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Bensham Hospital, Gateshead,Tyne and Wear NE8 4YL, e-mail: klfranks{at}doctors.org.uk
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Abstract |
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 Top Abstract IntroductionMethodResultsDiscussionReferences |
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The aim of the study was to assess the response to the guidance from the Committee on Safety of Medicines (CSM) on prescribing olanzapine and risperidone for older adults. Information on 96 older patients who were prescribed olanzapine or risperidone was gathered from psychiatric case notes, general practitioners and care homes. Data were gathered 10 weeks after the CSM guidance (Time 1) and again 6 months later (Time 2).
RESULTS
At Time 1, 71 out of 96 patients (74%) hadbeen reviewed and 90 (94%) by Time 2. By 6 months after the guidance 34 of 52 patients with dementia (65%) and 10 of 35 patients with functional diagnoses had been withdrawn from medication; 29% (14/49) of those withdrawn from medication had significant problems associated with withdrawal. In many cases medication was continued following risk-benefit decisions taken at review and despite CSM guidance.
CLINICAL IMPLICATIONS
Guidance has prompted review of prescribing in existing patients and some re-referrals, which has increased workload. The guidance has changed the management of existing patients, but there has been a high rate of associated clinical problems and numerous patients remain on, or return to, olanzapine or risperidone.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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A working group, including members from the Faculty for the Psychiatry of Old Age of the Royal College of Psychiatrists, the Royal College of General Practitioners, the British Geriatrics Society and the Alzheimer's Society, produced recommendations in light of the CSM guidance (Royal College of Psychiatrists, 2004).
Since the advice, a number of studies have investigated the risk of cerebrovascular incidents with these antipsychotics. Herrmann & Lanctot (2005) reassessed the data from 11 randomised controlled trials (RCTs) and found an increase in ‘cerebrovascular adverse events’ but suggested that many were non-specific and not strokes. Another meta-analysis of RCTs reported a small increase in the risk of death compared with placebo (Schneider et al, 2005).
Two large retrospective population-based cohort studies of 32 000 and 11 000 patients respectively failed to find any increased risk of stroke (Herrmann et al, 2004; Gill et al, 2005). However, a third large population-based retrospective study found an increased risk of cerebrovascular accidents with risperidone (but not with other atypicals) compared with traditional antipsychotics (Percudani et al, 2005). Other studies have found no increased risk of cerebrovascular events with atypical antipsychotics (Finkel et al, 2005; Liperoti et al, 2005; Moretti et al, 2005; Suh & Shah, 2005).
Mowat et al (2004) argued that the CSM advice could prove detrimental to patient care. They advocated discussion with relatives and carers and argued that stroke, although serious, was a rare excess risk and demanded balanced thinking against other possible benefits of medication.
It was decided to study the response of doctors to the guidelines in Gateshead. A population-based sample was chosen in order to capture the response in primary as well as secondary care. This was done as part of an ongoing audit cycle.
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Method |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Results |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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By Time 2, 9 people had died and 5 had left the area, leaving 82 patients available for full follow-up. None of the deaths was related to cerebrovascular incidents.
Contact with psychiatric services
At Time 1, 43 patients were in contact with old age psychiatry services; 40
had been discharged from old age psychiatry services; 9 had not been seen by
psychiatric services; 1 was an adult psychiatry patient; 1 had been discharged
from adult services and 2 had been discharged from learning disability
psychiatry services. At Time 2, 33 remained in contact with old age psychiatry
services.
Diagnoses
Of those sampled, 52 people had a diagnosis of dementia,7 had other organic
diagnoses and 35 had functional diagnoses. There were 2 others, 1 with
schizoid personality traits and 1 with a personality dysfunction
(Table 1).
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Medication
Initially, 34 patients were on risperidone and 61 on olanzapine; 1 was on
quetiapine but had been identified by the GP who was concerned about
cerebrovascular risks. For olanzapine the most common total daily dose was 2.5
mg (range 2.5-20 mg); that for risperidone was 0.5 mg (range 0.5-2 mg). One
patient was on a risperidone depot. The average time that people had spent on
medication was 23.4 months (range 0-120 months).
There were 56 patients who were prescribed one or more other psychotropic medications. These included 30 who were receiving selective serotonin reuptake inhibitors, 7 on other antidepressants, 10 on cholinesterase inhibitors and others on mood stabilisers, benzodiazepines and hypnotics.
Cerebrovascular disease and risk factors
Of 52 people with dementia, 31 (60%) had cerebrovascular disease compared
with 3 of 7 (43%) of those with other organic diagnoses and 9 of 35 (26%) with
functional diagnoses. A further 16 people with functional diagnoses had other
risk factors for cerebrovascular disease.
