Antipsychotics in the Elderly: A Double-Edged Sword

I read with interest Dr Gregory Rutecki’s Top Papers Of The Month feature, “Treat Dementia in Elderly Patients With Caution” (CONSULTANT, January 2009, page 60). Elderly patients who live at home and those in long-term–care facilities often pose management challenges, whether they have evident Alzheimer disease or other diagnoses. While I am not in favor of bad medicine, consideration should be given to treating agitated, violent, and apparently angry and hostile persons with what works. I do not favor quieting noisy patients with drugs. These are people who need and deserve love, compassion, and human touching. However, many care facilities, including ICUs, are short-staffed and do not have continuous one-on-one care capability.

I would challenge anyone responsible for the treatment of patients with severe dementia to avoid all medications that have adverse effects. The study Dr Rutecki discusses showed an increase in hospital admissions, falls with hip fracture, and deaths among those who received antipsychotics.¹ But the glaring question is how many elderly persons with severe agitation/violence/dangerous behavior had serious events when they received no antipsychotics or other medications. The study did not look at all fractures, deaths, and admissions to hospitals, including those among patients not receiving antipsychotics.

—— Paul Esaki, MD
Kapaa, Hawaii

I agree with a number of Dr Esaki’s observations. First, he appropriately stratifies the geriatric population clinically, favoring sedation for “agitated, violent, seemingly angry and hostile persons” but not for those who are only “noisy.” Second, he is accurate in his observation that a proposal for treating patients with severe dementia without any sedation, at present-day staffing levels, is an impossible dream. Finally, he is correct about the flaws in the design of the Rochon study. Thus, ultimately there is more that Dr Esaki and I have in common than there is that separates us.

We must carefully consider who receives sedatives and who does not, and we must be prudent in our dosing. Sedation in this population is a necessary evil; however, clinicians need to be aware that it is a double-edged sword.

—— Gregory W. Rutecki, MD
Professor of Medicine
University of South Alabama College of Medicine
Mobile