nNew York Times
Doctors Say Medication Is Overused in Dementia
By LAURIE TARKAN
June 24, 2008

Ramona Lamascola with her mother, Theresa Lamascola.
Ramona Lamascola thought she was losing her 88-year-old mother to
dementia. Instead, she was losing her to overmedication.
Last fall her mother, Theresa Lamascola, of the Bronx, suffering from
anxiety and confusion, was put on the antipsychotic drug Risperdal.
When she had trouble walking, her daughter took her to another doctor
— the younger Ms. Lamascola’s own physician — who found that she had
unrecognized hypothyroidism, a disorder that can contribute to
dementia.

Mrs. Lamascola no longer takes antipsychotics.

Theresa Lamascola was moved to a nursing home to get these problems
under control. But things only got worse. “My mother was screaming and
out of it, drooling on herself and twitching,” said Ms. Lamascola, a
pediatric nurse. The psychiatrist in the nursing home stopped the
Risperdal, which can cause twitching and vocal tics, and prescribed a
sedative and two other antipsychotics.
“I knew the drugs were doing this to her,” her daughter said. “I told
him to stop the medications and stay away from Mom.”

Not until yet another doctor took Mrs. Lamascola off the drugs did she
begin to improve.

The use of antipsychotic drugs to tamp down the agitation, combative
behavior and outbursts of dementia patients has soared, especially in
the elderly. Sales of newer antipsychotics like Risperdal, Seroquel
and Zyprexa totaled $13.1 billion in 2007, up from $4 billion in 2000,
according to IMS Health, a health care information company.

Part of this increase can be traced to prescriptions in nursing homes.
Researchers estimate that about a third of all nursing home patients
have been given antipsychotic drugs.

The increases continue despite a drumbeat of bad publicity. A 2006
study of AlzheimerÂ’s patients found that for most patients,
antipsychotics provided no significant improvement over placebos in
treating aggression and delusions.

In 2005, the Food and Drug Administration ordered that the newer drugs
carry a “black box” label warning of an increased risk of death. Last
week, the F.D.A. required a similar warning on the labels of older
antipsychotics.

The agency has not approved marketing of these drugs for older people
with dementia, but they are commonly prescribed to these patients “off
label.” Several states are suing the top sellers of antipsychotics on
charges of false and misleading marketing.

Ambre Morley, a spokeswoman for Janssen, the division of Johnson &
Johnson that manufactures Risperdal, would not comment on the suits,
but said: “As with any medication, the prescribing of a medication is
up to a physician. We only promote our products for F.D.A.-approved
indications.”

Nevertheless, many doctors say misuse of the drugs is widespread.
“These antipsychotics can be overused and abused,” said Dr. Johnny
Matson, a professor of psychology at Louisiana State University. “And
there’s a lot of abuse going on in a lot of these places.”

Dr. William D. Smucker, a member of the American Medical Directors
Association, a group of health professionals who work in nursing
homes, agreed. Though the group encourages doctors to conduct a
thorough assessment and prescribe antipsychotics only as a last
resort, he said, “Many physicians are absent without leave in the
nursing home and donÂ’t take an active role in the assessment of the
patient.”

Some nursing homes are trying a different approach, so-called
environmental intervention. The strategies include reducing boredom,
providing intellectual and physical stimulation, exercise, calming
music, bringing in pets for therapy and improving how the staff
approaches and talks to dementia patients.

At the Margaret Teitz Nursing and Rehabilitation Center in Queens,
social workers do life reviews of patients to understand their
interests, lifestyle and former occupations.

“I had a patient who used to be in fashion,” said Nancy Goldwasser,
the director of social services. “So we got her fabric samples. And
sheÂ’d sit and look through the books, touch the fabric, and it would
calm her.”

But such approaches are time consuming, they do not help all patients,
they can be prohibitively expensive and they will be more difficult to
provide as AlzheimerÂ’s continues to increase.

“Our health care system isn’t set up to address the mental, emotional
and behavioral problems of the elderly,” said Dr. Gary S. Moak,
president of the American Association for Geriatric Psychiatry.

