Physicians prescribe antipsychotic medications to the elderly at a disproportionate rate. The prevalence of dementia within the elderly population, often associated with Alzheimer’s disease or critical illness, calls for pharmaceutical solutions. In residential-care facilities, antipsychotic drugs are often seen as “chemical restraints,” and public health officials have expressed concern that these medications are overused. Evidence has pointed to the likelihood that the typical antipsychotic agents—those that have been in circulation for several decades—may result in higher mortality rates among the elderly. The recent development of atypical antipsychotic drugs has led to a shift in prescribing patterns. Doctors are now more likely to prescribe one of the atypical medications rather than the older, typical antipsychotic drugs.
Following on the heels of a similar study in America, a Canadian study sought to quantify the relative mortality rates for elderly people prescribed one of the two classes of antipsychotic drugs. They analyzed a database of current patients in the Canadian health-care system, identifying more than 37,000 elderly people for inclusion. Researchers made every effort to account for intervening variables such as prior health conditions and socioeconomic status. Both the American and Canadian studies concluded that in the elderly population, age and frailty combined lead to a higher incidence of mortality, often unrelated to medications. For example, a history of cardiovascular disease or cancer may lead to early onset dementia and premature death. A prescription for an antipsychotic medication, then, can’t always be considered a factor in an individual’s mortality.
Researchers in the Canadian study looked to the first 180 days of use of an antipsychotic drug as their test period. For those individuals prescribed a typical antipsychotic medication, the mortality rate during that period was about 14%. Of all the atypical antipsychotics, Loxitane (loxapine) produced the least significant bump in mortality, while Haldol (haloperidol) was statistically the most dangerous. With the newer class of antipsychotics, mortality was slightly less than 10%. Risperdal (risperidone) was the safest among the new class of antipsychotic drugs. That 4% variation between the two drug classes appears significant, and it is. In fact, recent guidelines from the U.S. Food and Drug Administration recommend against the prescription of typical antipsychotics for the most frail and elderly patients, unless absolutely necessary.
The lesson to be learned from the Canadian study and all those before it is clear. Caution must always be taken when prescribing antipsychotic medications, especially to the elderly. Furthermore, doctors should be reluctant to prescribe the older variety of antipsychotic drugs to members of this population. The potential benefits rarely outweigh the risks.
Schneeweiss, S., Setoguchi, S., Brookhart, A., Cormuth, C., Wang, P. (2007). Risk of death associated with the use of conventional versus atypical antipsychotic drugs among elderly patients. Canadian Medical Association Journal, 176(5), 627-632.
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