In the sample there were 5 patients who had had a cerebrovascular event while on olanzapine or risperidone prior to the CSM advice. Four had transient ischaemic attacks and one had a stroke. Four had dementia and all had been prescribed the medication for psychotic symptoms. Four of these patients had had previous cerebrovascular events prior to being on medication.
At Time 2 there had been no reports of further cerebrovascular events in any of the patients. None of the deaths during the study was related to cerebrovascular events.
Review of medication
At Time 1, 71 of 96 patients (74%) had been reviewed; 41 of 43 (95%) of
those current to psychiatric services had been reviewed, 23 of 40 discharged
patients (58%) and 5 of 9 (56%) of those not seen by psychiatric services. By
Time 2, 90 of 96 patients (94%) had had their medication reviewed. This
included 7 who had since died and 3 who had since left the area.
Initially 71 patients had been reviewed, 53 by old age psychiatry services. Of those, 41 were current patients; GPs had reviewed 17 and adult psychiatry services 1. Of the patients not currently in contact with old age psychiatry services but who had been reviewed by them, 2 had been referred again; others were reviewed by community psychiatric nurses or specific advice was given to the GP. At Time 2, most of the additional reviews had been performed by GPs. Another patient had been referred back to old age psychiatry services.
Outcomes
Outcomes for each group of patients are shown in
Table 2.
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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The numbers of reported cerebrovascular events on medication were low. There were five reported events prior to the advice and none over the 8 months of the study. This agrees with the findings from most of the larger population-based studies (Herrmann et al, 2004; Gill et al, 2005). It should be noted, however, that this study was not designed to specifically investigate the occurrence of cerebrovascular events.
There was a high rate of significant problems associated with withdrawal of medication. In over a third of these cases, the eventual outcome was a return to the original antipsychotic following risk-benefit discussions with patients, relatives and carers.
A limitation of this relatively small study is that it only included data on patients who were already on olanzapine or risperidone. It did not investigate the effect of the guidance on new prescribing, which one would anticipate to be more dramatic.
Strengths of the study are that it gathered information from both primary and secondary care, included patients with a range of diagnoses and in following their progress over 8 months it investigated the initial response to the guidance and subsequent problems.
In conclusion, the CSM guidance on the prescription of atypical antipsychotics for older adults has changed practice for existing patients but with a high rate of clinical problems and numerous patients remaining on, or returning to, olanzapine or risperidone.
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Acknowledgments |
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References |
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FINKEL, S., KOZMA, C., LONG, S., et al (2005) Risperidone treatment in elderly patients with dementia: relative risk of cerebrovascular events versus other antipsychotics. International Psychogeriatrics, 17, 617 -629.[CrossRef][Medline]
GILL, S. S., ROCHON, P. A., HERRMANN, N., et al
(2005) Atypical antipsychotic drugs and risk of ischaemic stroke:
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HERRMANN, N. & LANCTOT, K. L. (2005) Do atypical antipsychotics cause stroke? CNS Drugs, 19, 91-103.[CrossRef][Medline]
HERRMANN, N., MADAMI, M. & LANCTOT, K. L. (2004)
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LIPEROTI, R., GAMBASSI, G., LAPANE, K. L., et al (2005) Cerebrovascular events among elderly nursing home patients treated with conventional or atypical antipsychotics. Journal of Clinical Psychiatry, 66, 1090 -1096.
MORETTI, R., TORRE, P., ANTONELLO, R. M., et al (2005) Olanzapine as a possible treatment of behavioural symptoms in vascular dementia: risks of cerebrovascular events. A controlled open-label study. Journal of Neurology, 252, 1186 -1193.[CrossRef][Medline]
MOWAT, D., FOWLIE, D. & MACEWAN, T.
(2004) CSM warning on atypical antipsychotics and stroke may be
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PERCUDANI, M., BARBUI, C., FORTINO, I., et al (2005) Second-generation antipsychotics and risk of cerebrovascular accidents in the elderly. Journal of Clinical Psychopharmacology, 25, 468 -470.[CrossRef][Medline]
ROYAL COLLEGE OF PSYCHIATRISTS FACULTY FOR THE PSYCHIATRY OF OLD AGE (2004) Atypical Antipsychotics and Behavioural and Psychiatric Symptoms of Dementia. Prescribing Update for Old Age Psychiatrists. http://www.rcpsych.ac.uk/pdf/Atypicalguidance.pdf
SCHNEIDER, L. S., DAGERMAN, K. S. & INSEL, P.
(2005) Risk of death with atypical antipsychotic drug treatment
for dementia: meta-analysis of randomised placebo-controlled trials.
JAMA, 294, 1934
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SUH, G. H. & SHAH, A. (2005) Effect of antipsychotics on mortality in elderly patients with dementia: a1-year prospective study in a nursing home. International Psychogeriatrics, 17, 429 -441.[CrossRef][Medline]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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