ‘typical’ (‘first-generation’) antipsychotics covers non-phenothiazines: thioxanthenes (flupentixol and zuclopenthixol), butyrophenones/diphenylbutylpiperidines (including one-time world market-leader haloperidol, and pimozide) and sulpiride, for many years the only substituted benzamide available in the UK. Several tolerability issues ascribed specifically or more frequently to older antipsychotics are also discussed.

Antipsychotics and the Risk of Cerebrovascular Accident: A Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Studies investigating the association between antipsychotic use and the risk of cerebrovascular accident (CVA) showed inconsistent results.

AIM

Conduct a systematic review and meta-analysis to evaluate whether use of antipsychotics is associated with increased risk of CVA.

METHODS

Major electronic databases were searched from 1970 to October 2016 for observational studies investigating the risk of CVA among users of antipsychotics. Pooled estimates of odds ratios (ORs) and 95% confidence intervals (CIs) were obtained by random effects meta-analysis.

RESULTS

Of 1171 citations identified, 10 studies were considered eligible. Significant increase in risk of CVA was associated with first-generation antipsychotics (OR 1.49; 95% CI 1.24-1.77) but not with second-generation antipsychotics (OR 1.31; 95% CI 0.74-2.30). Use of any antipsychotics in patients with dementia was associated with a low risk of CVA (OR 1.17; 95% CI 1.08-1.26).

CONCLUSIONS

The available evidence suggests use of with first-generation antipsychotics as opposed to second-generation antipsychotics significantly increased the risk of CVA.

Is cerebrovascular disease a silent condition in patients with chronic schizophrenia-related disorders?

Patients with chronic schizophrenia-related disorders are at a heightened risk of developing cardiovascular disease. The presence and interpretation of cerebral vascular lesions in neuroimaging tests in these patients represents a common clinical challenge. Nevertheless, the literature on cerebrovascular disease in this population is scarce and contradictory. The aim of this study was to analyse the relationship between schizophrenia-related disorders and cerebrovascular morbidity. A case-control study compared cerebrovascular morbidity in a group of patients with schizophrenia-related disorder versus a group of patients with another severe mental illness. The risk of presenting cerebrovascular morbidity was four times higher and statistically significant in patients with schizophrenia-related disorders compared with controls, paired by age and sex. However, both groups were homogeneous in terms of cardiovascular risk factors. There were significant differences between the two groups only in the time using first-generation antipsychotic drugs and taking two or more antipsychotic medications simultaneously. The relationship between chronic schizophrenia-related disorders and cerebrovascular disease may be beyond the classic cardiovascular risk factors and related to certain medications. This is one of the first studies to focus on the relation among cerebrovascular morbidity, antipsychotic drugs and disorders related to schizophrenia in middle-aged and elderly adults.

Automatic identification of type 2 diabetes, hypertension, ischaemic heart disease, heart failure and their levels of severity from Italian General Practitioners' electronic medical records: a validation study

OBJECTIVES

The Italian project MATRICE aimed to assess how well cases of type 2 diabetes (T2DM), hypertension, ischaemic heart disease (IHD) and heart failure (HF) and their levels of severity can be automatically extracted from the Health Search/CSD Longitudinal Patient Database (HSD). From the medical records of the general practitioners (GP) who volunteered to participate, cases were extracted by algorithms based on diagnosis codes, keywords, drug prescriptions and results of diagnostic tests. A random sample of identified cases was validated by interviewing their GPs.

SETTING

HSD is a database of primary care medical records. A panel of 12 GPs participated in this validation study.

PARTICIPANTS

300 patients were sampled for each disease, except for HF, where 243 patients were assessed.

OUTCOME MEASURES

The positive predictive value (PPV) was assessed for the presence/absence of each condition against the GP's response to the questionnaire, and Cohen's κ was calculated for agreement on the severity level.

RESULTS

The PPV was 100% (99% to 100%) for T2DM and hypertension, 98% (96% to 100%) for IHD and 55% (49% to 61%) for HF. Cohen's kappa for agreement on the severity level was 0.70 for T2DM and 0.69 for hypertension and IHD.

CONCLUSIONS

This study shows that individuals with T2DM, hypertension or IHD can be validly identified in HSD by automated identification algorithms. Automatic queries for levels of severity of the same diseases compare well with the corresponding clinical definitions, but some misclassification occurs. For HF, further research is needed to refine the current algorithm.

The Effect of Safety Warnings on Antipsychotic Drug Prescribing in Elderly Persons with Dementia in the United Kingdom and Italy: A Population-Based Study

BACKGROUND

Antipsychotic (AP) drugs are commonly used to manage the behavioural symptoms of dementia. Nevertheless, international (i.e. the European Medicines Agency in Europe) and national (i.e. the Medicines and Healthcare products Regulatory Agency in the UK and the Italian Drug Agency) regulatory agencies issued safety warnings against AP use in dementia in 2004 and 2009.

OBJECTIVE

The aim of this study is to investigate the short- and long-term impact of safety warnings on the use of APs in UK and Italian persons with dementia using two nationwide databases: The Health Improvement Network (THIN) from the UK and the Health Search Database-Cegedim-Strategic Data-Longitudinal Patient Database (HSD-CSD-LPD) from Italy.

METHODS

We calculated the overall quarterly prevalence of AP use by class and by individual drug in persons with dementia aged ≥65 years and used generalized linear models to explore the effect of the safety warnings.

