Antipsychotics & Risk of Mortality in Patients with Dementia

Risk of Mortality Among Individual Antipsychotics in Patients With Dementia
Am J Psychiatry 2012;169:71-79.


Objective:
The use of antipsychotics to treat the behavioral symptoms of dementia is associated with greater mortality. The authors examined the mortality risk of individual agents to augment the limited information on individual antipsychotic risk.

Method:
The authors conducted a retrospective cohort study using national data from the U.S. Department of Veterans Affairs (fiscal years 1999–2008) for dementia patients age 65 and older who began outpatient treatment with an antipsychotic (risperidone, olanzapine, quetiapine, or haloperidol) or valproic acid and its derivatives (as a nonantipsychotic comparison).

Results:
- Haloperidol was associated with the highest mortality rates (relative risk=1.54, 95% confidence interval [CI]=1.38–1.73) followed by risperidone, olanzapine (relative risk=0.99, 95% CI=0.89–1.10), valproic acid and its derivatives (relative risk=0.91, 95% CI=0.78–1.06), and quetiapine (relative risk=0.73, 95% CI=0.67–0.80).
- The mortality risk with haloperidol was highest in the first 30 days but decreased significantly and sharply thereafter.
- Among the other agents, mortality risk differences were most significant in the first 120 days and declined in the subsequent 60 days during follow-up.

Conclusions:
There may be differences in mortality risks among individual antipsychotic agents used for treating patients with dementia. The use of valproic acid and its derivatives as alternative agents to address the neuropsychiatric symptoms of dementia may carry associated risks as well.

Read the full article: http://ajp.psychiatryonline.org/article.aspx?articleid=181225

Admin wrote:Risk of Mortality Among Individual Antipsychotics in Patients With Dementia
Am J Psychiatry 2012;169:71-79.


Objective:
The use of antipsychotics to treat the behavioral symptoms of dementia is associated with greater mortality. The authors examined the mortality risk of individual agents to augment the limited information on individual antipsychotic risk.

Method:
The authors conducted a retrospective cohort study using national data from the U.S. Department of Veterans Affairs (fiscal years 1999–2008) for dementia patients age 65 and older who began outpatient treatment with an antipsychotic (risperidone, olanzapine, quetiapine, or haloperidol) or valproic acid and its derivatives (as a nonantipsychotic comparison).

Results:
- Haloperidol was associated with the highest mortality rates (relative risk=1.54, 95% confidence interval [CI]=1.38–1.73) followed by risperidone, olanzapine (relative risk=0.99, 95% CI=0.89–1.10), valproic acid and its derivatives (relative risk=0.91, 95% CI=0.78–1.06), and quetiapine (relative risk=0.73, 95% CI=0.67–0.80).
- The mortality risk with haloperidol was highest in the first 30 days but decreased significantly and sharply thereafter.
- Among the other agents, mortality risk differences were most significant in the first 120 days and declined in the subsequent 60 days during follow-up.

Conclusions:
There may be differences in mortality risks among individual antipsychotic agents used for treating patients with dementia. The use of valproic acid and its derivatives as alternative agents to address the neuropsychiatric symptoms of dementia may carry associated risks as well.

Read the full article: http://ajp.psychiatryonline.org/article.aspx?articleid=181225

Following Information is from "Medscape Psychiatry":

- The crude 6-month mortality rates were 20.0% for haloperidol, 12.6% for olanzapine, 12.5% for risperidone, 9.8% for valproic acid and its derivatives, and 8.8% for quetiapine.
- Although these numbers seem high, they represent mortality in persons with severe illness and possible delirium.
- A substantial amount of selection bias is also present: Patients taking haloperidol were older and sicker, and they generally received their prescriptions at nonpsychiatric visits.
- The investigators also suggest that persons with milder dementia or less urgent behavioral disturbances could have preferentially received prescriptions for quetiapine, because there is no rapid-acting form of quetiapine as there is for other atypical antipsychotics.

** Readers are reminded that a black-box warning is present in labeling for all antipsychotics regarding increased mortality in elderly patients with dementia-related psychosis and that no antipsychotic is currently approved for this indication **

Source: http://www.medscape.com/viewarticle/757750

Here is an old but very important post on this topic from "Forum For Psychiatry Residents":

Minimizing medicolegal liability when prescribing atypical antipsychotics for dementia-related behavioral disturbances.


Some of my older patients with dementia develop severe behavioral disturbances, and when other treatments don’t work, I sometimes use second-generation antipsychotics (SGAs) to help them cope better. But I worry about the liability I might face because of the “black-box” warning about prescribing SGAs to these patients. How can I minimize the legal risks of doing this?

Read this link: http://bit.ly/zzFq9O

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