Thursday, 19 June 2008

Antipsychotics

If you've Behavioural and Psychological Symptoms of Demetia (BPSD) then how should these be managed?

The National Institute of Health and Clinical Excellence (NICE) have a view on non-drug approaches which they explain in their Clinical Guideline, CG 42, on page 28 :
"Approaches that may be considered, depending on availability, include:
● aromatherapy
● multi-sensory stimulation
● therapeutic use of music and/or dancing
● animal-assisted therapy
● massage"


I'm not opposed to these. NICE continue to say that this is, ". . . because there is some evidence of their clinical effectiveness."
NICE is correct. They can work. Of course, the truth of it is in divining what works. Is it that essential oils in aromatherapy works, or is it that having a staff member spend half an hour to an hour giving one to one time, reassauring physical contact, continuous dialogue and eye contact, all is useful? I would imagine so. I am not sold on lavender as a panacea for all ills, helping sleep and relaxing one and all. Yet the evidence is sound, for many folks it can help. We do it in our service and, for some folk, it really is useful.

What perturbs me is the vogue to move wholly away from medication.

If you've dementia and your memory is poor, your concentration is poor, your language and organisation of words is poor, your sequencing is poor, your information processing is poor, how do you think the flow of your thoughts fairs? Unsurprisingly, focussing on thoughts, generating notions and words and structuring these, following a train of thought, communicating it all is harder as the dementia progresses.

Misperceptions, misinterpretations, flawed cognitions all mean that someones thoughts aren't as clear and lucid and flowing as once they were.

Can't find your glasses? Can't find your wallet? No idea where your bank book is? Ak, someone must have broken in to your home and nicked off with them, why else aren't they where (you believe) you left them? Paranoid thoughts increase. Sometimes they become delusional and distressing. You live in a world where you're uncertain, unable to recall details of what's been happening, it's bewildering, and now it seems you've someone nicking or moving stuff in your own home. Much badness.

Can this be improved upon? Why, yes it can. You've abberant ideation through thoughts being more jumbled up than they should be. But, huzzah, we've medication that can help improve the flow of thoughts, we've antipsychotics. They can help damp down paranoid and delusional beliefs too. Splendid, a patient has unpleasant symptoms but we've medication to help so all's good. But, sadly not.

Although the benefit of antipsychotics in dementia care for some patients is widely accepted, they have risks. They increase the risk of disability and death. If you have dementia and you're on olanzapine or risperidone for a year your chance of a stroke is about 3% (compared to folk off the drugs, where the chance is about 1%). That's the problem. They're not placebo, they're proper drugs, they have real effects, so can cause serious adverse events as they change how your body ticks. As clinicians we know this and discuss it with our patients (or, more frequently, with their carers too). Carers say they can't cope, we look at interventions that can help, but the changed thoughts and psychotic symptoms persist. There're a lot of retired miners in my corner. Many are used to getting up in the early hours of the morning and when dementing know with absolute conviction that they need to be getting up for work in the wee hours. To have a man getting up and wandering the streets at 4.00am each and every night is not the easiest thing to manage. Medication isn't a solution on its own but it can mean that he can understand and appreciate reassaurance and reality orientation that carers proffer. It can help. It can mean that my patient is less distraught and their carer can cope.

I agree, totally, that antipsychotics should only ever be used as part of a package of care and the drug should not be seen as a cure or solution to problems on its own. I agree that they can be over prescribed. I agree that acetylcholinesterase inhibitors have a greater role in the treatment of BPSD in Alzheimer's disease than antipsychotics do. I agree that other classes of drugs, such as benzodiazepines, can be more useful for some patients some of the time. I agree that antipsychotics have a risk (but an additional 2% chance a year of a stroke means there's a 98% chance that it won't cause one, which for many carers having intolerable situations are odds they'll go with each and every day).

It worries me that the MHRA said that olanzapine and risperidone shouldn't be used in dementia, but to give them their dues it has been clinical advice and not an edict written in tablets of stone. Clinical freedom's curtailed but still there's room for me to prescribe them if I really believe it's in my patient's best interests.

In the USA the risks of morbidity and death that antipsychotics cause scares clinicians so much (they then get sued a lot) that they're not commonly used in BPSD. Other techniques like physical restraint are used instead. Wandering? We can cure that, let's just handcuff both wrists of the patient to either side of the bed. Happened this month. Acceptable practice, to de-escalate risks with no serious chance of strokes that nasty drugs cause. As well as not giving drugs for BPSD, they're shy about drugs in frank barn door psychosis when paranoid delusions and the consequent disturbed behaviour are present.

This week, on Monday 16th June, in America the FDA said, "Antipsychotics are not indicated for the treatment of dementia-related psychosis."

If you have dementia, and have psychosis, you don't get an antipsychotic. They work, but since there's some risk, they're banned across the continent of North America.

Handcuffs or medication. I really, really hope folk in the UK take a more balanced view.

12 comments:

Quacktitioner said...

Thank you for a balanced view of why antipsychotics are used and how they can help. There seems to be the view that these are only prescribed as some sort of chemical cosh, when they do help alleviate the psychotic symptoms that go with dementia, including paranoia and delusions but also some of the disturbing/distressing hallucinations that many experience.