RESULTS

We identified 58,497 and 10,857 individuals aged ≥65 years with dementia from the THIN and HSD-CSD-LPD databases, respectively, over the period 2000-2012. After the 2004 warnings, the use of atypical APs decreased, whereas the use of conventional APs increased, in Italy and the UK until 2009. However, the trend for APs individually showed that the use of risperidone/olanzapine decreased, whereas the use of quetiapine increased in both countries. After the 2009 warnings (until 2012), the use of atypical and conventional APs decreased in the UK (from 11 to 9 and 5 to 3 %, respectively), but such use increased in Italy (from 11 to 18 and 9 to 14 %, respectively).

CONCLUSION

The 2004 warnings led to a reduction in the use of olanzapine and risperidone and increased the use of quetiapine/conventional APs in both countries. From 2009, the use of APs decreased in persons with dementia in the UK but not in Italy. Possible reasons for the difference in AP use between the two countries include a more proactive approach towards reducing the use of APs in the UK than in Italy.

Mediators of First- Versus Second-generation Antipsychotic-related Mortality in Older Adults

BACKGROUND

Observational studies of older adults showed higher mortality for first-generation antipsychotics than their second- generation counterparts, which led to US Food and Drug Administration warnings, but the actual mechanisms involved remain unclear.

METHODS

A cohort of 9,060 initiators of first-generation antipsychotics and 17,137 of second-generation antipsychotics enrolled in New Jersey and Pennsylvania Medicare were followed for 180 days. Medical events were assessed using diagnostic and procedure codes on inpatient billing claims. For the individual and joint set of medical events (mediators), we estimated the total, direct, and indirect effects of antipsychotic type (first versus second generation) on mortality on the risk ratio scale and the proportion mediated on the risk difference scale, obtaining 95% confidence intervals through bootstrapping. We performed bias analyses for false-negative mediator misclassification in claims data, with sensitivity ranging from 0.25 to 0.75.

RESULTS

There were 3,199 deaths (outcomes), 862 cardiovascular events, 675 infectious events, and 491 hip fractures (potential mediators). Mortality was higher for first- than second-generation antipsychotic initiators (adjusted risk ratio: 1.14; 95% confidence interval: 1.06, 1.22). In naïve analyses, that ignored potential misclassification, less than 4% of this difference was explained by any particular medical event. In bias analyses, the proportion mediated ranged from 6% to 16% for stroke, 3% to 9% for ventricular arrhythmia, 3% to 11% for myocardial infarction, 0% venous thromboembolism, 3% to 9% for pneumonia, 0% to 1% for other bacterial infection, and 1% to 3% for hip fracture.

CONCLUSIONS

Acute cardiovascular events and pneumonia may explain part of the mortality difference between first- and second-generation antipsychotic initiators in this analysis.

Mortality and use of psychotropic medication in patients with stroke: a population-wide, register-based study

OBJECTIVES

The study sought to describe whether psychotropic medication may have long-term side effects in patients with stroke compared with controls.

SETTING

Use of national register data from healthcare services were identified from the Danish National Patient Registry in Denmark. Information about psychotropic medication use was obtained from the Danish Register of Medicinal Product Statistics.

OBJECTIVES

We aimed to evaluate all-cause mortality in relation to the use of benzodiazepines, antidepressants and antipsychotics in patients with stroke and matched controls.

PARTICIPANTS

Patients with a diagnosis of stroke and either no drug use or preindex use of psychotropic medication (n=49,968) and compared with control subjects (n=86,100) matched on age, gender, marital status and community location.

PRIMARY OUTCOME MEASURE

All-cause mortality.

RESULTS

All-cause mortality was higher in patients with previous stroke compared with control subjects. Mortality HRs were increased for participants prescribed serotonergic antidepressant drugs (HR=1.699 (SD=0.030), p=0.001 in patients; HR=1.908 (0.022), p<0.001 in controls, respectively), tricyclic antidepressants (HR=1.365 (0.045), p<0.001; HR=1.733 (0.022), p<0.001), benzodiazepines (HR=1.643 (0.040), p<0.001; HR=1.776 (0.053), p<0.001), benzodiazepine-like drugs (HR=1.776 (0.021), p<0.001; HR=1.547 (0.025), p<0.001), first-generation antipsychotics (HR=2.001 (0.076), p<0.001; HR=3.361 (0.159), p<0.001) and second-generation antipsychotics (HR=1.645 (0.070), p<0.001; HR=2.555 (0.086), p<0.001), compared with no drug use. Interaction analysis suggested statistically significantly higher mortality HRs for most classes of psychotropic drugs in controls compared with patients with stroke.

CONCLUSIONS

All-cause mortality was higher in patients with stroke and controls treated with benzodiazepines, antidepressants and antipsychotics than in their untreated counterparts. Our findings suggest that care should be taken in the use and prescription of such drugs, and that they should be used in conjunction with adequate clinical controls.

Are the safety profiles of antipsychotic drugs used in dementia the same? An updated review of observational studies

With an increase in the global prevalence of dementia, there is also an increase in behavioural and psychological symptoms of dementia (BPSD) for which antipsychotic drugs are often used. Despite several safety warnings on antipsychotic use in dementia, there is little evidence to support the efficacy of antipsychotics in individual BPSD symptoms or to evaluate the drug safety profile by individual antipsychotic drug. There is emerging but scarce evidence that suggests an inter-drug variability between antipsychotic safety outcomes in BPSD. The objective of this review was to examine the existing literature on antipsychotic drug use in dementia patients; in particular to see whether inter-drug differences regarding antipsychotic safety were reported. A literature search was conducted for observational studies published in the English language from 2004 to 2014 that reported the risk of all-cause mortality, cerebrovascular events, pneumonia and other outcomes such as hip/femur fracture, deep vein thrombosis (DVT) and hyperglycaemia. Six of 16 mortality studies (38%), 7 of 28 stroke studies (25%), 1 of 6 pneumonia (17%) studies and 2 of 6 fracture studies (33%) investigated inter-drug safety outcomes in elderly patients/dementia patients, while to our knowledge, there are no studies investigating the inter-drug variation of deep-vein thrombosis and hyperglycaemia risk. The results of the observational studies provide mixed results on the safety of antipsychotics in BPSD but it is clear that there are differences between the safety profiles of antipsychotic drugs. Robust evidence of such inter-drug variability could significantly improve patient safety as antipsychotics become more targeted to clinical risk factors.

