My condolences if your father is experiencing some symptoms of dementia.
Given that the atypicals have been connected to increased mortality in elders with dementia, is that outcome included as part of the rationale for prescribing?
I certainly hope a doctor would do so. I have recommended antipsychotics to demented patients, but did so when the benefit outweighed the risk. E.g. a demented patient who is throwing items at staff, is paranoid & agitated, threatening staff etc. The risk of danger to the patient (not even considering the staff) is far higher to the patient vs the risk of death from an antipsychotic.
If a practitioner were to not take the black box warning into consideration, that IMHO would be a violation of the standard of care. Blackbox warnings as far as I know in all 50 states should be considered as part of the standard of care (I'm only throwing geography into this because standard of care is often times defined by a local geographical standard).
Take this into consideration. Physical restraints cause death in about 1% of those restrained. That's higher than the mortality caused by antipsychotics use in demented patients. That's not considering the morbidity (broken bones, cuts, bruises, etc) with physical restraints which is far higher than 1%.
In cases where the demented patient is dangerous enough to justify restraints, there's pretty much no question that the benefit of an antipsychotic outweighs the risks because the alternative--restraints already has a good data pool on its level of morbidity & mortality that exceeds that of antipsychotics on demented patients. However in patients that are very difficult to manage that do not meet justifiable grounds for restraint--this is a grey area that will lead to some debate and several differing opinions. In cases such as that, and assuming the person lacks capacity (e.g. a patient who is not responding to verbal redirection, causing some disruption on the unit, but not in a dangerous manner), I recommend to call the patient's guardian or next of kin or someone with power of attorney of the situation, appraise them of the situation, warn them of the risks & benefits of an antipsychotic, and ask them if they would allow an antipsychotic be prescribed, or would like other interventions attempted.
Any person diagnosed with early signs of dementia IMHO should be advised by their doctor of the prognosis, and have that person pre-plan what type of care will be given to them when they lose capacity to make their own medical decisions. Unfortunately, during my experience in CL psychiatry, I've rarely seen patients with such end of life planning. In fact, I've seen a few doctors recommend an antipsychotic to a patient they diagnosed as having dementia when that patient didn't even meet DSM criteria for dementia, nor was showing any signs of danger, in fact were showing no symptoms of dementia. (This was very frustrating for me because I'd spend several hours trying to clear up why they were diagnosed with dementia in the first place, which is very difficult given the medical floor attending often times did not make the diagnosis, and the PCP starts playing defensive medicine when you call them up and ask for a justification of dementia when that patient scored a perfect 30/30 on the MMSE & has no symptoms of dementia).
I would though for the safety of the health care providers & patient detail the grey area I mentioned above, and discuss this with the patient, so that patient could pre-plan what type of management they would like. This will make life much easier not only for the health care provider, but for the patient & their loved ones should that patient eventually reach a point where they are very difficult to manage.
But does it cross any presciber's mind that a "fortunate" side effect might be that the individual may not live as long suffering with dementia?
It may. This is often times a typical USMLE question--a patient has a terminal illness and has high intensity chronic pain. The question is something to the effect of--the only dosage of opioid strong enough to treat the pain may be life threatening. Do you administer the medication?
This question is pretty complicated, and quite complex. Some patients may while having capacity have clear mandated instructions requesting their doctor to take more drastic & life threatening actions. Others may not. If any actions were taken by a doctor that could lead to a loss of life or morbidity that was within the realm of reason--that doctor should take some precautions--as I mentioned above, or perhaps an ethical committee consult or 2nd opinion.
