Intermittent antipsychotic medication and mortality in institutionalized older adults: A scoping review

Abstract

Objective/Background Antipsychotic use appears to increase mortality risk among older adults with dementia. Whether this risk is similar for regular or intermittent use is unknown. This scoping review aims to explore the temporal association between antipsychotic use and mortality risk for older institutionalized adults. Method We conducted a scoping review using Medline (PubMed), EMBASE, CINAHL, and the Cochrane libraries between October 2018 and January 2019. Results Twenty‐eight articles met review criteria. We found that different antipsychotic medications present different safety profiles. The risk of mortality was highest with conventional antipsychotic use and within 40 days of antipsychotic initiation. Conclusions Conventional antipsychotic use increases mortality for older institutionalized adults. The evidence for atypical antipsychotics is less clear. Mortality risk appears highest within 30 to 40 days of initiating antipsychotic treatment. This temporal association suggests increased mortality may actually be the result of some previously unrecognized illness, comorbidity, change in health status, or increased frailty, rather than an idiosyncrasy of the antipsychotic itself.

Effects of Antipsychotic Medication on Mortality in Long-Term Care Home Residents

“…The motivation that underlies the present research is to explain our earlier finding that daily use of antipsychotic medication ameliorates mortality, which contradicts conclusions reported in the majority of previous studies [9][10][11]. The research that follows analyzes the same database as our earlier chapter [1] to answer questions about the frequencies of concurrent combinations of antipsychotic with other psychotropic usage and their associations with subsequent mortality.…”

“…A final analysis in this section relates mortality to the duration of residence in a LTCH. Because previous reviews indicate higher mortality during the beginning phase of antipsychotic use, we would be remiss not to examine such effects [10,11]. We report at the beginning of this section that nearly half the deaths occurred within 90 days of the admission assessment.…”

“…Second, the majority of studies of relationships between antipsychotic medication and mortality report the type and dosage of medication but not the frequency of usage [11]. Although a few studies treat PRN use as an exclusionary criterion [11], it is more likely grouped with daily use in the majority of studies. The implications of such inclusion include augmented mortality beyond that associated with daily use.…”

“…Recent meta-analysis [10] and scoping reviews [11] draw the following conclusions about mortality and antipsychotic usage in elderly people. The mortality risks are comparable between typical and atypical antipsychotics, and approximately twice that of people without such usage.…”

“…The risks are comparable between individuals with or without dementia; they increase with dosage, and are highest during with first month(s) of usage. The latter suggests to authors of the scoping review [11] that factors other than antipsychotic medication may contribute to findings of elevated mortality. The authors of the meta-analytic study [10] recommend restriction and de-prescribing of antipsychotics with older people.…”