Neither Atypical Nor Conventional Antipsychotics Increase Mortality or Hospital Admissions Among Elderly Patients With Dementia: A Two-Year Prospective Study

doi:10.1097/JGP.0b013e31802d0b00

The American Journal of Geriatric Psychiatry

Volume 15, Issue 5, May 2007, Pages 416-424

https://doi.org/10.1097/JGP.0b013e31802d0b00 Get rights and content

Background

Antipsychotics are widely used to manage behavioral disorders in patients with dementia. Recently, serious concerns have been raised about the stroke and mortality risk of atypical antipsychotics when administered to patients with dementia.

Aim

The aim of this study was to examine the impact of atypical and conventional antipsychotics on mortality and hospital admissions among Finnish elderly institutionalized patients with dementia in a two-year follow up and to compare their prognosis with that of nonusers.

Patients and Methods

The authors examined 254 very frail patients with dementia, mean age 86 years, from seven Finnish nursing homes and two hospitals in1999–2000. Medical records provided information on the use of daily antipsychotic medication; central registers confirmed mortality for up to two years.

Results

Nearly one-half (48.4%) of the patients used antipsychotic medication: 37.4% received conventional neuroleptics (N = 95) and 11.0% received atypical antipsychotics (N = 28). The mean number of hospital admissions was higher among the nonusers than among the users of conventional or atypical antipsychotics. Of the users of atypical antipsychotics (risperidone, olanzapine), 32.1% died within 2 years. The respective figures for users of conventional neuroleptics were 45.3%, and for the nonusers, 49.6%. In the Cox proportional hazard model, a high number of medications and the use of physical restraint predicted higher mortality at two years. The use of atypical antipsychotics showed lower risk of mortality, if any. The respective test for conventional antipsychotics was nonsignificant.

Conclusion

Among these frail and very old patients with dementia, neither the use of atypical antipsychotics nor the use of conventional neuroleptics increased mortality or hospital admissions. The use of restraints, however, doubled the risk of mortality.

Section snippets

PATIENTS AND METHODS

This is a study consisting of cross-sectional detailed assessments of geriatric patients at baseline 1999–2000 and follow-up data concerning mortality and further hospital admissions during a two-year follow up in seven acute wards of two acute geriatric hospitals and in 13 wards of seven nursing homes in Helsinki, Finland. The acute geriatric hospitals serve a population of 200,000 inhabitants, and mainly elderly subjects with acute illnesses and a need for rehabilitation are admitted to these

RESULTS

The mean age of the whole sample was 86 years. Of the whole sample, 60% (N = 254 of 424) of patients had dementia according to our consensus judgment. A larger proportion of females existed among patients with dementia (85%) than among those without (76%) (χ² = 6.19, df =1, p = 0.013). The patients with dementia had more comorbidities and were more dependent in their activities of daily living skills. The patients with dementia used significantly more both atypical and conventional

DISCUSSION

Of the elderly and frail patients with dementia, nearly one-half received antipsychotics. The total mortality rate was high; one-half of these elderly patients with dementia died within two years. Compared with nonuse, the use of conventional or atypical antipsychotics did not increase either mortality nor hospital admissions. The number of admissions to hospitals and the number of deaths was lower among users of conventional or atypical antipsychotics than among nonusers. In the Cox

