Psychotropic medication use for behavioral symptoms of dementia

Wang, Philip S.; Brookhart, M. Alan; Setoguchi, Soko; Patrick, Amanda R.; Schneeweiß, Sebastian

doi:10.1007/s11910-006-0051-6

Cited by 13 publications

(17 citation statements)

References 50 publications

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“…Reasons for this APM use include dementia, delirium, psychosis, agitation, and affective disorders, with much use outside FDA-approved indications 4,5. In addition to rising use, there have been rapid shifts from first-generation conventional agents (e.g., haloperidol, phenothiazines, and butyrophenones) to heavily marketed second-generation atypical agents (e.g., aripiprazole, clozapine, olanzapine, quetiapine, risperidone, and ziprasidone) 6…”

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confidence: 99%

Assessing Residual Confounding of the Association between Antipsychotic Medications and Risk of Death using Survey Data

et al. 2009

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Objectives Studies using linked claims databases found that conventional antipsychotic medications (APMs) were associated with short-term mortality compared with atypical APMs. It has been suggested that such results may be due to residual confounding by factors that cannot be measured in claims databases. Using detailed survey data we identified the direction and magnitude of such residual confounding. Design Cross-sectional survey data Setting Medicare Current Beneficiary Survey (MCBS) Participants 17,776 survey participants ≥ 65 years Measurements To determine the association between conventional APM use and potential confounding factors we assessed 5 factors not measured in Medicare claims data but in the MCBS: body mass index, smoking, activities of daily living (ADL) score, cognitive impairment, and Rosow-Breslau physical impairment scale. We estimated adjusted associations between these factors and APM use. Combined with literature estimates of the independent effect of confounders on death we computed the extent of residual confounding caused by a failure to adjust for these factors. Results Comparing conventional APM users with atypical APM users, we found that not adjusting for impairments in ADL score led to an underestimation of the association with death (-13%) as did a failure to adjust for cognitive impairment (-7%). All 5 unmeasured confounders combined resulted in net confounding of -5% (range: -19% to +2%). After correction, the reported association between conventional APM use and death compared with atypical APM use was slightly increased from RR= 1.37 to RR = 1.44 (95% confidence interval: 1.33 to 1.56). Comparing any APM use with non-users would result in overestimations of > 50% if cognitive impairment remained unadjusted. Conclusion Claims data studies tend to underestimate the association of conventional APMs with death compared with atypical APMs because of residual confounding by measures of frailty. Studies comparing APM use with non-users may substantially overestimate harmful effects of APMs.

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confidence: 99%

Assessing Residual Confounding of the Association between Antipsychotic Medications and Risk of Death using Survey Data

et al. 2009

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“…These medications tend to be used because the effectiveness of psychosocial and behavioural interventions remains unclear, and because implementation of those alternate interventions is often hampered by a lack of resources. 1 In nursing homes, psychotropic agents are given to up to twothirds of dementia patients. [2][3][4][5] The safety of antipsychotic medications in older adults has been called into question.…”

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confidence: 99%

“…[6][7][8][9][10][11] Given this problematic safety record, physicians may increasingly resort to alternative psychotropic agents for management of behavioural symptoms in older adults. 1,12,13 However, comparative studies of the safety of other classes of psychotropic medications in such patients have not been conducted.…”

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“…Rigorous methodologic approaches need to be applied to ensure that epidemiologic studies are unbiased by the selective prescribing that occurs in nonrandomized studies. 1 We aimed to examine the association between various classes of psychotropic medications and a range of unintended health outcomes among older adults admitted to nursing homes. We focused on patients in nursing homes because use of psychotropic medication is known to be extensive in this setting, [2][3][4][5] and medication safety is of particular concern given the complex array of medical illnesses among these patients.…”

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Risk of death and hospital admission for major medical events after initiation of psychotropic medications in older adults admitted to nursing homes

Huybrechts¹,

Rothman²,

Silliman³

et al. 2011

Canadian Medical Association Journal

109

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Research CMAJBackground: Despite safety-related concerns, psychotropic medications are frequently prescribed to manage behavioural symptoms in older adults, particularly those with dementia. We assessed the comparative safety of different classes of psychotropic medications used in nursing home residents. Methods:We identified a cohort of patients who were aged 65 years or older and had initiated treatment with psychotropics after admission to a nursing home in British Columbia between 1996 and 2006. We used proportional hazards models to compare rates of death and rates of hospital admissions for medical events within 180 days after treatment initiation. We used propensity-score adjustments to control for confounders. CI 0.86-1.94 for antidepressants). Users of benzodiazepines had a higher risk of death (RR 1.28, 95% CI 1.04-1.58) compared with users of atypical antipsychotics. The RR for heart failure was 1.54 (95% CI 0.89-2.67), and for pneumonia it was 0.85 (95% CI 0.56-1.31). ResultsInterpretation: Among older patients admitted to nursing homes, the risks of death and femur fracture associated with conventional antipsychotics, antidepressants and benzodiazepines are comparable to or greater than the risks associated with atypical antipsychotics. Clinicians should weigh these risks against the potential benefits when making prescribing decisions. Abstract

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“…5 APs are frequently used in this setting for behavioral disturbances that may accompany dementia, such as aggression and agitation 6 ; however, such use is generally considered outside the U.S. Food and Drug Administration-approved indications. 7 …”

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confidence: 99%

Association of Antipsychotic Use With Hospital Events and Mortality Among Medicare Beneficiaries Residing in Long-Term Care Facilities

Simoni

Ryder

Qian

et al. 2009

The American Journal of Geriatric Psychiatry

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Objective Antipsychotic (AP) utilization has grown significantly in long-term care (LTC) settings. Although a growing literature associates AP use with higher mortality in elderly with dementia, the association of APs with hospital events is unclear. The authors examine prevalence and trends in AP use by Medicare beneficiaries residing in LTC and the association of APs and other drug use variables with hospital events and mortality. Design Retrospective analysis using sequential multivariate Cox proportional hazards models. Setting Medicare Current Beneficiary Survey linked to Institutional Drug Administration and Minimum Data Set files. Participants A total of 2,363 LTC Medicare beneficiaries, 1999–2002. Measurements Trends in LTC AP use overall and by type and duplicative use; association of AP utilization and two outcomes: hospital events and all-cause mortality. Results AP use rose markedly from 1999 to 2002 (26.4%–35.9%), predominantly due to increased use of atypical agents. After controlling for sociodemographic and clinical factors, AP use is not related to hospital events (hazard ratio [HR] = 0.98, 95% confidence interval [CI] = 0.82–1.63 p = 0.7951). AP use is associated with reduced mortality in unadjusted and intermediate models, but loss of significance in the final model (HR = 0.83, 95% CI = 0.69–1.00, p = 0.0537) suggests that disease and drug burden factors may confound the AP-mortality relationship. Conclusion This study provides no evidence of increased hospital events or mortality in LTC residents who use AP medications. Findings contribute to a growing body of evidence that APs, particularly atypical agents, may be associated with reduced mortality in LTC residents.

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Psychotropic medication use for behavioral symptoms of dementia

Cited by 13 publications

References 50 publications

Assessing Residual Confounding of the Association between Antipsychotic Medications and Risk of Death using Survey Data

Assessing Residual Confounding of the Association between Antipsychotic Medications and Risk of Death using Survey Data

Risk of death and hospital admission for major medical events after initiation of psychotropic medications in older adults admitted to nursing homes

Association of Antipsychotic Use With Hospital Events and Mortality Among Medicare Beneficiaries Residing in Long-Term Care Facilities

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