Risk of ischemic stroke associated with the use of antipsychotic drugs in elderly patients: a retrospective cohort study in Korea

Objective

Strong concerns have been raised about whether the risk of ischemic stroke differs between conventional antipsychotics (CAPs) and atypical antipsychotics (AAPs). This study compared the risk of ischemic stroke in elderly patients taking CAPs and AAPs.

Method

We conducted a retrospective cohort study of 71,584 elderly patients who were newly prescribed the CAPs (haloperidol or chlorpromazine) and those prescribed the AAPs (risperidone, quetiapine, or olanzapine). We used the National Claims Database from the Health Insurance Review and Assessment Service (HIRA) from January 1, 2006 to December 31, 2009. Incident cases for ischemic stroke (ICD-10, I63) were identified. The hazard ratios (HR) for AAPs, CAPs, and for each antipsychotic were calculated using multivariable Cox regression models, with risperidone as a reference.

Results

Among a total of 71,584 patients, 24,668 patients were on risperidone, 15,860 patients on quetiapine, 3,888 patients on olanzapine, 19,564 patients on haloperidol, and 7,604 patients on chlorpromazine. A substantially higher risk was observed with chlorpromazine (HR = 3.47, 95% CI, 1.97–5.38), which was followed by haloperidol (HR = 2.43, 95% CI, 1.18–3.14), quetiapine (HR = 1.23, 95% CI, 0.78–2.12), and olanzapine (HR = 1.12, 95% CI, 0.59–2.75). Patients who were prescribed chlorpromazine for longer than 150 days showed a higher risk (HR = 3.60, 95% CI, 1.83–6.02) than those who took it for a shorter period of time.

Conclusions

A much greater risk of ischemic stroke was observed in patients who used chlorpromazine and haloperidol compared to risperidone. The evidence suggested that there is a strong need to exercise caution while prescribing these agents to the elderly in light of severe adverse events with atypical antipsychotics.

Cardiovascular and cerebrovascular risk factors and events associated with second-generation antipsychotic compared to antidepressant use in a non-elderly adult sample: results from a claims-based inception cohort study

This is a study of the metabolic and distal cardiovascular/cerebrovascular outcomes associated with the use of second-generation antipsychotics (SGAs) compared to antidepressants (ADs) in adults aged 18-65 years, based on data from Thomson Reuters MarketScan® Research Databases 2006-2010, a commercial U.S. claims database. Interventions included clinicians' choice treatment with SGAs (allowing any comedications) versus ADs (not allowing SGAs). The primary outcomes of interest were time to inpatient or outpatient claims for the following diagnoses within one year of SGA or AD discontinuation: hypertension, ischemic and hypertensive heart disease, cerebrovascular disease, diabetes mellitus, hyperlipidemia, and obesity. Secondary outcomes included the same diagnoses at last follow-up time point, i.e., not censoring observations at 365 days after SGA or AD discontinuation. Cox regression models, adjusted for age, gender, diagnosis of schizophrenia and mood disorders, and number of medical comorbidities, were run. Among 284,234 individuals, those within one year of exposure to SGAs versus ADs showed a higher risk of essential hypertension (adjusted hazard ratio, AHR=1.16, 95% CI: 1.12-1.21, p<0.0001), diabetes mellitus (AHR=1.43, CI: 1.33-1.53, p<0.0001), hypertensive heart disease (AHR=1.34, CI: 1.10-1.63, p<0.01), stroke (AHR=1.46, CI: 1.22-1.75, p<0.0001), coronary artery disease (AHR=1.17, CI: 1.05-1.30, p<0.01), and hyperlipidemia (AHR=1.12, CI: 1.07-1.17, p<0.0001). Unrestricted follow-up results were consistent with within one-year post-exposure results. Increased risk for stroke with SGAs has previously only been demonstrated in elderly patients, usually with dementia. This study documents, for the first time, a significantly increased risk for stroke and coronary artery disease in a non-elderly adult sample with SGA use. We also confirm a significant risk for adverse metabolic outcomes. These findings raise concerns about the longer-term safety of SGAs, given their widespread and chronic use.

Effect of different antipsychotic drugs on short-term mortality in stroke patients

The safety, tolerability, and efficacy data for antipsychotic drugs used in the acute phase of stroke are limited. The primary aim of this study was to examine the effectiveness and safety of typical and atypical antipsychotics on acute ischemic stroke mortality.This observational study was conducted in a retrospective cohort of patients selected from the 2010-2011 National Health Research Institute database in Taiwan. Patients were tracked for 1 month from the time of their first hospitalization for acute ischemic stroke. A nested case-control analysis was used to estimate the odds ratio (OR) of 30-day mortality associated with antipsychotic drug, adjusted for age, gender, disease severity, and comorbidities.The study cohort included 47,225 subjects with ischemic stroke, including 9445 mortality cases and 37,780 matched controls. After adjustment for the covariates, antipsychotics users before ischemic stroke are associated with a 73% decrease in the rate of mortality (OR 0.27; 95% CI 0.23-0.31). After ischemic stroke, the use of antipsychotics is associated with 87% decrease in the rate of mortality (OR 0.13; 95% CI 0.1-0.16). The users of conventional antipsychotics are associated with a 78% decrease in the rate of mortality (OR 0.22; 95% CI 0.18-0.26). The users of atypical antipsychotics are also associated with a 86% decrease in the rate of mortality (OR 0.14; 95% CI 0.12-0.17).We found that 1-month mortality among acute stroke patients treated with antipsychotics is significantly lower. The benefit on lower mortality was found not only among ischemic stroke patients who had received antipsychotics previously but also among patients who start antipsychotics after their stroke.

