Elderly Patients with Psychosis Pose Treatment Dilemma

Delirium, agitation and psychosis are common in older people with dementia. Last spring the Food and Drug Administration (FDA) said newer antipsychotic drugs used for these conditions can kill some older people. And now, a new study in this week's New England Journal of Medicine says older drugs may be worse.

More than a quarter of Medicare patients in nursing homes are on some sort of antipsychotic medication. In April, the FDA said that in short experimental trials, newer drugs like Abilify, Zyprexa, Risperdal and Zyprexa increased the death rate from an average of 2.6 percent to 4.5 percent. Most of the excess deaths were from heart problems or pneumonia.

Psychiatrist and epidemiologist Philip Wang of Harvard and his colleagues figured that doctors might switch to the older antipsychotic drugs. Then the FDA said it was concerned about those drugs, too, but didn't have as much data.

So Wang and his colleagues gathered what data they could — records on 23,000 elderly Pennsylvanians enrolled in a state assistance program. The researchers compared death rates of those on older antipsychotics such as Haldol, Thorazine and Stelazine to death rates on the newer drugs.

They found that the older, conventional drugs were associated with a 37 percent higher death rate.

Faced with warnings on both groups of antipsychotic drugs, physicians are in a difficult position, says Juergen Bludau, director of clinical geriatrics at Brigham and Women's Hospital in Boston. Psychotic events in the elderly can't be left untreated, says Bludau. The confusion and hallucinations can be awful, both for the patient and the caregiver. And there aren't good, safe alternatives, he says. Drugs like Valium are too sedating.

Epidemiologist Wayne Ray of Vanderbilt University says recognizing the risk of these drugs has one benefit. Antipsychotics can be used to sedate people who don't have psychosis, making elderly people easier to handle. Ray says this study might limit overuse of the drugs.

For his part, Bludau will continue to prescribe the drugs, carefully and in low doses. He says they can mean the difference between having to institutionalize disoriented people, and keeping them alert and at home.

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