Magazine article Clinical Psychiatry News

Data Flag Risks of Anticonvulsants in Dementia

Magazine article Clinical Psychiatry News

Data Flag Risks of Anticonvulsants in Dementia

Article excerpt

SAVANNAH, GA. -- Black box warnings on antipsychotics led to a decrease in their use to treat patients with dementia, but not a commensurate increase in use of antianxiety or other psychotropic agents. What did increase slightly was the use of anticonvulsant therapies, some of which appear to be riskier than the antipsychotics in older patients.

In fact, valproate appears to have a higher mortality than the antipsychotics studied.

Dr. Helen C. Kales and Kara Zivin, Ph.D., of the University of Michigan and the VA Healthcare System in Ann Arbor, reported these preliminary findings from an ongoing National Institutes of Health-funded study at the annual meeting of the American Association for Geriatric Psychiatry.

Antipsychotics once were widely prescribed as an off-label treatment for dementia, but concerns started to arise and in 2005, the Food and Drug Administration issued a black box warning that the use of atypical antipsychotics in the treatment of behavioral disorders in elderly patients with dementia was associated with increased mortality. A similar warning for conventional antipsychotics was issued in 2008.

To see how the warnings affected practice patterns, Dr. Kales and Dr. Zivin looked at national data from 254,564 Department of Veterans Affairs outpatients with dementia. They found that the decline in use of atypical antipsychotics began in 2003, coinciding with the release of data from randomized controlled trials about cerebrovascular events. The decline accelerated after the black box warning.

For conventional antipsychotics, the major decline in use came in the 1990s with the introduction of atypical antipsychotics; after 2003, rates of conventional antipsychotic use among outpatients with dementia were less than 2%.

But, interestingly, no significant compensatory increase was found in the use of antianxiety or antidepressant agents. That was a surprise, Dr. Zivin said. In an interview, Dr. Kales speculated that possibly those drugs are not viewed as substitute therapies for the types of behaviors for which antipsychotics are prescribed.

The research did turn up a small but statistically significant increase in anticonvulsant use among outpatients with dementia.

The researchers then examined mortality for 13,857 elderly patients with any diagnosis and 3,954 patients with dementia who had been prescribed individual antipsychotics (haloperidol, olanzapine, quetiapine, and risperidone) and individual anticonvulsants (valproate and carbamazepine). …

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