A 79-year-old female nursing home resident is brought to the clinic by a nurse from the facility. Three years ago, the patient was diagnosed with dementia, and her memory and behavior have gradually worsened. Staff members report that she has been exhibiting increased aggression and paranoia over the last few weeks. She has pushed staff members and tried to rush out of the nursing facility. The patient does not recall these episodes. Gabapentin, valproate, citalopram, and trazodone were tried but did not improve her worsening symptoms. She has a history of hypertension and diabetes, which are well controlled with medication. She had a myocardial infarction approximately 10 years ago with no cardiac symptoms since then. The patient's vital signs are within normal limits, and on examination there are no abnormal findings except for areas of ecchymosis on her upper extremities. ECG is normal, and QTc interval is 430 msecs. The physician recommends low-dose risperidone. The patient's daughter, who is her guardian, is notified of the treatment plan and is concerned as she heard there is an increased risk of death associated with antipsychotics. She asks the physician about the safety of the medication. Which of the following is the most appropriate response regarding the potential safety risks of this class of medications?

Question

A 79-year-old female nursing home resident is brought to the clinic by a nurse from the facility.  Three years ago, the patient was diagnosed with dementia, and her memory and behavior have gradually worsened.  Staff members report that she has been exhibiting increased aggression and paranoia over the last few weeks.  She has pushed staff members and tried to rush out of the nursing facility.  The patient does not recall these episodes.  Gabapentin, valproate, citalopram, and trazodone were tried but did not improve her worsening symptoms.  She has a history of hypertension and diabetes, which are well controlled with medication.  She had a myocardial infarction approximately 10 years ago with no cardiac symptoms since then.  The patient's vital signs are within normal limits, and on examination there are no abnormal findings except for areas of ecchymosis on her upper extremities.  ECG is normal, and QTc interval is 430 msecs.  The physician recommends low-dose risperidone.  The patient's daughter, who is her guardian, is notified of the treatment plan and is concerned as she heard there is an increased risk of death associated with antipsychotics.  She asks the physician about the safety of the medication.  Which of the following is the most appropriate response regarding the potential safety risks of this class of medications?

Quizplus · Accepted Answer

Explanation: Multiple studies have demonstrated an overall increased risk of death from the use of antipsychotics in patients with dementia. Both first- and second-generation antipsychotics can increase mortality. Increased risk of death may be due to increased cardiac events, as well as from complications of stroke, falls, and aspiration pneumonia, and from other causes. These and other risks of medication use in the elderly highlight the importance of informed consent, patient and family education, and the physician's need to be educated about benefits and risks. These medications can be considered for use in elderly patients in certain situations in the context of potential benefits, risk of harm from not treating (ie, short-term safety risk), and viability of other management options. The presence of psychotic symptoms in the elderly (or the presence of dangerous behaviors that have not responded to other medications) often indicates a need for judicious use of antipsychotics to decrease the risk of harm. Minimization of dosage and duration of treatment plus continuous reevaluation of symptoms are indicated. (Choices A, B, D, and E) There is an increased risk of mortality with the use of antipsychotics in patients with dementia, and the risks are not limited to those with pre-existing cardiovascular disease. Mortality risks are not eliminated by monitoring for ECG changes, given that there are multiple noncardiac causes of death possible with the use of these medications. Educational objective: Antipsychotics increase the risk of mortality in patients with dementia and should be used with caution. Short-term benefits may outweigh long-term risks when other measures fail and the behavior poses safety risks. When antipsychotic drugs are deemed necessary, low-dose antipsychotics can be recommended after informing families of the increased mortality risk. References: Atypical antipsychotic use in patients with dementia: managing safety concerns. (http://www.ncbi.nlm.nih.gov/pubmed/22952071) A review of adverse outcomes associated with psychoactive drug use in nursing home residents with dementia. (http://www.ncbi.nlm.nih.gov/pubmed/27812994) Use of antipsychotics for the treatment of behavioral symptoms of dementia. (http://www.ncbi.nlm.nih.gov/pubmed/26953213)

A 79-Year-Old Female Nursing Home Resident Is Brought to the Clinic