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In the adjusted models, use of APDs at the time of dementia diagnosis was associated with increased mortality risk in the total cohort (hazard ratio = 1.4; 95% confidence interval 1.3–1.5). After stratifying for dementia types, increased mortality risks associated with APDs were found in patients with Alzheimer's disease, mixed dementia, unspecified dementia, and vascular dementia. Higher risk for mortality was found with typical APDs in patients with mixed and vascular dementia and with atypical APDs in patients with Alzheimer's disease, mixed, unspecified, and vascular dementia. Furthermore, in patients with Alzheimer's disease who had typical APDs, use lower risk of death emerged in comparison with patients with atypical APDs.
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We studied the mortality risk of long term and new antipsychotic drug use in Alzheimer's disease (AD) patients in Japan to determine improved treatment protocols.
This 24-week prospective cohort study included 10,079 Japanese AD patients (female, 69%; average age, 81 years) under routine clinical care in 357 medical sites. The antipsychotic medication history was varied (63.7% were long-term users). Mortality rates and odds ratio were analyzed (initial 10 weeks and from 11–24 weeks).
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New use of antipsychotic drugs represents a distinct risk for mortality; those on long-term antipsychotic therapy seem to be at less risk. The warning issued 10 years earlier on antipsychotics use for AD patients should be reviewed.
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The finding of neuropsychiatric symptoms as an independent factor for mortality risk20 was not confirmed in our study. A Finnish study found that the use of restraints was associated with increased mortality risk.17 In the present study, the use of restraints was associated with mortality risk in the bivariate, but not in the multivariate analysis.
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In unadjusted Cox regression, a lower mortality risk was associated with the use of other psychotropic drugs, but not APs, compared with nonusers. In the adjusted analysis, neither use of APs nor other psychiatric drugs was associated with increased mortality risk. Higher age, male gender, not being married, medical disease burden, lower level of functioning, more severe degree of dementia, and a higher number of drugs were all associated with increased mortality risk.
In this long-term study of nursing home patients, AP drug use was not associated with increased risk of mortality. This is in line with results from earlier studies of clinical samples, but contrasts with results from randomized controlled trials and registry-based studies. The findings should be interpreted with caution. Taking into account the modest benefit and high risk of adverse effects of AP drug use, nonpharmacological treatment remains the first-line treatment approach.
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Thus, the frailest and oldest residents were not administered PHMs to the same extent as other residents. The lack of association with mortality was consistent with studies that have reported no association between Beers Criteria medications,6,47 anticholinergic medications,10,15,17,48 and psychotropic medications,49 and mortality. Conversely, several previous studies have reported associations among Beers Criteria medications,50 NSAIDs,51 and mortality.
This study investigated the overlap among 3 different definitions of potentially harmful medication (PHM) use and the corresponding associations with resident quality of life and mortality.
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PHM use was defined as (1) use of medications with anticholinergic properties, (2) use of Beers Criteria medications, and (3) concomitant use 3 or more psychotropic medications. Health-related quality of life (HRQoL) was assessed using the 15D and psychological well-being (PWB) scale. Residents self-rated their own health using a 4-point scale. Mortality data were obtained from central registers.
There were 38.0%, 28.2%, and 12.6% of residents who used PHMs according to 1 (G1), 2 (G2), and 3 definitions (G3), respectively. Overall, 21.2% of residents did not use PHMs according to any of the 3 definitions (G0). There were no significant differences in comorbidity, cognition, or functioning among groups. In adjusted analyses, there was a stepwise association between use of multiple PHMs and poorer self-rated health, poorer PWB, and poorer HRQoL. There was no association in adjusted analyses between PHM use and 3-year mortality (47.8%–63.8%).
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2014, American Journal of Geriatric Psychiatry
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This population-based study used data from the Norwegian Prescription Database. The study sample included 26,940 dementia outpatients aged 65 years or older prescribed antidementia drugs and psychotropics from Norwegian pharmacies between 2004 and 2010.
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: This study was supported by Societas Gerontologica Fennica, the Finnish Geriatric Association, the Uulo Arhio Foundation, and the Medical Society of Kyminlaakso, Duodecim, Finland.

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Regular Research ArticlesNeither Atypical Nor Conventional Antipsychotics Increase Mortality or Hospital Admissions Among Elderly Patients With Dementia: A Two-Year Prospective Study

Background

Aim

Patients and Methods

Results

Conclusion

Section snippets

PATIENTS AND METHODS

RESULTS

DISCUSSION

Am J Med

Am J Geriatr Psychiatry

Am J Geriatr Psychiatry

Am J Geriatr Psychiatry

J Psychiatr Res

J Chronic Dis

Gen Hosp Psychiatry

Behavioral symptoms and the administration of psychotropic drugs to aged patients with dementia in nursing homes and in acute geriatric wards

Int Psychogeriatr

Drug use in the nursing home

Ann Intern Med

Use of antipsychotic drugs in nursing homes: current compliance with OBRA regulations

J Am Geriatr Soc

Newer psychotropic medication use in nursing home residents

J Am Geriatr Soc

The use of atypical antipsychotics in nursing homes

J Clin Psychiatry

Survey of neuroleptic prescribing in residents of nursing homes in Glasgow

BMJ

An indicator of appropriate neuroleptic prescribing in nursing homes

Age Ageing

Anti-psychotic drug use in older people

Age Ageing

Drug utilisation in Dutch nursing homes

Eur J Clin Pharmacol

Psychotropic drug use in nursing homes—diagnostic indications and variations between institutions

Eur J Clin Pharmacol

Determinants for the use of psychotropics among nursing home residents

Int J Geriatr Psychiatry

Psychotropic drugs in nursing- and old-age homes: relationships between needs of care and mental health status

Eur J Clin Pharmacol

The use of psychotropic drugs among elderly nursing home residents with and without dementia in Helsinki, Finland

Drugs Aging

Regular Research Articles
Neither Atypical Nor Conventional Antipsychotics Increase Mortality or Hospital Admissions Among Elderly Patients With Dementia: A Two-Year Prospective Study