Balancing the benefits and risks of antipsychotic use in elderly patients

Abstract

The use of antipsychotics to treat behavioral problems in dementia is common but controversial. This thesis aims to increase the knowledge about the prevalence and the effectiveness of antipsychotics among patients with dementia in Dutch long term care facilities (LTCFs), and to increase the knowledge of cardiovascular adverse effects. We assessed differences in the prevalence of antipsychotic use among patients with dementia in different LTCFs in the Netherlands, using the VU University Resident Assessment Instrument Database (VURAI-DB), which contains functional, cognitive and behavioral items of patients residing in LTCFs, and facility-level resident satisfaction surveys from the National Institute for Public Health and the Environment (RIVM). We found a remarkable large variability in antipsychotic drug use (5%-52%), which could not be fully explained by differences in the prevalence of behavioral symptoms between the facilities. Facilities with a high prevalence of antipsychotic use were associated with average to below average satisfaction with staff, personal care and choice of activities. Facilities with a high prevalence of antipsychotic use were often large and located in an urban area. The available scientific evidence demonstrates that the effectiveness of antipsychotics is limited, and cannot explain the high prevalence of antipsychotic use. Therefore, we assessed the reasons why experienced elderly care physicians prescribe antipsychotics, and asked them about their expectations of the intended effects and side effects. The interviewed elderly care physicians expected that almost half of their patients with dementia and behavioral problems benefit from antipsychotics. Serious side effects are thought to occur only sporadically. We described the course of behavioral problems in patients with dementia during treatment with antipsychotics, using the VURAI-DB. The severity of behavioral problems increased in most patients, with only one in six patients improving. Although we do not know how this increase would have been without treatment, these results indicate that the effect is limited. The use of antipsychotics in patients with dementia has been associated with an increased mortality. We examined three possible cardiovascular complications of antipsychotic use in elderly patents witch may contribute to this increased mortality. These studies were conducted using the PHARMO database. This database contains information from public pharmacies that are linked to hospital discharge data. Exposure to antipsychotics was associated with an increased risk of cerebrovascular adverse events compared to nonusers (odds ratio [OR] 1.7). A novel finding was the strong temporal relationship; the OR for use less than one week was 9.9. We examined the risk of venous thrombosis and pulmonary embolism in elderly patients taking antipsychotics. We found no relationship between antipsychotics and the risk of venous thromboembolism. Antipsychotic use has been associated with an increased risk of developing metabolic syndrome, diabetes and hyperlipidemia. We therefore looked at the risk of acute coronary syndrome in elderly antipsychotic users. We found a reduced risk of hospitalization for ACS in elderly patients who use antipsychotics. Further research is needed to determine whether there is a true cardioprotective effect of antipsychotics or the results are biased by a low referral rate among elderly antipsychotic drug users with acute myocardial infarction.