I for one am glad the UK has not endorsed physical restraint and has moved away from some of the more dubious practices of the past, where nursing/residential homes did use furniture and bedding to restrict (restrain) their patients.

Jobbing Doctor said...

I agree with the tenor of the main post (thoughtful and sensitive as ever from the shrink) and also with the quacktitioner.

The problem is that these balanced and sensible views are not reflected in the near hysterical outbursts of Dr Tim Kendall, and also some fairly poor journalism from the BBC.

These complex issues will no doubt land of the desk of some politician who will not say - lets trust the professionals - but will set up some sort of enquiry/review which will come out with some fairly unworkable recommendations.

The Jobbing Doctor has seen it time and time again.

Petronius said...

For a view of dealing with severe behavioural problems (In this case, mainly kids with autistic spectrum disorders), without the use of neuroleptics try googling "The Judge Rotenberg Center" and its leader Matthew Israel.

DeeDee said...

I have a question for you that is somewhat related. Yes I have googled first but not found the answer.

Many years ago I was under the inpatient care of a psychiatrist (as an adult, not an old one) whose favourite pet anti-psychotic was promazine (brand name Sparine, sickly sweet yellow liquid).

I was told by the nurses that "yeah that's a granny drug but it's one of that consultants' pet meds, that's why you're on it". I've not since ever met anyone else who had ever had it prescribed for them other than other patients of the same consultant (I don't have any co-morbid physical conditions or disability btw and was in my 20s).

A friend who is a vet says it gets used on dogs though as an anasethetic!

So, the question for you is: is this drug then one that is mainly used on the elderly because it's perceived as being "weaker" than, say, haloperidol? I'm unlikely to encounter another old age psychiatrist either IRL or on-line and I've always wondered what the main market for this stuff was...

DeeDee Ramona

Socrates said...

The Judge Rotenberg centre's favourite method of behavioural control is electric skin shocks via electrodes and a battery backpack operated via remote control (about 50% of the kids, and no, I'm not joking). They also withhold food and they've a whole range of physical restraints. Several children have died while in their care. There's many posts on the subject at http://www.actionforautism.co.uk

The Shrink said...

Jobbing Doctor, agreed, think tanks in ivory towers generate unwieldy idealistic and impractical edicts. To date I'm managing to eschew such nonsense (and am supported in doing so) but I fear I won't be able to do so forever.

DeeDee, promazine isn't a very effective antipsychotic. At all. It's not really used in the treatment of psychotic illnesses. In fact, it's not even licensed for that. It has two medical indications (copied and pasted from the BNF) :
1) Short-term adjunctive management of psychomotor agitation
2) Agitation and restlessness in elderly
So it's used to manage agitation, not influence thoughts.

DeeDee said...

Thanks - that would explain why it's known as a drug mainly for the elderly (1 of the 2 uses you cite).

Re the other use, agitation, hmm I certainly was agitated at the time. Makes sense. Thanks. (It was all very old-school and no-one told me what the drugs were for).

Mind you, I don't recommend playing tennis while on this. Your arms and legs will fall off shortly afterwards, or at least you'll feel that way...

After getting some free work out of you there I guess I should offer to help you fix your computer or sort out any IT queries you might have!

Tainted_Halo said...

I'm undecided. In the right circumstances, there are likely to be benefits to the individual.

Given that anti-psychs can be effective in qualming disturbed processes in anyone psychotic; the main presentation for this in the elderly is by way of agitation or "unsettled behaviour" - which could be any number of alternate explanations - and psychoses is rarely discovered by a mental state assessment through verbal interactions from someone who is confabulating and has impaired memory and intellect.

As you describe, paranoia (?suspicion) and distress are often secondary to the impairments of dementia - rather than as a uniquely psychotic process. Is it not possible to mitigate for these in a non-medicinal way?

I do not work in elderly care as I cannot abide the poor standards that are frequently tolerated in the name of insufficient funds or services. (Let me know when vacancies arise in your area tho Shrink!)

In regards the debate on externalised restraints - I think the benefit of the anti-psychotic (psychomotor reducing) medication is often preferential as it doesn't look so bad to visitors or other residents as seeing "guests" strapped on a bed or trapped in a chair.

Of course, those residents on such medications then run triple risk of falls and fractured femur leading to shock or septicaemia and death - so are "encouraged" to remain in their chairs.

It's not an easy dilemma to resolve and I'm not proposing there is a better solution under the current resources.

But there should be.

Jobbing Doctor said...

One of my anxieties here is that edicts from organisations such a the FDA and the MHRA will be used by politicians to clamp down on clinical freedom based upon the best needs of individuals.

We are professional people who make judgements based on evidence, the patient's individual circumstances and experiences.

I do not wish to spend the remainder of my (not very glorious) career being scared of being sued or on a 'disciplinary'.

laystranger said...
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laystranger said...

Okey-dokey two silly questions:

Wouldn't handcuffing someone to a bed increase the risk of them having a stroke, too (as well as a lot of other horrible things)?

AND

Is is possible that many of the dementia patients who have psychotic symptoms that make antipsychotic medications something you might consider prescribing, be folk who have already suffered multiple small strokes and so are more at risk of a really significant stroke in the next year anyway? Maybe the increased rate of stroke is not entirely the fault of the medications themselves but a reflection of the status of the particular sub-set of patients in which they are being used?

laystranger said...
This comment has been removed by the author.