The explanatory role of stroke as a mediator of the mortality risk difference between older adults who initiate first- versus second-generation antipsychotic drugs

Antipsychotic drugs are used to treat dementia-related symptoms in older adults, and observational studies show higher risks of death and stroke associated with the use of first-generation antipsychotic drugs (FGAs) compared with second-generation antipsychotic drugs (SGAs). However, the extent to which stroke explains the differential mortality risk between FGA use and SGA use in older adults is unclear. We followed those who initiated use of antipsychotic drugs (9,777 FGA users and 21,164 SGA users) aged 65 years or older, and who were enrolled in Medicare and either the New Jersey or Pennsylvania pharmacy assistance program during 1994 to 2005, over 180 days for the outcomes of stroke and death. We estimated direct and indirect effects by comparing 180-day mortality risks associated with the use of FGAs versus SGAs as mediated by stroke on the risk ratio scale, as well as the proportion mediated on the risk difference scale. FGA use was associated with marginally higher risks of stroke (risk ratio =1.24, 95% confidence interval (CI): 1.01, 1.53) and death (risk ratio = 1.15, 95% CI: 1.08, 1.22) compared with SGA use, but stroke explained little (2.7%) of the observed difference in mortality risk. The indirect effect was null (risk ratio = 1.004, 95% CI: 1.000, 1.008), and the direct effect was equal to the total effect of antipsychotic drug type (FGA vs. SGA) on mortality risk (risk ratio = 1.15, 95% CI: 1.08, 1.22). These results suggest that the difference in mortality risk between users of FGAs and SGAs may develop mostly through pathways that do not involve stroke.

Management of non-cognitive symptoms associated with dementia

Up to 75% of patients with dementia will experience non-cognitive symptoms.1 These often present as psychotic symptoms, behavioural disturbances and changes in mood.1 Such symptoms provide a significant challenge for patients and their carers, and are often difficult to manage. Antipsychotic drugs have been widely used to treat non-cognitive symptoms of dementia. However, in 2004 data emerged linking the use of some antipsychotic drugs with an increased risk of stroke and death in patients with dementia.2 Since then, there has been a national drive to ensure that antipsychotic drugs are used appropriately. In 2007, we reviewed the safety of antipsychotics in people with dementia.3 Here, we provide an update on the evidence for the efficacy and safety of interventions used to manage non-cognitive symptoms of dementia.

Quantifying the role of adverse events in the mortality difference between first and second-generation antipsychotics in older adults: systematic review and meta-synthesis

BACKGROUND

Observational studies have reported higher mortality among older adults treated with first-generation antipsychotics (FGAs) versus second-generation antipsychotics (SGAs). A few studies examined risk for medical events, including stroke, ventricular arrhythmia, venous thromboembolism, myocardial infarction, pneumonia, and hip fracture.

OBJECTIVES

1) Review robust epidemiologic evidence comparing mortality and medical event risk between FGAs and SGAs in older adults; 2) Quantify how much these medical events explain the observed mortality difference between FGAs and SGAs.

DATA SOURCES

Pubmed and Science Citation Index.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

Studies of antipsychotic users that: 1) evaluated mortality or medical events specified above; 2) restricted to populations with a mean age of 65 years or older 3) compared FGAs to SGAs, or both to a non-user group; (4) employed a "new user" design; (5) adjusted for confounders assessed prior to antipsychotic initiation; (6) and did not require survival after antipsychotic initiation. A separate search was performed for mortality estimates associated with the specified medical events.

STUDY APPRAISAL AND SYNTHESIS METHODS

For each medical event, we used a non-parametric model to estimate lower and upper bounds for the proportion of the mortality difference-comparing FGAs to SGAs-mediated by their difference in risk for the medical event.

RESULTS

We provide a brief, updated summary of the included studies and the biological plausibility of these mechanisms. Of the 1122 unique citations retrieved, we reviewed 20 observational cohort studies that reported 28 associations. We identified hip fracture, stroke, myocardial infarction, and ventricular arrhythmias as potential intermediaries on the causal pathway from antipsychotic type to death. However, these events did not appear to explain the entire mortality difference.

CONCLUSIONS

The current literature suggests that hip fracture, stroke, myocardial infarction, and ventricular arrhythmias partially explain the mortality difference between SGAs and FGAs.

Short- and long-term mortality risk associated with the use of antipsychotics among 26,940 dementia outpatients: a population-based study

OBJECTIVE

To investigate short- and long-term mortality risk associated with the use of antipsychotics in dementia outpatients, assessing the risk over specific time frames and quantifying the risk by the individual antipsychotics.

METHODS

This population-based study used data from the Norwegian Prescription Database. The study sample included 26,940 dementia outpatients aged 65 years or older prescribed antidementia drugs and psychotropics from Norwegian pharmacies between 2004 and 2010.

