going to give this student an A.....

[vistaril]

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She asks me(after covering geripsych unit one day for a colleague out) "so if second generation antipsychotics don't really work for all these
demented patients with behaviors, and they aren't formally indicated as a treatment, and they increase risk of death.....why are so many of the patients on them?"

my answer- hmmm, thats a good question.

 

[nexus73]

The first line behavioral interventions are not available at nursing homes...

 

[Old&InTheWay]

She asks me(after covering geripsych unit one day for a colleague out) "so if second generation antipsychotics don't really work for all these
demented patients with behaviors, and they aren't formally indicated as a treatment, and they increase risk of death.....why are so many of the patients on them?"

my answer- hmmm, thats a good question.

I think my non-flip answer is that in my experience, antipsychotics do indeed work to suppress some of the problematic behaviors in patients with dementia. They come with a whole host of side effects and I believe that in prescribing them, we are often essentially providing palliative sedation and in doing so sometimes shortening the length of a person's lifespan. Ultimately, we are treating patients in the context of a system that can't actually provide optimal care (as @nexus73 points out above) and are doing our best to address acute risk and distress (for patient, staff, and/or family).

 

[hebel]

I think my non-flip answer is that in my experience, antipsychotics do indeed work to suppress some of the problematic behaviors in patients with dementia. They come with a whole host of side effects and I believe that in prescribing them, we are often essentially providing palliative sedation and in doing so sometimes shortening the length of a person's lifespan. Ultimately, we are treating patients in the context of a system that can't actually provide optimal care (as @nexus73 points out above) and are doing our best to address acute risk and distress (for patient, staff, and/or family).

Quality of life over quantity.

 

[vistaril]

The first line behavioral interventions are not available at nursing homes...

yet they theoretically are on geripsych units(which are staffed by psych rns, MH techs, and a psychiatrist and/or psych np rounds) and nobody would argue that "first line behaioral interventions" are the foundation of what goes on in geripsych units. No, the dementia with behaviors patients are loaded up on meds, especially atypical antipsychotics.

One can argue "oh they just do this because they are going back to the nursing homes". And sure, some are(some arent as well btw). But what the hell does that say about geriatric psychiatry as a field?

I mean think about how powerful and sad that statement is- one of the foundations of what happens from a practical everyday perspective in the field is not clinically indicated, not effective, and has an increased risk of death.

 

[Old&InTheWay]

yet they theoretically are on geripsych units(which are staffed by psych rns, MH techs, and a psychiatrist and/or psych np rounds) and nobody would argue that "first line behaioral interventions" are the foundation of what goes on in geripsych units. No, the dementia with behaviors patients are loaded up on meds, especially atypical antipsychotics.

One can argue "oh they just do this because they are going back to the nursing homes". And sure, some are(some arent as well btw). But what the hell does that say about geriatric psychiatry as a field?

I mean think about how powerful and sad that statement is- one of the foundations of what happens from a practical everyday perspective in the field is not clinically indicated, not effective, and has an increased risk of death.

Are you saying that atypical antipsychotics make no difference in the behavior of aggressive patients with dementia? That has not been my clinical experience. Granted, it comes with serious side effects (including increased risk of death), but that doesn't mean it doesn't have an effect. Also, I'm not sure "clinically indicated" actually means anything.

 

[vistaril]

Are you saying that atypical antipsychotics make no difference in the behavior of aggressive patients with dementia? That has not been my clinical experience. Granted, it comes with serious side effects (including increased risk of death), but that doesn't mean it doesn't have an effect. Also, I'm not sure "clinically indicated" actually means anything.

A lot of things would 'make a difference'......do they have some effect? Sure. So would giving the patient a lot of things.

As for clinically indicated....use whatever clinical jargon you want. The bottom line is still the same

 

[Old&InTheWay]

A lot of things would 'make a difference'......do they have some effect? Sure. So would giving the patient a lot of things.

As for clinically indicated....use whatever clinical jargon you want. The bottom line is still the same

So what would you use instead? SSRIs can help a bit but don't seem sufficient to control really problematic behavior. Benzodiapines and opioids will cause delirium. I guess you could use isolation and mechanical restraints instead of meds but that would come with some serious ethical and safety risks. Euthanasia might be the most humane treatment, but given that that is frowned upon in this country, we choose from the imperfect tools available to us. Remember, we are talking about advanced dementia patients with unsafe and unmanageable behaviors, and who appear to be living in near constant distress.

Regarding your bottom line, I think that based upon your response it's not the same at all, and you'd actually have to revise it to something like "one of the foundations of what happens from a practical everyday perspective in the field is somewhat effective, and has an increased risk of death."

Also FYI, the use of APs is supported both ethically (in terms of QOL) and by literature (when behavior is severe and other approaches have failed) so they are indeed a reasonable choice for a subset of dementia patients.

