By: Dr. Geoffrey Modest
There was an article in the NY Times highlighting the overuse of anti-psychotics in the elderly in nursing homes. The basic thrust is that federal investigators “have found evidence of widespread overuse of psychiatric drugs by older Americans with Alzheimer’s disease, and are recommending that Medicare officials take immediate action to reduce unnecessary prescriptions”, especially of “abilify, risperdal, zyprexa and clozapine”. They also comment that “officials need to focus on overuse of such drugs by people with dementia who live at home or in assisted living facilities”.
So, this brings up a really muddy issue. On the one hand, there is undoubtedly inappropriate drugging of elderly patients with dementia to compensate for understaffed nursing homes, using these medications to “medically constrain” patients (ie, putting them to sleep, or at least rendering them placid). This is clearly an abusive practice. And there are even frankly egregious examples of physician self-interest (they quote a Chicago psychiatrist who “pleaded guilty last month to taking illegal kickbacks of nearly $600,000 to prescribe an antipsychotic drug for his patients” and ultimately agreed to pay $3.79 million to the feds and state of Illinois, and the drug company took a $27.6M hit). But, on the other hand, I have had several elderly patients with dementia who really have needed antipsychotics. Typically, these are people with significant paranoia, who are themselves very unhappy (ie, scared, distrustful of their family caregivers) and set up a dynamic whereby the family caregivers are really not capable of continuing taking care of the patient (the patient is paranoid and not able to trust any help offered, and lashes out at the caregiver). And in these cases, sertraline works quite well for helping with the anxiety associated with dementia (again, making the patient happier and more comfortable, as well as the caregiver), but I am certain that my prescribing lowish doses of quetiapine (up to 125mg or so) for the paranoia or more psychotic features has made the patient happier, more communicative with their caregiver, and permitted the caregiver to keep the patient in the home (which is so much better for all concerned). I do discuss the potential adverse effects, such as the possibility of premature death with this class of meds (ie, the “black box warning”), but in each case the caregiver has been willing to take that risk in order to continue taking care of their parent at home.
What does this all mean? My sense is that there really is an important place for antipsychotics in the care of the elderly, but as with most medical interventions, there is a potential for abuse. Sometimes that is clear (the oncologists getting huge amounts of money for providing and administering chemotherapeutic agents, or the physician who charges exorbitantly for lab tests or EKGs done in their own labs). Sometimes it is less clear (controlling agitated patients in the setting of understaffed nursing homes). But the effect of articles in the NY Times as this one, effectively a one-sided critique of these medications, can lead to over-stigmatizing a potentially very important therapeutic approach and making it difficult for providers to prescribe medications even when it really is in the best interests of the patient.