RESULTS

Cox survival analyses, adjusted for age, gender, mean daily defined dose, and severe medical conditions, showed that antipsychotic use compared with other psychotropics involved approximately twice the mortality risk in outpatients with dementia. Furthermore, these results are consistent for all investigated time points after first dispensing the drugs (hazard ratio [HR]30 days = 2.1 [95% confidence interval {CI}: 1.6-2.9] to HR 730-2,400 days = 1.7 [95% CI: 1.6-1.9]). Haloperidol was associated with higher mortality risk (HR 30 days = 1.7 [95% CI: 1.0-3.0] to HR 730-2,400 days = 1.4 [95% CI: 1.0-1.9]) than risperidone.

CONCLUSION

This first study to observe antipsychotic use and mortality in dementia outpatients over more than 6 years clearly shows that antipsychotics involve increased short- and long-term mortality risk. Physicians may justly consider antipsychotics to be the best option for some dementia patients among available nonpharmacologic and pharmacologic treatments. However, although causal conclusions are precluded due to limited adjustments in the analyses, the findings support the current treatment recommendations that antipsychotics should be avoided or used with great caution.

Use and safety of antipsychotics in behavioral disorders in elderly people with dementia

In recent years, the use of antipsychotics has been widely debated for reasons concerning their safety in elderly patients affected with dementia. To update the use of antipsychotics in elderly demented people, a MEDLINE search was conducted using the following terms: elderly, conventional and atypical antipsychotics, adverse events, dementia, and behavioral and psychotic symptoms in dementia (BPSD). Owing to the large amounts of studies on antipsychotics, we mostly restricted the field of research to the last 10 years. Conventional antipsychotics have been widely used for BPSD; some studies showed they have an efficacy superior to placebo only at high doses, but they are associated with several and severe adverse effects. Atypical antipsychotics showed an efficacy superior to placebo in randomized studies in BPSD treatment, with a better tolerability profile versus conventional drugs. However, in 2002, trials with risperidone and olanzapine in elderly patients affected with dementia-related psychoses suggested the possible increase in cerebrovascular adverse events. Drug regulatory agencies issued specific recommendations for underlining that treatment of BPSD with atypical antipsychotics is "off-label." Conventional antipsychotics showed the same likelihood to increase the risk of death in the elderly as atypical agents, and they should not replace the atypical agents discontinued by Food and Drug Administration warnings. Before prescribing an antipsychotic drug, the following are factors to be seriously considered: the presence of cardiovascular diseases, QTc interval on electrocardiogram, electrolytic imbalances, familiar history for torsades des pointes, concomitant treatments, and use of drugs able to lengthen QTc. Use of antipsychotics in dementia needs a careful case-by-case assessment, together with the possible drug-drug, drug-disease, and drug-food interactions.

Antipsychotics prescription and cerebrovascular events in Italian older persons

Meta-analyses have found conflicting evidence on the link between antipsychotics and cerebrovascular events (CVEs). The primary aim of this study was to evaluate the association between any antipsychotic prescription and CVEs in Italian elderly; second, to compare the effect of typical and atypical antipsychotics on CVEs; and third, to investigate the effect of antipsychotics on CVEs in the subgroup of persons coprescribed with acetylcholinesterase inhibitors (AChEIs). Administrative claims from community-dwelling people aged 65 to 94 years living in Northern Italy were analyzed using a retrospective case-control design, from 2003 to 2005. The primary outcome measure was a hospital discharge diagnosis of CVEs during 2005. Four age-, sex-, and local health unit-matched control subjects were identified for each case. Antihypertensive drugs, anticoagulants, platelet inhibitors, antidiabetic drugs, lipid-lowering drugs, and AChEI were used as covariates in conditional logistic regression models testing the odds ratio (OR) for CVEs due to antipsychotics use. Three thousand eight hundred fifty-five cases of CVEs were identified and matched with 15,420 control subjects. In multiadjusted models, the association of any antipsychotics, typical or atypical with CVEs, was not significant. When antipsychotics were categorized according to the number of boxes prescribed during the observational period, being prescribed with at least 19 boxes of typical antipsychotics was significantly associated with CVEs (OR, 2.4; 95% confidence interval, 1.08-5.5). An interaction was found between any antipsychotic and AChEI coprescription on CVEs (OR, 0.46; 95% confidence interval, 0.23-0.92). In conclusion, only typical antipsychotics were associated with an increased odd of CVEs, but the association was duration dependent. Persons prescribed simultaneously with AChEI and antipsychotics may be at a lower risk of CVEs.

Risk of ischemic stroke with the use of risperidone, quetiapine and olanzapine in elderly patients: a population-based, case-crossover study

We conducted a case-crossover study to evaluate the comparative risk of ischemic stroke associated with the use of risperidone, quetiapine and olanzapine in geriatric patients using the Korean Health Insurance Review and Assessment Service database. Cases included elderly patients >64 years old who had experienced their first ischemic stroke (International Classification of Disease, Tenth Revision (ICD-10), I63) hospitalization from July 2005 to June 2006 and who had been without prior cerebrovascular diseases (ICD-10, I60-I69), or transient ischemic attack (ICD-10, G45). Exposures to risperidone, quetiapine and olanzapine were assessed during the 30 days prior to the stroke episode. We set two control periods with lengths which were the same as the hazard periods. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were estimated by conditional logistic regression. A total of 1601 cases of ischemic stroke with a mean age of 75.6 (±6.7) years were identified, among which 933 (58.3%) were female. An increased risk of ischemic stroke was associated with the use of risperidone (aOR=3.5, 95% CI 3.3-4.6) and quetiapine (aOR=2.7, 95% CI 2.0-3.6) during the 30 days prior to stroke: however, no significant risk was observed with olanzapine (aOR=1.2, 95% CI 0.7-2.0). The increased stroke risk in demented patients, assessed within 30 days after exposure, was also observed with olanzapine. However, the sample of olanzapine users was small and underpowered.

