Managing Risk When Considering the Use of Atypical Antipsychotics for Elderly Patients with Dementia-Related Psychosis

Abstract

In 2005, responding to several studies, the FDA issued a black box warning on atypical (second generation) antipsychotic medications, noting that the drugs may increase the risk of cerebrovascular adverse events in elderly patients with dementia-related behavior disturbances. The black box warning has raised concern for clinicians, among whom atypical antipsychotics have gained favor for having a more tolerable side-effect profile than many other pharmacological treatment options. Complicating this concern are studies suggesting that other medications may have similar risks and a dearth of unbiased head-to-head studies comparing different treatment options. To effectively manage risk when treating elderly patients with dementia-related psychosis, physicians, patients, and caregivers must consider both acute risks (such as danger of bodily harm to the patient and others) and long-term risks (such as placement in a restrictive nursing home). If an atypical antipsychotic is chosen, additional risk management may be warranted. This paper presents a brief overview of relevant concerns and suggests some techniques to help minimize and manage risk, such as increased monitoring, informed consent, and thorough documentation. A sample clinical risk management form and a sample letter to the primary care physician are provided to help guide clinicians in improving their risk management practices when working with elderly patients suffering from dementia-related psychosis and related behavioral difficulties.

Targeting Group II Metabotropic Glutamate (mGlu) Receptors for the Treatment of Psychosis Associated with Alzheimer’s Disease: Selective Activation of mGlu2 Receptors Amplifies β-Amyloid Toxicity in Cultured Neurons, Whereas Dual Activation of mGlu2 and mGlu3 Receptors Is Neuroprotective

“…The lack of weight gain with group II mGlu receptor ligands (Patil et al, 2007) is particularly advantageous in AD patients, which have an increased risk of metabolic syndrome and cerebrovascular events in response to conventional antipsychotic medication (Bullock, 2005;Herrmann and Lanctôt, 2005;Recupero and Rainey, 2007;Mazzucco et al, 2008;Trifirò et al, 2009). With mGlu2 receptor PAMs, however, this advantage will be frustrated if these drugs amplify neurodegeneration associated with AD.…”

Safety and Tolerability of Antipsychotics

“…Risk management procedures recommended are to avoid unnecessary medications, balancing acute versus long-term risks, informed consent from the patient and family members, and documentation in the medical records (Jeste et al 2008 ;Recupero and Rainey 2007 ). The ACNP White Paper recommended these 11 steps: (1) determine the etiology of psychotic symptoms, (2) general treatment considerations, (3) shared decision-making, (4) identify specifi c target symptoms for treatment, (5) pharmacotherapy selection, (6) dose, (7) monitor for effi cacy, (8) monitoring for safety, (9) educate patient and caregivers, (10) know when to discontinue or switch pharmacotherapy, and (11) coordinate care among the treatment team and family members (Jeste et al 2008 ).…”

Perspectives on the Pre-Admission Screening and Annual Resident Review Process: Why Can't This Program Just Grow Up?

“…Guardians, medical-decision surrogates, or designated family members are often involved in care decisions and may provide informed consent for antipsychotic medication use. Furthermore, family members are also often directly involved in their relative's care and can provide important information about the individual's wishes (Recupero & Rainey, 2007). In most instances where impaired individuals do not have identified surrogates or relatives, health care providers will need to act as de facto decision makers and proceed in the best interests of the patient (American Medical Directors Association, 2003).…”