Unnecessary Use of Tranquillizers in Elderly Patients

Barton, Russell; Hurst, Lindsay

doi:10.1192/bjp.112.491.989

Cited by 59 publications

(29 citation statements)

References 3 publications

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“…Barton and Hurst (1966) found a deterioration in agitation, overactivity, resistiveness and 'noisiness'. Findlay et al (1989) reported no overall change in the level of behaviour disturbance, though, within this, some patients improved while others deteriorated quite markedly.…”

Section: Discussionmentioning

confidence: 96%

An audit of the use of antipsychotics in a geriatric psychiatry continuing care unit in Scotland

Connelly

1992

Int J Geriat Psychiatry

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SUMMARYBehaviour problems, dependency levels and use of antipsychotic medication were assessed, using an audit approach, in 104 patients in a geriatric psychiatry continuing care unit. High levels of dependency and behaviour disturbance were found. 37.5% of the population were receiving regular antipsychotic medication. The severity of a cluster of four symptoms (diurnal restlessness, agitation, irritability and active aggression) tended to discriminate this group from those on no antipsychotics, though frequency of problems and total number of problems were also higher in the group on regular antipsychotics. Antidepressants were rarely used, though conversely there was only one case of 'missed' depression. Changes following the audit are described and recommendations for improved monitoring of medication use are made.KEY WORDS-Dementia, audit, antipsychotic drugs, dependency, behaviour problems.The use of drugs to control behaviour disturbance associated with severe dementia is controversial. Antipsychotic drugs remain the first-line intervention though there is concern that they can be used inappropriately because of the difficulty in recognizing depression in severely demented patients. Studies tend to be complicated by methodological problems (Helms, 1985), by a sizeable non-response rate, and by the presence of side-effects despite the relatively low doses used. Schneider et al. (1990) found only seven studies (all inpatient) suitable for inclusion in a meta-analysis, reporting that in only 18% of cases could a clear drug effect be presumed. (Overall drug response 59% vs placebo response 41Y0.) They also report no significant differences between antipsychotic drugs used, though individual studies (Rada and Kellner, 1976;Petrie et al., 1982) suggest that high-potency antipsychotics are more effective than low-potency but have more side-effects. There is, however, no evidence to support the hypothesis that sedative compounds are more effective than non-sedating compounds, which suggests that clinical efficacy is a result of antipsychotic effects rather than the effect of 'blanket sedation'.Although large numbers of hospital beds are occupied by those with advanced dementia, there are few studies of the rates of antipsychotic use in this population (Christopher et al., 1978; Michel and Kolakowska 198 1 ;Gilleard et al., 1983; Mann et al., 1984). The first three found rates of 4248%, but the first two include 'prn' medication and all patients over the age of 65, without stating specifically how many had dementia, so rates are not strictly comparable. Mann et al. (1984) report lower rates (28%). Only Michel and Kolakowska (1981) reported numbers of patients on no psychotropics A number of studies examine specific behavioural problems in dementia (eg Burns et al., 1990;Berrios and Brook, 1985; Cummings et al., 1987;Merriam et al., 1988), but only Reisberg et al. (1987). Swearer et al. (1988) and Teri et al. (1988) give figures for total numbers showing behaviour problems in their (outpatient) study populations....

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Section: Discussionmentioning

confidence: 96%

An audit of the use of antipsychotics in a geriatric psychiatry continuing care unit in Scotland

Connelly

1992

Int J Geriat Psychiatry

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“…There are several other possible mechanisms by which neuroleptics might contribute to cognitive decline. The most parsimonious explanation is that the anticholinergic effect of the neuroleptics resulted in reduced attention 12 37. A second possibility is that both the faster cognitive decline and the persecutory ideas were due to unidentified episodes of delirium.…”

Section: Discussionmentioning

confidence: 99%

“…The side effects of neuroleptics include the worsening of behavioural disturbance of patients with dementia,10 11 12 falls,13 and fractures 14. The possibility that the cognitive function of patients with dementia may be made worse by neuroleptics has received little attention.…”

Section: Introductionmentioning

confidence: 99%

Do neuroleptic drugs hasten cognitive decline in dementia? Prospective study with necropsy follow up