Use of antipsychotics and risk of cerebrovascular events in schizophrenic patients: a nested case-control study

OBJECTIVE

This nested case-control study assessed the association between antipsychotic use and cerebrovascular adverse events among schizophrenic patients.

METHODS

Using Taiwan's National Health Insurance Research Database, we identified 9715 newly diagnosed schizophrenic patients during 2001 to 2009. Within the schizophrenic cohort, 386 cases of cerebrovascular events and 772 matched control subjects (1:2 ratio) were further identified. Conditional logistic regression models were used to examine the association between the use of antipsychotics (timing, duration, and type) and risk of cerebrovascular events.

RESULTS

Current users of antipsychotics were associated with a 2-fold risk of stroke (adjusted odds ratio [OR], 1.94; 95% confidence interval [CI], 1.11-1.39; P = 0.02) as compared with nonusers. Among current users, patients who used antipsychotics less than 15 days (adjusted OR, 9.41; 95% CI, 3.08-28.71; P < 0.01) and 16 to 30 days (adjusted OR, 6.90; 95% CI, 1.09-43.69; P = 0.04) were associated with an extremely high risk of stroke. The risk of stroke was greater for patients who used first-generation antipsychotics alone or combination of first- and second-generation antipsychotics, with adjusted ORs of 2.75 (95% CI, 1.34-5.64; P < 0.01) and 2.37 (95% CI, 1.20-4.68; P = 0.01), respectively, but not in patients who used second-generation antipsychotic alone.

CONCLUSIONS

This population-based study extends previous evidence by documenting the increased cerebrovascular events associated with antipsychotic use in a schizophrenic cohort. A temporal association of such risk was reported in our study. Further studies are needed to assess the risk-benefit profile of first- and second-generation antipsychotics in this patient population.

The impact of antipsychotics and neuropsychiatric symptoms on the quality of life of people with dementia living in nursing homes

OBJECTIVE

This study aimed to establish whether antipsychotic (AP) use in patients with dementia negatively affects quality of life (QoL) independent of neuropsychiatric symptoms (NPS).

METHOD

We tested 290 patients with dementia living in nine nursing homes throughout the Netherlands in a longitudinal study. The measurements were repeated every 6 months over 2 years. We studied the change in NPS and AP use and their effect on QoL over time in two separate generalized estimating equations. We assessed QoL and NPS using the Qualidem questionnaire and the Neuropsychiatric Inventory-Nursing Home Version (NPI-NH), respectively.

RESULTS

Antipsychotic prescriptions did not significantly change participant QoL, whereas NPI-NH total score changes consistently predicted changes in QoL. According to the Qualidem, the development of QoL in patients who chronically used APs did not differ from AP-free patients, except on the restless tense behavior subscale. AP-free patients' "restless tense behavior" improved compared with patients who chronically used APs, who showed a slight deterioration in these symptoms; however, this effect did not significantly influence total QoL.

CONCLUSION

Antipsychotic use does not necessarily have detrimental effects on the QoL of patients with dementia; rather, NPS consistently and negatively affects QoL. The use of APs to treat NPS is justified when used carefully (i.e., their benefits and side effects should be monitored).

Association of stroke with the receptor-binding profiles of antipsychotics-a case-crossover study

BACKGROUND

Previous research suggests a link between antipsychotic use and stroke, but the relationships between receptor-binding profiles of antipsychotics and the risk of cerebrovascular events are unclear.

METHODS

A total of 14,584 patients with incident stroke were enrolled in the National Health Insurance Research Database in Taiwan from 1998 to 2007. We conducted a case-crossover study to compare the rates of antipsychotic use. The effects of receptor-binding profiles of antipsychotics on stroke risk were estimated, while the moderating effects of age, sex, presence of dementia, and duration of antipsychotic treatment were evaluated by stratified analyses.

RESULTS

The adjusted odds ratio of stroke risk with antipsychotics exposure was 1.60 (95% confidence interval, 1.51-1.69) using a 14-day time window. The use of antipsychotics with a high binding affinity of M1 muscarinic and α2 adrenergic receptors was associated with a greater risk of stroke than the use of other types of antipsychotics. An increased risk of stroke with antipsychotic use was noted in the patients who were older and/or who suffered from dementia. Moreover, our results showed that stroke risk with antipsychotic use was in a dose-related relationship.

CONCLUSIONS

Our findings suggest an association between stroke risk and high M1 muscarinic and α2 adrenergic affinity. The clinical implication is to start antipsychotics treatment at low dosages and to closely monitor the side effects in the initial treatment, particularly for individuals with older age and the presence of dementia.

Choice of observational study design impacts on measurement of antipsychotic risks in the elderly: a systematic review

Background

Antipsychotics are frequently and increasingly prescribed to treat the behavioural symptoms associated with dementia despite their modest efficacy. Evidence regarding the potential adverse events of antipsychotics is limited and little is known about the longer-term safety of these medicines in the elderly. The aim of this review was to determine the impact of the choice of observational study design and methods used to control for confounding on the measurement of antipsychotic risks in elderly patients.

Methods

We searched PUBMED and the Cochrane controlled trials register for double-blind randomised controlled trials (RCTs), meta-analyses and published observational studies of antipsychotics.

