STEVE INSKEEP, host:

Doctors are suddenly struggling to find a safe way to manage the effects of dementia, such as delirium, agitation and psychosis. Those effects are all common in older people. Last spring, the Food and Drug Administration said newer antipsychotic drugs used for these conditions can kill some older people. And a study in this week's New England Journal of Medicine says older drugs may be even worse. NPR's Joanne Silberner reports that the study leaves physicians and patients in a quandary.

JOANNE SILBERNER reporting:

More than a quarter of Medicare patients in nursing homes are on some sort of antipsychotic medication. In April, the Food and Drug Administration issued a warning about newer antipsychotics such as Zyprexa, Apilophie(ph), Risperdal and Seroquel. The agency said that in short experimental trials, the drugs 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 Wong of Harvard and his colleagues figured that doctors might switch to the older antipsychotic drugs. The FDA said it was concerned about those drugs, too, but didn't have as much data.

Dr. PHILIP WONG (Harvard): We were interested in studying whether there was a risk from these older drugs.

SILBERNER: So they 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.

Dr. WONG: What we found is that the older, conventional drugs, if anything, have a higher risk, higher risk of death.

SILBERNER: Thirty-seven percent higher, in his study. That leaves physicians in a difficult position, says Yergin Blueda(ph). He's the director of geriatrics at Brigham and Women's Hospital in Boston.

Dr. YERGIN BLUEDA (Brigham and Women's Hospital): Well, what's going to happen now, especially if it's in The New England Journal, you are going to be, as a physician, increasingly under pressure not to use these medications.

SILBERNER: But Blueda says you can't leave full psychotic events in the elderly untreated.

Dr. BLUEDA: These people suffer from hallucinations. These people suffer from acute confusion. It's like I'm telling you or come to you and say, `Hello, I'm your son,' and you say, `I beg your pardon.' And you look around and everybody says, `Yes, that's your son.' And you think, `Am I losing my mind?' Or the patient sees, hallucinates and sees things which are frightening. They feel this. This is not just in their mind. They feel that. It is true to them. These people suffer from this. This is awful. And we have to, as physicians, treat this. It would be cruel and very poor standard of care not treating the psychosis.

SILBERNER: Blueda says there aren't good, safe alternatives.

Dr. BLUEDA: These behavioral issues in ...(unintelligible) they're agitated, will be treated with Benzodiazepines, with Valium-like medications, things which--or medications which we also don't want to use because they accumulate in the body, they are too sedated. They are at risk for falls because they're too sedated. So we use medications which are really not appropriate or we don't use any medications.

SILBERNER: In the meantime, 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.

Dr. WAYNE RAY (Vanderbilt University): These are very potent drugs. Reserve their use for instances when they're absolutely necessary.

SILBERNER: For his part, Yergin Blueda 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. Joanne Silberner, NPR News.

INSKEEP: This is NPR News.

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