Nursing homes are short staffed, and insurers do not generally pay for
the attentive medical care and hands-on psychosocial therapy that
advocates recommend. It is much easier to use sedatives and
antipsychotics, despite their side effects.

The first generation of antipsychotics, like Haldol, carry a
significant risk of repetitive movement disorders and sedation.
Second-generation antipsychotics, also called atypicals, are more
commonly prescribed because the risk of movement disorders is lower.
But they, too, can cause sedation, and they contribute to weight gain
and diabetes.

Used correctly, the drugs do have a role in treating some seriously
demented patients, who may be incapacitated by paranoia or are
self-destructive or violent. Taking the edge off the behavior can keep
them safe and living at home, rather than in a nursing home.

If patients are prescribed an antipsychotic, it should be a very low
dose for the shortest period necessary, said Dr. Dillip V. Jeste, a
professor of psychiatry and neuroscience at the University of
California, San Diego.

It may take a few weeks or months to control behavior. In many cases,
the patient can then be weaned off of the drugs or kept at a very low
dose.

Some experts say another group of medications — antidementia drugs
like Aricept, Exalon and Menamda — are underused. Research shows that
10 to 20 percent of AlzheimerÂ’s patients had noticeable positive
responses to the drugs, and 40 percent more showed some cognitive
improvement, even if it was not noticeable to an observer.

“Sometimes, it’s enough to take the edge off the behavioral problems,
so the family and patient can live with it and you donÂ’t expose people
to much risk,” said Dr. Gary J. Kennedy, director of geriatric
psychiatry at the Montefiore Medical Center in the Bronx.
Other experts cite a lack of research backing these drugs for
behavioral problems.

If patients begin showing behavioral symptoms of dementia, doctors
said, they should have complete medical and psychiatric workups first,
especially if symptoms develop suddenly.

“Just because someone is 95 does not mean one should not do a workup,
especially if she’s been healthy,” Dr. Kennedy said.

Common causes of the symptoms include ministrokes, reparable brain
hemorrhage from a mild bump on the head, hypothyroidism, dehydration,
malnourishment, depression and sleep disorders.

Some doctors point out that simply paying attention to a nursing home
patient can ease dementia symptoms. They note that in randomized
trials of antipsychotic drugs for dementia, 30 to 60 percent of
patients in the placebo groups improved.

“That’s mind boggling,” Dr. Jeste said. “These severely demented
patients are not responding to the power of suggestion. TheyÂ’re
responding to the attention they get when they participate in a
clinical trial.

“They receive both T.L.C. and good general medical and humane care,
which they did not receive until now. ThatÂ’s a sad commentary on the
way we treat dementia patients.”

To family members looking at a nursing home for an aging parent,
experts recommend seeking out homes with low staff turnover, a high
ratio of staff members to patients, and programs with psychosocial
components.

The Medicare Web site has basic information on individual homes at
www.medicare.gov/NHcompare. The National CitizensÂ’ Coalition for
Nursing Home Reform, at www.nccnhr.org, offers a consumer guide to
choosing a nursing home.

If medications are necessary, a family member should communicate with
the prescribing doctor, learn the goal of each medication and be
involved in making the decision.

Dr. Moak, of the psychiatry association, emphasized seeking out the
doctor. Family members, he said, “often speak through the nursing
staff, and that’s a huge mistake.”

Family members who are not convinced that a relative is receiving the
best care should get a second opinion, as Ramona Lamascola did.

The physician she consulted, Dr. Kennedy of Montefiore, stopped her
motherÂ’s antipsychotics and sedatives and prescribed Aricept.

“It’s not clear whether it was getting her hypothyroid and other
medical issues finally under control or getting rid of the offending
medications,” he said. “But she had a miraculous turnaround.”

Theresa Lamascola still has dementia, but she went from confinement in
a wheelchair — unable to sit still and screaming out in fear — to
being able to walk with help, sit peacefully, have some memory and
ability to communicate, understand subtleties of conversations and
even make jokes.

Or, as her daughter put it, “I got my mother back.”

+++

Articles on antipsychotics here: http://tmap.wordpress.com/