Guidelines on antipsychotics for dementia: are we losing our minds?

Use of antipsychotic drugs and cholinesterase inhibitors and risk of falls and fractures: self-controlled case series

OBJECTIVE

To evaluate the association between the use of antipsychotic drugs and cholinesterase inhibitors and the risk of falls and fractures in elderly patients with major neurocognitive disorders.

DESIGN

Self-controlled case series.

SETTING

Taiwan's National Health Insurance Database.

PARTICIPANTS

15 278 adults, aged ≥65, with newly prescribed antipsychotic drugs and cholinesterase inhibitors, who had an incident fall or fracture between 2006 and 2017. Prescription records of cholinesterase inhibitors confirmed the diagnosis of major neurocognitive disorders; all use of cholinesterase inhibitors was reviewed by experts.

MAIN OUTCOME MEASURES

Conditional Poisson regression was used to derive incidence rate ratios and 95% confidence intervals for evaluating the risk of falls and fractures for different treatment periods: use of cholinesterase inhibitors alone, antipsychotic drugs alone, and a combination of cholinesterase inhibitors and antipsychotic drugs, compared with the non-treatment period in the same individual. A 14 day pretreatment period was defined before starting the study drugs because of concerns about confounding by indication.

RESULTS

The incidence of falls and fractures per 100 person years was 8.30 (95% confidence interval 8.14 to 8.46) for the non-treatment period, 52.35 (48.46 to 56.47) for the pretreatment period, and 10.55 (9.98 to 11.14), 10.34 (9.80 to 10.89), and 9.41 (8.98 to 9.86) for use of a combination of cholinesterase inhibitors and antipsychotic drugs, antipsychotic drugs alone, and cholinesterase inhibitors alone, respectively. Compared with the non-treatment period, the highest risk of falls and fractures was during the pretreatment period (adjusted incidence rate ratio 6.17, 95% confidence interval 5.69 to 6.69), followed by treatment with the combination of cholinesterase inhibitors and antipsychotic drugs (1.35, 1.26 to 1.45), antipsychotic drugs alone (1.33, 1.24 to 1.43), and cholinesterase inhibitors alone (1.17, 1.10 to 1.24).

CONCLUSIONS

The incidence of falls and fractures was high in the pretreatment period, suggesting that factors other than the study drugs, such as underlying diseases, should be taken into consideration when evaluating the association between the risk of falls and fractures and use of cholinesterase inhibitors and antipsychotic drugs. The treatment periods were also associated with a higher risk of falls and fractures compared with the non-treatment period, although the magnitude was much lower than during the pretreatment period. Strategies for prevention and close monitoring of the risk of falls are still necessary until patients regain a more stable physical and mental state.

Syndrome-Based Prescription to Optimize Psychotropics: Are CHROME Criteria a Game Changer?

A variety of medical and social factors have contributed over the last decades to the overuse of psychotropic drugs in people with dementia. One social factor is probably the frequent failure to provide adequate person-centered care, be it in the community or in institutional settings. This unfortunate reality has been reacted upon with numerous guidelines to reduce prescriptions of the most dangerous drugs (e.g., neuroleptics). Each psychotropic drug prescription can in principle be assessed around three dimensions: (a) adequate, (b) inadequate, and (c) chemical restraint. The CHemical Restraints avOidance MEthodology (CHROME) defined chemical restraint as any prescription based on organizational convenience, rather than justified with medical diagnosis. Two validation studies revealed that one of the main medical reasons of over- and miss-prescriptions was symptom-based prescription. By switching to syndrome-based prescription, a large proportion of drugs could be de-prescribed and some re-adjusted or kept. Paucity of research and weakness of data are not conclusive about the adequacy of specific drugs for the myriad of cases presented by patients with dementia and comorbid conditions. Clinical practice, however, leads us to believe that even under optimal care conditions, psychotropics might still contribute to quality of life if based on an adequate diagnosis. This article explains the rationale that underlies a syndromic approach aimed at optimizing psychotropic treatment in people with dementia whose significant suffering derives from their thought, affective, or behavioral problems. The results of previous validation studies of this new methodology will be discussed and conclusions for future results will be drawn.

Antipsychotics in people with dementia: frequency of use and rationale for prescribing in a UK mental health service

Aims and method

To determine how often and why antipsychotic medicines are prescribed to people with dementia. A cross-sectional survey of all clinical records was conducted in one National Health Service mental health trust.

Results

Of 946 people with dementia in the trust, 186 (20%) were prescribed an antipsychotic. Prevalence increased with the severity of dementia. The most common indication for initiating treatment was agitation/distress (70%), followed by verbal aggression (45%), psychotic symptoms (44%) and physical aggression (33%). The mean number of indications per patient was 2.6. In 58% of cases, the antipsychotic had been prescribed for more than a year, and a third of patients had not been reviewed in the past 6 months.

Clinical implications

People with dementia who are prescribed antipsychotic drugs generally display a range of challenging behaviours, but most notably are distressed. Systems for ongoing clinical review need improvement.

Assessing the overuse of medicines

The use of medicines has increased markedly in many countries over recent years, providing clear evidence of the increasing 'pharmacaeuticalisation' of society. This paper contributes to the sociological analysis of pharmaceuticalisation by starting to explore how we can begin to make judgements as to when and to what extent some medicines are being overused--an important aspect that, rather surprisingly, has not so far been the focus of attention those analysing the process. It considers the World Health Organisation's criteria for the 'rational' use of medicines, pointing to some of the issues they raise. It then develops a typology of over and underuse derived from these criteria. This provides a framework for the discussion of assessing overuse that focuses in particular on the widespread and increasing use of medicines that are not very effective for the conditions for which they are prescribed, and their use where the issue of clinical need is in doubt. Some of the factors that encourage overuse are also considered.