Results

Forty four studies were identified for the endpoints; death, cerebrovascular events, hip fracture and pneumonia. RCTs found a 20% to 30% increased risk of death, or an absolute increase of 1extra death per 100 patients with atypical antipsychotics compared to non-use. Cohort and instrumental variable analyses estimated between 2 to 7 extra deaths per 100 patients with conventional compared to atypical antipsychotics. RCTs found a 2 to 3 times increased risk of all cerebrovascular events with atypical antipsychotics compared to placebo and no association with serious stroke that required hospitalisation. Observational studies using cohort and self-controlled case-series designs reported similar results; no association where the endpoint was stroke causing hospitalisation and a doubling of risk when minor stroke was included. No RCTs were available for the outcome of hip fracture or pneumonia. Observational studies reported a 20% to 40% increased risk of hip fracture with both antipsychotic classes compared to non-use. The risk of pneumonia was a 2 to 3 times greater with both classes compared to non-use while a self-controlled case-series study estimated a 60% increased risk. Conventional antipsychotics were associated with a 50% greater hip fracture risk than atypical antipsychotics, while the risk of pneumonia was similar between the classes.

Conclusions

Choice of observational study design is critical in studying the adverse effects of antispychotics. Cohort and instrumental variable analyses gave more consistent results to clinical studies for mortality outcomes as have self-controlled case-series for the risk of cerebrovascular events and stroke. Observational evidence has highlighted the potential for antipsychotics to be associated with serious adverse events that were not reported in RCTs including hip fracture and pneumonia. Good quality observational studies are required, that employ appropriate study designs that are robust towards unmeasured confounding, to confirm the potential excess risk of hip fracture and pneumonia with antipsychotics.

Are atypical antipsychotics safer than typical antipsychotics for treating behavioral and psychological symptoms of dementia?

Atypical antipsychotics seem to be preferable than conventional agents in treating psychological symptoms of dementia (BPSD), because they have substantially lower risks of extrapyramidal neurological effects with lower reported rates of parkinsonism and tardive dyskinesia. However, in the course of time, with the increase in their use, more and more side effects have been reported. The benefits and risks of antipsychotic treatment should be carefully evaluated according to the co-morbidity and the severity of the psychological and behavioral symptoms and their impact on the individual elderly patient. It is recommended to keep those medications in the lower range of therapeutic doses. Due to the complexity of the individual patient, no guidelines have been yet established. Therefore, clinical judgment should be used in applying the dose and the type of those drugs.

Sundown syndrome in persons with dementia: an update

"Sundowning" in demented individuals, as distinct clinical phenomena, is still open to debate in terms of clear definition, etiology, operationalized parameters, validity of clinical construct, and interventions. In general, sundown syndrome is characterized by the emergence or increment of neuropsychiatric symptoms such as agitation, confusion, anxiety, and aggressiveness in late afternoon, in the evening, or at night. Sundowning is highly prevalent among individuals with dementia. It is thought to be associated with impaired circadian rhythmicity, environmental and social factors, and impaired cognition. Neurophysiologically, it appears to be mediated by degeneration of the suprachiasmatic nucleus of the hypothalamus and decreased production of melatonin. A variety of treatment options have been found to be helpful to ameliorate the neuropsychiatric symptoms associated with this phenomenon: bright light therapy, melatonin, acetylcholinesterase inhibitors, N-methyl-d-aspartate receptor antagonists, antipsychotics, and behavioral modifications. To decrease the morbidity from this specific condition, improve patient's well being, lessen caregiver burden, and delay institutionalization, further attention needs to be given to development of clinically operational definition of sundown syndrome and investigations on etiology, risk factors, and effective treatment options.

Risk of hospitalization for stroke associated with antipsychotic use in the elderly: a self-controlled case series

BACKGROUND

Antipsychotics are commonly used in the elderly despite a lack of safety data from randomized trials, particularly for the typical antipsychotics. Observational studies have investigated the association between antipsychotics and stroke but results vary, which may be due to lack of control for unmeasured confounding.

OBJECTIVE

To estimate the risk of hospitalization for stroke in elderly users of antipsychotics.

STUDY DESIGN AND SETTING

Using the Australian Government Department of Veterans' Affairs administrative claims dataset we utilized a self-controlled case series design to risk-adjust for potential unmeasured confounding. Risk periods prior to antipsychotic initiation were also included to search for evidence of confounding by indication. Unexposed patients were included to adjust for the increasing incidence of hospitalization for stroke with age.

RESULTS

There were 10 638 patients aged ≥65 years with at least one hospitalization for stroke identified during the 4-year period from 1 January 2003 to 31 December 2006. Of these, 514 patients were initiated on typical antipsychotics and 564 patients were initiated on atypical antipsychotics. Hospitalization for stroke was increased in the first week after initiation of a typical antipsychotic (incidence rate ratio [IRR] 2.3; 95% CI 1.3, 3.8). There was no evidence of an increased risk of hospitalization for stroke after initiation of atypical antipsychotics. The risk of hospitalization for stroke progressively increased in the weeks leading up to first-time antipsychotic treatment. However, while the risk of hospitalization for stroke in the week prior to initiating antipsychotic therapy was significantly increased for patients initiated on typical antipsychotics (IRR 7.2; 95% CI 5.3, 9.8), patients initiated on atypical antipsychotics had no excess risk in the same period (IRR 1.2; 95% CI 0.7, 2.3).

