Dementia: the one contraindication to prescribing antipsychotics

medication cartoonStated in an article by NPR.org Old And Overmedicated: The Real Drug Problem In Nursing Homes, “Almost 300,000 nursing home residents are currently receiving antipsychotic drugs, usually to suppress the anxiety or aggression that can go with Alzheimer’s disease and other dementia.”

They go on to say, “Antipsychotics, however, are approved mainly to treat serious mental illnesses like schizophrenia and bipolar disorder. When it comes to dementia patients, the drugs have a black box warning, saying that they can increase the risk for heart failure, infections and death.”

The story is about Marie Sherman’s experience of placing her mother into a nursing home; “It wasn’t long before the nursing home staff told Manuel DeLeon, Beatrice’s husband, that his wife was agitated and they wanted to give her some medication for that. So he said OK. “They kept saying she was making too much noise, and that they give her this medicine to quiet her down,” he says.

Federal law prohibits the use of antipsychotics and other psychoactive drugs for the convenience of staff. It’s called a “chemical restraint.” There has to be a documented medical need for the drugs. “But they just kept giving her more and more,” says DeLeon, “and I noticed when I used to go see her, she’d just kind of mumble, like she was lost.”

Professor Henry Brodarty and colleagues in their study, Halting Antipsychotic use in Long Term care (HALT) Project  propose a model for deprescribing antipsychotics in residential care through person-centred approaches to managing challenging behaviours. A targeted, evidence-based training package has been developed to up-skill general practitioners and nursing home staff in this area, as well as in the quality use of medicines.

After my horror story on Sundays blog, it is about time staff in the acute sector and aged care sector stopped allowing this abuse. The fact that antipsychotic drugs are in fact abuse and have been reported to have killed many people with dementia, and is not only incompatible with dementia, but in fact, dementia is the one contra-indication to them, seems often to be ignored totally…

I remain extremely sceptical about the use of the Behavioural and Psychological Symptoms of Dementia (BPSD) and believe the categorisation of behaviours into things like wandering, aggressive, absconder, screamer, poor feeders, and so on, simply increases the likelihood of person centred care not being delivered.

There is no respect or personhood when someone is called things such as wanderer, screamer or absconder…

The official category BPSD was the result of a consensus conference in Lansdowne in 1996, and interestingly this was sponsored by Janssen Pharmaceuticals, and it had a major impact on research, intervention, and definition of dementia. In terms of interventions, previously existing drugs, like the cognitive enhancers, began to be tested for non-cognitive outcomes such as activities of daily living, behavior, and global outcome (Leibing 2014).

It appears from this article that the term BPSD has been developed by pharmaceutical companies, and my simplistic and cynical consumer/student perspective suggests to me it was simply a way to define people with dementia in ways that can be managed by drugs, for example anti-anxiety or anti-agitation medications. People with dementia have been labelled disparagingly, to allow the prescribing of ‘behaviour’ modifying drugs, simply because of a failure of the pharmaceutical industry to find enough dementia (disease) modifying drugs and the lack of drugs for a cure.

Reference:

Leibing, A 2014, The earlier the better: Alzheimer’s prevention, early detection, and the quest for pharmacological interventions, Culture, medicine and psychiatry, vol. 38, no. 2, pp. 217-236.

10 thoughts on “Dementia: the one contraindication to prescribing antipsychotics

  1. Less medication is BEST! I have proven that with my husband who had been over dosed in the Residential Care facility. Thank You DBMAS

  2. I share the skepticism and associated DANGERS in over prescription of anti-psychotics for the treatment of dementia! My mother was prescribed a “widely used anti-psychotic” for Alz Disease called ZYPREXA and had a toxic reaction to it which saw her go into seizures and taken by ambulance for 12 awful days in hospital with life threatening infection and four days of awful hallucinations. ZYPREXA also left my Mum OVERNIGHT both unable to walk on her own ever again and double incontinent …
    The Mum I brought home with me from hospital was a very different Mum to the one I was caring for prior to ZYPREXA . I would never have allowed her to have it had I known the possible repercussions. I had read the warnings on the packet but all pharmaceuticals carry possible side effects and I thought if Mum’s specialist has prescribed it perhaps it will “help”. How wrong I was and this decision still lingers with me two years later.

    • My Physician this morning said to me, he thought almost all the drigs being used in the dementia sector were a complete waste of time, and doing far more harm than good… nice to be seeing someone honest! xx

  3. Hey Kate,

    Its so frustrating that medical professionals continue to believe that it is appropriate to drug people because they do not understand them, and for caregivers to do this to make their work related rigid task orientated lives easier. Chemical restraint is definitely considered elder abuse Kate, and I know you and i agree on this as an area that requires urgent change. You are such a wonderfully strong advocate as to why this is not necessary.

    The old archaic philosophies of care do not apply any more, nor should they, as we are meant to be educated, civilized people who understand how to care for people without drugging them to the eyeballs. The ignorance that the medical profession used to have is not an excuse any longer!!!

    The judgmental attitudes that are directed towards people living with dementia are unfair and discriminatory. Especially when you look at the fact that many people sit back and decree how it should be from a totally cognitive viewpoint. Have they no compassion and empathy for those that have a condition that affects cognition???

    Can they not understand that all people, regardless of whether they have dementia or not, will exhibit behavior if they are not treated in a humane way???? Do they drug an old man who gets anxious because he has COPD???? No. Do they drug their children when they have a tantrum in the supermarket??? No. Do they drug their husbands or wives when they have an argument???? No – they may want too, haha, but they do not. The moral boundaries are firmly set in place for all but people living with dementia. How dreadfully unfair that concept is, and where does it come from???

    I find it very difficult to comprehend why the same behaviors that people who do not have dementia exhibit, are seen as more of an issue just because someone has a diagnosis of dementia. The answer is right in front of us all, and is common sense. It is not acceptable to drug people with dementia for expressing themselves the best way they know, instead of trying to resolve the issue that has triggered that behavior. It really is a destructive cop out and I do not believe this is ‘caring’ for someone in any way.

    Behavioural expression is a right and every single human being, whether they have dementia or not, exhibit behaviors every day, to communicate, to express if they are unhappy or frustrated, or if their needs are not being met.

    This continual focus on people living with dementia and behavior is a failing on the part of those caring for them. If these professionals understood how to connect and communicate effectively, if they provided true person centered care and if they understood that most behaviors are triggered by ‘them’ and their attitude, then the need to express behaviors would be resolved, or be minimized. Then the abusive reliance on drugging people could cease, except in extenuating circumstances where it is required as a last resort only.

    Why are people not listening Kate???? The information is out there. We all know right from wrong. Has the industry become so blinkered that they cannot grow, or is it because its all about them and they really just don’t get it or care??????? This is not care giving in the true sense of the word and frustrates, disappoints and saddens me constantly.

    xx

    .

      • sadly, that is partly the truth… the other is the “experts” have been flogging the BPSD message and reinforcing people with dementia are constantly spoken about, and as, challenging behavioursw… there is a big job ahead of thos of us who wish to change this. Whilst PEOPLE are referred to as behaviours, both in the clinical setting and in the literature, and by the “experts”, person centred care will NEVER be delivered.. IMHO of course.

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