The Psychiatric Approach

When a patient comes to a psychiatric hospital setting, typically they are referred with some combination of depression, anxiety and/or psychotic behavior. The first goal is to rule out any medical problem like a UTI, or to modify/clear the patient of their medications that might be contributing. We work them up for tick bite, vitamin deficiency, hypo- or hyper-hydration, brain tumor, infection, etc. Then, if the problems still persist, it should not surprise you that in a medical setting we turn to psychiatric medications. A family history may be taken, but except for the discharge meeting there is little in the way of examining for “triggers” of the problem behavior events or interactions in the family or home.

For agitation, the typical pattern for a patient with a diagnosed dementia is to start with the Alzheimer’s medications (Aricept and Namenda) and see if they help clarify the mind and reduce the agitation. Next up might be prescribing trazodone as needed (it is simply too sedating to use on a regular daily basis and it also increases risk of falls due to inducing orthostatic hypotension), followed by low dose atypical antipsychotic medications (Risperdal, Zyprexa, etc.). These drugs are then titrated up in an effort to gain improvement without inducing the side effects and sedation they induce. Since they are believe to work at minimal levels in dementia/agitation treatment, we call this low-dose atypical antipsychotic therapy. For example, in a schizophrenic patient a psychiatrist could prescribe up to eight mg daily, but for a senior in most psychiatric hospitals the maximum dose would be 0.5 mg twice daily. While the research has failed to show good efficacy of the atypical antipsychotics in the treatment of dementia-related agitation or psychosis, there is wide spread belief that these drugs do help. Perhaps, our most popular referents to our geropsychiatric hospitals come from difficult to manage nursing home patients–but then they don’t have the mite, money or staff to set up the “external” sources of intellectual and social stimulation argued for above. Instead, they try to quell the internal mind’s chaotic distress by using sedating drugs.

A History
 It all began around the 2000’s when the the use of these drugs (approved for schizophrenia only, in the 1990s) started being used in nursing homes in an attempt to quell agitation in dementia patients.  Of course, nursing home (NH) staff loved it as sedated patients are less of a hassle.  While around 9% of NH patients carry a diagnosis of schizophrenia, when those were eliminated CMS data showed an increase of about 20% in this dx from 2011-2015.  Sudden onset schizophrenia in the elderly!  I don’t think so.  More likely to rationalize the use of antipsychotics.  The use of these drugs continued to rise, but not because of their benefit to patients, it appears improper kickbacks to physicians in NH settings was the biggest factor in this.  Dr. Wendy Lane in JAMA, 11/14/17 noted “..the major drug companies [also] dispatched special drug representatives or pharmacists to provide disinformation about antipsychotics to nursing homes physicians until the Department of Justice put a stop to these practices.”  The proof of the pudding, as reported by Dr. Lane, came in the $515 million in 2007, $1.4 billion in 2009, $520 million in 2010 and $2.2 billion paid, respectively, by the manufacturers of Abilify, Zyprexa, Seroquel and Risperdal in criminal and civil fines for this widespread illegal practice.  All this got little attention in the media.

By 2005 the FDA was warning about the “doubled" increase in mortality for the above four drugs which led the black box warning.  As I explain it to patients the sudden death (mostly heart attack due to prolonged QT interval) doubled from about 2.5% to 5% in placebo vs. antipsychotic groups, so I have always felt, while scary, that the drugs were still warranted if they could keep someone home rather than in a NH.  Here’s a more recent 
article on this issue from 2010.  BTW Zyprexa and Abilify are less likely to increase mortality than Geodone (used a lot in ER's as it is injectable) or Seroquel.

Overall thinking in the field seems well summed up in this recent 
article (12/2017) indicating that antipsychotics have some “moderate” benefit as a last ditch effort in agitation/aggression especially if psychosis is involved.  At the inpt psych units at general hospitals where I’ve consulted in Taunton, Brockton, Fall River, Dorchester, New Bedford, etc. (note: none on Cape Cod–go figure!) we’ve found Risperdal the most likely to work at the lowest dose.  Seroquel always had to be pushed to pretty high dose to get an effect, and then there was daytime sedation that came with higher dosing.  Zyprexa seems to induce the largest weight gain (9-60 lbs is typical) increasing risk of diabetes 2. Abilify and the newer drugs were way too expensive (around $7000 per year, surpassing the “donut hole” in folks’ typical Medicare drug benefit by a lot).  I used to do drug talks for Lilly on Zyprexa since it seemed to cause the least Parkinsonian features, and they pushed that edge.  [Disclaimer/Admission: this writer was part of this “conspiracy” for many years and complicit with the use of these drugs, having sent hundreds of seniors from the Cape to various geropsychiatric hospitals.]

Here’s one of the original  
articles in (JAMA, 2005), which started me rethinking my role, which looked at all the studies to date and found a tiny bit of help in treating neuropsychiatric symptoms of dementia for Zyprexa and Risperdal, only.  Here’s another study (AM J Geri Psych, 2006) finding a little benefit with Ability and Risperdal over 15 different studies, but tons of side effects which pretty much cancelled out the overall benefits.  New research has not helped the cause for using antipsychotics in geriatric populations, and the drug companies never got the indication for use of atypicals in dementia from the FDA.  And they all paid the fines.  This writer gradually fell away from an interest in psychiatric interventions for dementia and shifted more to recommending day programs, specialized companionship, training family members in how to interact with dementia patients, family support programs and working with assisted living settings to better stimulate patients.  I do believe these drugs have their place, but not as first-line treatments any more.

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