Use of atypical antipsychotics in the elderly: a clinical review - PMC

The use of atypical antipsychotic drugs in the elderly has become wider and wider in recent years; in fact, these agents have novel receptor binding profiles, good efficacy with regard to negative symptoms, and reduced extrapyramidal symptoms. ...

www.ncbi.nlm.nih.gov

SAGE Journals: Your gateway to world-class research journals

Subscription and open access journals from SAGE Publishing, the world's leading independent academic publisher.

journals.sagepub.com

A systematic review of the efficacy and safety of atypical antipsychotics in patients with psychological and behavioral symptoms of dementia - Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews - NCBI Bookshelf

 

[TexasPhysician]

She asks me(after covering geripsych unit one day for a colleague out) "so if second generation antipsychotics don't really work for all these
demented patients with behaviors, and they aren't formally indicated as a treatment, and they increase risk of death.....why are so many of the patients on them?"

my answer- hmmm, thats a good question.

That’s a fairly basic question. Obviously they do work, and there is research supporting them. They just come at a price.

Typical facilities do not have the staff to manage difficult behaviors. They could raise prices to do so, but many don’t have funds to support that. Caregivers at home get burnt out. The end result is the same - a lack of behavioral interventions.

 

[vistaril]

That’s a fairly basic question. Obviously they do work, and there is research supporting them. They just come at a price.

Typical facilities do not have the staff to manage difficult behaviors. They could raise prices to do so, but many don’t have funds to support that. Caregivers at home get burnt out. The end result is the same - a lack of behavioral interventions.

where is this research stating they work good?

 

[Old&InTheWay]

where is this research stating they work good?

What do you mean by "good"? I don't think anyone here has made claims as to how well they work. You clearly have strong feelings about this topic which can sometimes make it difficult to approach such discussions objectively and openly. As it is not clear to me that you are engaging in this discussion in good faith, I'm not sure there is much more I can constructively add. Anyhow, I posted three recent reviews a few posts above which generally conclude that they have modest efficacy; hopefully they are helpful in answering your questions.

 

[FlowRate]

where is this research stating they work good?

Behavioral and Psychological Symptoms of Dementia - PMC

Behavioral and psychological symptoms of dementia (BPSD), also known as neuropsychiatric symptoms, represent a heterogeneous group of non-cognitive symptoms and behaviors occurring in subjects with dementia. BPSD constitute a major component of the ...

www.ncbi.nlm.nih.gov

 

[Stagg737]

So what would you use instead?

We typically use Trazodone first line where I'm at. Anywhere between 12.5mg to 50mg up to QID depending on how fragile and agitated a patient is. It's not on AGS Beers Criteria at all whereas all antipsychotics have moderate quality evidence and strong consensus recommendation to avoid unless a patient has bipolar or schizophrenia and APs have the same ratings specifically for patients with NCD. Where I'm at trazodone works wonderfully a fair amount of the time without the nasty antipsychotic side effects, especially given that Seroquel is often chosen as the go-to AP.

Depakote in low doses is also a much better long-term option if something scheduled is needed. Results in studies vary significantly, but we've had patients on doses as low as 125mg BID do really well with it and require very minimal PRNs.

For some context, our geri-psych rotation was on a unit with almost exclusively neurocog patients with a random bipolar or psychotic patient here and there. The attending had a policy that unless someone had active mania or schizophrenia, APs were to not be used on the unit. Period. I expected the unit to be messy, but I was very surprised how infrequently behavioral interventions were necessary and how well a lot of the patients were doing. I've really cut down on how often I recommend APs in agitated patients with delirium or NCDs and when I do I've usually been suggesting much lower doses. Sometimes APs are necessary, but there's other medications options that can and should be attempted first, especially if needing something scheduled long-term.

PS: Any facility that doesn't have activity vests for delirious patients needs to make an investment in them yesterday. Most effective treatment I've seen for mild to moderate agitated delirium.

 

[vistaril]

What do you mean by "good"? I don't think anyone here has made claims as to how well they work. You clearly have strong feelings about this topic which can sometimes make it difficult to approach such discussions objectively and openly. As it is not clear to me that you are engaging in this discussion in good faith, I'm not sure there is much more I can constructively add. Anyhow, I posted three recent reviews a few posts above which generally conclude that they have modest efficacy; hopefully they are helpful in answering your questions.

yeah none of those links are saying they are really effective or very good...side effects/risks aside.

 

[FlowRate]

yeah none of those links are saying they are really effective or very good...side effects/risks aside.

You're kinda "begging the question." There's no "very effective and good" treatment for BPSD. But there is evidence for a lot of approaches, including antipsychotics.

Everyone's in agreement with you that antipsychotics are overused, but it's not that they're totally useless/inappropriate.