CONCLUSIONS

The results of this study are consistent with randomized controlled trial evidence indicating that there is no increased risk of serious cerebrovascular events requiring hospitalization in patients taking atypical antipsychotics. No randomized controlled trial evidence is available on the risk of hospitalization for stroke with use of typical antipsychotics in the elderly. This study found a small but significantly increased risk of hospitalization for stroke immediately following the initiation of typical antipsychotics. Antipsychotics are likely to be initiated after hospitalization for stroke. This practice is likely to reflect the prescribing of antipsychotics during hospital admission for post-stroke complications such as delirium; however, the long-term effects of this practice are unknown.

Risk of cerebrovascular adverse events and death in elderly patients with dementia when treated with antipsychotic medications: a literature review of evidence

Behavioral and Psychological Symptoms of Dementia (BPSD) are increasingly recognized as a major risk factor for caregiver burden, institutionalization, greater impairment in activities of daily living (ADLs), more rapid cognitive decline, and a poorer quality of life. BPSD contribute significantly to the direct and indirect costs of caring for patients with dementia even after adjusting for the severity of cognitive impairment and other co-morbidities. Research on these symptoms has indicated a complex interplay between the biological, psychological and social factors involved in the disease process. Although some psychotropic medications have shown modest efficacy in the treatment of these behaviors, their use has generated controversy due to increasing recognition of the side effects of these medications especially the antipsychotic medications. In this review, we examine the risk of cerebrovascular adverse events (CVAEs) and death with antipsychotic medications when used to treat elderly patients with dementia.

Combining electronic healthcare databases in Europe to allow for large-scale drug safety monitoring: the EU-ADR Project

PURPOSE

In this proof-of-concept paper we describe the framework, process, and preliminary results of combining data from European electronic healthcare record (EHR) databases for large-scale monitoring of drug safety.

METHODS

Aggregated demographic, clinical, and prescription data from eight databases in four countries (Denmark, Italy, Netherlands, the UK) were pooled using a distributed network approach by generation of common input data followed by local aggregation through custom-built software, Jerboa(©). Comparison of incidence rates of upper gastrointestinal bleeding (UGIB) and nonsteroidal anti-inflammatory drug (NSAID) utilization patterns were used to evaluate data harmonization and quality across databases. The known association of NSAIDs and UGIB was employed to demonstrate sensitivity of the system by comparing incidence rate ratios (IRRs) of UGIB during NSAID use to UGIB during all other person-time.

RESULTS

The study population for this analysis comprised 19,647,445 individuals corresponding to 59,929,690 person-years of follow-up. 39,967 incident cases of UGIB were identified during the study period. Crude incidence rates varied between 38.8 and 109.5/100,000 person-years, depending on country and type of database, while age-standardized rates ranged from 25.1 to 65.4/100,000 person-years. NSAID use patterns were similar for databases within the same country but heterogeneous among different countries. A statistically significant age- and gender-adjusted association between use of any NSAID and increased risk for UGIB was confirmed in all databases, IRR from 2.0 (95%CI:1.7-2.2) to 4.3 (95%CI: 4.1-4.5).

CONCLUSIONS

Combining data from EHR databases of different countries to identify drug-adverse event associations is feasible and can set the stage for changing and enlarging the scale for drug safety monitoring.

The elderly safety imperative and antipsychotic usage

Behavioral and psychotic symptoms are common problems in older adults, and as the population ages, understanding the benefits and risks of antipsychotic usage is increasingly important. In this age group, psychotic symptoms may occur in patients with dementia or as part of schizophrenia, mood disorders, delirium, or delusional disorder. Various antipsychotics have been studied in older adults with psychotic symptoms, demonstrating mixed, but real, benefit, especially in relation to carefully selected patients. Caution is required because of the potential side effects and risks, which include increased mortality and cardiovascular and cerebrovascular events. This article reviews the use of antipsychotics in older adults, with emphasis on the risks and side effects, particularly in dementia patients with behavioral and psychotic symptoms.

Risiken von Antipsychotika im Alter, speziell bei Demenzen 1Prof. Dr. Hans Gutzmann zum 60. Geburtstag gewidmet

Antipsychotika werden häufig zur Behandlung von herausforderndem Verhalten bei Demenz eingesetzt. Antipsychotika der zweiten Generation («atypische Neuroleptika») spielen dabei mittlerweile eine größere Rolle als die älteren Substanzen. Der nur mäßigen Wirksamkeit stehen schwerwiegende Risiken gegenüber: so ist unter allen Antipsychotika die Mortalität insgesamt erhöht, aber auch das Risiko für plötzlichen Herztod, Schlaganfallereignisse oder venöse Thrombosen. Die Unterschiede zwischen Antipsychotika der ersten und der zweiten Generation sind dabei gering: hochpotente Antipsychotika der ersten Generation führen häufiger zu extrapyramidalmotorischen Symptomen, unter Antipsychotika der zweiten Generation ist das allgemeine Mortalitätsrisiko wahrscheinlich etwas geringer, andererseits wahrscheinlich venöse Thrombosen und metabolische Nebenwirkungen häufiger. Für die übrigen Nebenwirkungen bestehen keine gesicherten Unterschiede. Angesichts der großen Heterogenität der Antipsychotika erscheint der Nutzen einer pauschalen Aufteilung in Antipsychotika der ersten und zweiten Generation fragwürdig. Für die Auswahl einer Substanz sind substanzspezifische Nebenwirkungen, Dosierung, Aufdosierungsgeschwindigkeit sowie Beachtung von Komorbidität, Kontraindikationen und Arzneimittelinteraktionen in Relation zum individuellen Patienten erheblich wichtiger als die Wahl nach bloßer pauschaler Zuordnung zu einer dieser beiden Gruppen. Am wichtigsten ist aber, dass Antipsychotika nur bei klarer Indikation zur Anwendung kommen!