It’s a complicated story and one that I don’t think the Wall Street Journal really told all that well.
Their premise is simple — that antipsychotic medications, especially newer ones, are being over-prescribed in nursing homes. It starts off noting how many people in a nursing home are being prescribed antipsychotics (30%, which is an amazing number), and then goes on to recount how antipsychotics are only approved by the FDA for schizophrenia and bipolar disorder. All good points and good data. The most damning datapoint is this one — that 21% of nursing-home patients who don’t have a psychosis diagnosis are on antipsychotic drugs. (The article, however, fails to say what diagnosis these people carry, since a diagnosis is required before a physician can prescribe a drug of this nature.)
Halfway through the article, we get to the crux of the problem faced by short-staffed and underfunded nursing homes:
The use of antipsychotic drugs comes amid a wider debate about how to care for the rising numbers of seniors, many of whom have behavior problems stemming from dementia. They can be difficult to manage, at home or in an institution. They can cry, lash out, wander or even be violent, to themselves or others. There aren’t many effective methods to calm them, doctors say.
A big question is whether to use a medical model — administering antipsychotics as the way to alleviate distressing symptoms of dementia — or trying to find other ways to help these patients.
It’s the “trying to find other ways to help” that is the “gotchya.” There are very few other methods available to control or keep psychotic symptoms at bay other than medications, especially in older people. Dementia makes learning other kinds of coping skills or psychological techniques far more challenging than with a healthy adult. Even in schizophrenia, medication is the first-line treatment of choice, because virtually no psychotherapeutic techniques have proven effective.
So the obvious question in my mind was this… If Alzheimer’s is a fairly common disease nursing homes have to deal with in their clients, how many people with Alzheimer’s disease actually end up having psychotic symptoms? Because psychotic symptoms are a legitimate focus of treatment for an antipsychotic.
The WSJ article doesn’t say (I’m not sure why), but the answer (according to Ropacki & Jeste, 2005) is 41%. So 2 our of every 5 people with Alzheimer’s suffer from psychotic symptoms — symptoms that are wholly appropriate for antipsychotic pharmaceutical treatments.
But you wouldn’t know it from the article. Instead, we get a quote like this:
Dr. Pollock, a professor of neuropsychiatry at the University of Toronto, says one problem is that the psychosis in Alzheimer’s disease is not the same as psychosis in younger patients with schizophrenia.
Really now? I searched the research literature up and down and couldn’t find any study that implied we know this to be true. The DSM also makes no such differentiation. It certainly may be Dr. Pollock’s opinion based upon his own experiences, but its portrayed in the article as some sort of fact.
And despite all the hand-wringing and crying out for alternative treatments done in the article, the author fails to mention a single alternative treatment that has any research to support its widespread use. Sure, we can all agree atypical antipsychotics are being overused and overprescribed in many nursing homes, but what’s the alternative?
Lots of questions, lot of concerns, but no answers.
I don’t have any either, but I just thought I’d point out that most doctors who are prescribing these drugs in nursing home settings are probably doing so because they have so few other choices available. And that psychosis in Alzheimer’s patients is a fairly common symptom.
Read the article: Prescription Abuse Seen In U.S. Nursing Homes
