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Body of Information: Antipsychotics and dementia: the good and bad news

By TOM VALEO
Published December 20, 2005

When older people slip into dementia, they often develop symptoms of psychosis. They may hear voices of people long dead, or mistake a bush for a bear. Some may become paranoid or violent.

A physician may suggest calming the patient with one of the antipsychotic drugs that schizophrenics take to control their delusions and hallucinations. If you're caring for someone with Alzheimer's disease who has become agitated and aggressive, you may welcome a drug that promises to curb such disruptive behavior. Just remember that many of the newer antipsychotic drugs can cause serious side effects in the elderly: They even increase the risk of death.

An October article in the Journal of the American Medical Association reported that elderly patients taking newer antipsychotic drugs, known as "atypicals," experienced a 54 percent increase in their rate of death. The pharmaceutical companies have vigorously promoted these drugs by contending that they are safer than the "conventional" antipsychotics, but now doctors are questioning that assurance.

"The bottom line: We have to be more careful," said Dr. Lon Schneider, the lead author of the article, from his office at UCLA. "What this should mean to neurologists is that they should be adjusting dosage and monitoring their patients closely."

The older antipsychotics also have drawbacks. An article in December's New England Journal of Medicine reports that the conventional antipsychotics increase the death rate among elderly patients even more than the atypical drugs.

Why do antipsychotic drugs increase the risk of death among the elderly?

Schneider is not sure they do, at least not directly.

"Any drug that is somewhat sedative, that causes patients to spend more time in bed, increases risk for pneumonia, stroke, heart failure, pulmonary and deep-vein thromboses, urinary tract infections and so on," Schneider said.

However, Dr. Philip Wang, the lead author of the New England Journal of Medicine study, suspects that the drugs may affect heart rate, blood pressure, the swallowing reflex and other vital functions, thereby contributing directly to death.

While Wang admitted this is merely a hypothesis, he noted that the most common causes of death in the study were heart problems and infections.

Whether the drugs do or don't contribute directly to death, the fact remains that the brain of a person with Alzheimer's already has many problems with the messenger chemicals that transmit signals throughout the body. Drugs designed to help Alzheimer's patients, such as donepezil (sold as Aricept) and tacrine (sold as Cognex), work by boosting levels of messenger chemicals that are declining as neurons in the brain die.

But severe anxiety and agitation are among the most heartbreaking symptoms of Alzheimer's, and the behavior problems that result, such as belligerence and aggression, often make caring for one of these patients at home almost impossible.

Antipsychotic drugs clearly help calm such patients, which may enable family members to care for them longer. That's why many people caring for a family member with Alzheimer's disease welcome the use of antipsychotic medications, even though the drugs may increase the risk of death.

If these drugs provide a better life during an elderly person's final days, a shorter life might be an acceptable tradeoff.

- Tom Valeo is a freelancer who writes about medical and health issues. Write to him c/o Seniority, the St. Petersburg Times, P.O. Box 1121, St. Petersburg, FL 33731 or e-mail features@sptimes.com

[Last modified December 16, 2005, 12:40:06]