McShane

Keene

Gedling

et al. 1997

BMJ

227

127

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Objective: To determine whether treatment with low dose aspirin and heparin leads to a higher rate of live births than that achieved with low dose aspirin alone in women with a history of recurrent miscarriage associated with phospholipid antibodies (or antiphospholipid antibodies), lupus anticoagulant, and cardiolipin antibodies (or anticardiolipin antibodies). Design: Randomised controlled trial. Setting: Specialist clinic for recurrent miscarriages. Subjects: 90 women (median age 33 (range 22-43)) with a history of recurrent miscarriage (median number 4 (range 3-15)) and persistently positive results for phospholipid antibodies. Intervention: Either low dose aspirin (75 mg daily) or low dose aspirin and 5000 U of unfractionated heparin subcutaneously 12 hourly. All women started treatment with low dose aspirin when they had a positive urine pregnancy test. Women were randomly allocated an intervention when fetal heart activity was seen on ultrasonography. Treatment was stopped at the time of miscarriage or at 34 weeks' gestation. Main outcome measures: Rate of live births with the two treatments. Results: There was no significant difference in the two groups in age or the number and gestation of previous miscarriages. The rate of live births with low dose aspirin and heparin was 71% (32/45 pregnancies) and 42% (19/45 pregnancies) with low dose aspirin alone (odds ratio 3.37 (95% confidence interval 1.40 to 8.10)). More than 90% of miscarriages occurred in the first trimester. There was no difference in outcome between the two treatments in pregnancies that advanced beyond 13 weeks' gestation. Twelve of the 51 successful pregnancies (24%) were delivered before 37 weeks' gestation. Women randomly allocated aspirin and heparin had a median decrease in lumbar spine bone density of 5.4% (range − 8.6% to 1.7%). Conclusion: Treatment with aspirin and heparin leads to a significantly higher rate of live births in women with a history of recurrent miscarriage associated with phospholipid antibodies than that achieved with aspirin alone.

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“…As all neuroleptic medications have significant side-effect profiles, especially in debilitated patients, it is crucial for the clinician to make accurate diagnoses before prescribing these drugs. This is by no means an easy task, and there have been signs that neuroleptics are often over-prescribed (10).…”

Section: General Indicationsmentioning

confidence: 99%

Antipsychotics in the elderly

Rosen¹,

Bohon²,

Gershon³

1990

Acta Psychiatr Scand

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Neuroleptics are commonly prescribed medications in the geriatric population and have a broader spectrum of indications than in younger patients. In spite of the frequent use of neuroleptics in elderly patients with organic brain syndromes, there are relatively few studies that use double-blind, placebo-controlled methodology. The results of these studies are conflicting; however, there is sufficient evidence that symptoms of agitation, behaviourial dyscontrol, and psychosis are often responsive to neuroleptic treatment. Elderly patients with schizophrenia or other psychotic disorders may also benefit from neuroleptic treatment. As there is a potential for overuse of these medications among the elderly, clear definition of checklist symptoms is imperative. Furthermore, periodic reduction of dose and possible discontinuation of the drug should be considered since many of the checklist symptoms in this age group are environmentally related and time-limited. There has so far been little evidence to support the use of one neuroleptic over another. Side-effect profiles suggest that low doses of the high potency agents are safer and better tolerated in the elderly. Both therapeutic effects 1 and side effects should be assessed at regular intervals.Neuroleptics are commonly prescribed in the geriatric population (1). It has been estimated that more than 90% of nursing home residents have a significant neuropsychiatric disability, and that perhaps 75% of these patients receive neuroleptics (2).0ther studies similarly suggest that the rates of neuroleptic use among the aged are high regardless of diagnosis. Prien (3) estimated in one nursing home sample that 20% of patients received neuroleptics. Gilleard et al. (4) surveyed the use of neuroleptics amongst patients in various settings. They found that the indications varied from setting to setting, and that disturbed mood or behaviour increased the probability of a patient receiving neuroleptics. Overall, 13% of patients in their sample had received neuroleptics in the 24 hours preceding their survey.The population at risk is enormous and increasing. At present about 11% (25 million) of the population of the USA is over the age of 65 years and current estimates suggest that the prevalence of dementia in those over that age is about 4% ( 5 ) and the incidence increases with age (6). Whereas about one million Americans are severely demented, it is estimated that by the year 2000, an additional 300,000 will be so affected (5). Over 75% of patients with dementia have disruptive behaviour or psychotic symptoms (7,8). With such a large population at risk, it is essential that the clinician be well-versed in the use of neuroleptics, and be aware of treatable symptoms.

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Unnecessary Use of Tranquillizers in Elderly Patients

Cited by 59 publications

References 3 publications

An audit of the use of antipsychotics in a geriatric psychiatry continuing care unit in Scotland

An audit of the use of antipsychotics in a geriatric psychiatry continuing care unit in Scotland

Do neuroleptic drugs hasten cognitive decline in dementia? Prospective study with necropsy follow up

Antipsychotics in the elderly

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