XPost: alt.society.mental-health, alt.psychology.personality   
   From: pjbrass@uswest.net   
      
   nNew York Times   
   Doctors Say Medication Is Overused in Dementia   
   By LAURIE TARKAN   
   June 24, 2008   
      
      
   Ramona Lamascola with her mother, Theresa Lamascola.   
   Ramona Lamascola thought she was losing her 88-year-old mother to   
   dementia. Instead, she was losing her to overmedication.   
   Last fall her mother, Theresa Lamascola, of the Bronx, suffering from   
   anxiety and confusion, was put on the antipsychotic drug Risperdal.   
   When she had trouble walking, her daughter took her to another doctor   
   — the younger Ms. Lamascola’s own physician — who found that she had   
   unrecognized hypothyroidism, a disorder that can contribute to   
   dementia.   
      
      
   Mrs. Lamascola no longer takes antipsychotics.   
      
   Theresa Lamascola was moved to a nursing home to get these problems   
   under control. But things only got worse. “My mother was screaming and   
   out of it, drooling on herself and twitching,” said Ms. Lamascola, a   
   pediatric nurse. The psychiatrist in the nursing home stopped the   
   Risperdal, which can cause twitching and vocal tics, and prescribed a   
   sedative and two other antipsychotics.   
   “I knew the drugs were doing this to her,” her daughter said. “I told   
   him to stop the medications and stay away from Mom.”   
      
   Not until yet another doctor took Mrs. Lamascola off the drugs did she   
   begin to improve.   
      
   The use of antipsychotic drugs to tamp down the agitation, combative   
   behavior and outbursts of dementia patients has soared, especially in   
   the elderly. Sales of newer antipsychotics like Risperdal, Seroquel   
   and Zyprexa totaled $13.1 billion in 2007, up from $4 billion in 2000,   
   according to IMS Health, a health care information company.   
      
   Part of this increase can be traced to prescriptions in nursing homes.   
   Researchers estimate that about a third of all nursing home patients   
   have been given antipsychotic drugs.   
      
   The increases continue despite a drumbeat of bad publicity. A 2006   
   study of Alzheimer’s patients found that for most patients,   
   antipsychotics provided no significant improvement over placebos in   
   treating aggression and delusions.   
      
   In 2005, the Food and Drug Administration ordered that the newer drugs   
   carry a “black box” label warning of an increased risk of death. Last   
   week, the F.D.A. required a similar warning on the labels of older   
   antipsychotics.   
      
   The agency has not approved marketing of these drugs for older people   
   with dementia, but they are commonly prescribed to these patients “off   
   label.” Several states are suing the top sellers of antipsychotics on   
   charges of false and misleading marketing.   
      
   Ambre Morley, a spokeswoman for Janssen, the division of Johnson &   
   Johnson that manufactures Risperdal, would not comment on the suits,   
   but said: “As with any medication, the prescribing of a medication is   
   up to a physician. We only promote our products for F.D.A.-approved   
   indications.”   
      
   Nevertheless, many doctors say misuse of the drugs is widespread.   
   “These antipsychotics can be overused and abused,” said Dr. Johnny   
   Matson, a professor of psychology at Louisiana State University. “And   
   there’s a lot of abuse going on in a lot of these places.”   
      
   Dr. William D. Smucker, a member of the American Medical Directors   
   Association, a group of health professionals who work in nursing   
   homes, agreed. Though the group encourages doctors to conduct a   
   thorough assessment and prescribe antipsychotics only as a last   
   resort, he said, “Many physicians are absent without leave in the   
   nursing home and don’t take an active role in the assessment of the   
   patient.”   
      
   Some nursing homes are trying a different approach, so-called   
   environmental intervention. The strategies include reducing boredom,   
   providing intellectual and physical stimulation, exercise, calming   
   music, bringing in pets for therapy and improving how the staff   
   approaches and talks to dementia patients.   
      
   At the Margaret Teitz Nursing and Rehabilitation Center in Queens,   
   social workers do life reviews of patients to understand their   
   interests, lifestyle and former occupations.   
      
   “I had a patient who used to be in fashion,” said Nancy Goldwasser,   
   the director of social services. “So we got her fabric samples. And   
   she’d sit and look through the books, touch the fabric, and it would   
   calm her.”   
      
   But such approaches are time consuming, they do not help all patients,   
   they can be prohibitively expensive and they will be more difficult to   
   provide as Alzheimer’s continues to increase.   
      
   “Our health care system isn’t set up to address the mental, emotional   
   and behavioral problems of the elderly,” said Dr. Gary S. Moak,   
   president of the American Association for Geriatric Psychiatry.   
      
   Nursing homes are short staffed, and insurers do not generally pay for   
   the attentive medical care and hands-on psychosocial therapy that   
   advocates recommend. It is much easier to use sedatives and   
   antipsychotics, despite their side effects.   
      
   The first generation of antipsychotics, like Haldol, carry a   
   significant risk of repetitive movement disorders and sedation.   
   Second-generation antipsychotics, also called atypicals, are more   
   commonly prescribed because the risk of movement disorders is lower.   
   But they, too, can cause sedation, and they contribute to weight gain   
   and diabetes.   
      
   Used correctly, the drugs do have a role in treating some seriously   
   demented patients, who may be incapacitated by paranoia or are   
   self-destructive or violent. Taking the edge off the behavior can keep   
   them safe and living at home, rather than in a nursing home.   
      
   If patients are prescribed an antipsychotic, it should be a very low   
   dose for the shortest period necessary, said Dr. Dillip V. Jeste, a   
   professor of psychiatry and neuroscience at the University of   
   California, San Diego.   
      
   It may take a few weeks or months to control behavior. In many cases,   
   the patient can then be weaned off of the drugs or kept at a very low   
   dose.   
      
   Some experts say another group of medications — antidementia drugs   
   like Aricept, Exalon and Menamda — are underused. Research shows that   
   10 to 20 percent of Alzheimer’s patients had noticeable positive   
   responses to the drugs, and 40 percent more showed some cognitive   
   improvement, even if it was not noticeable to an observer.   
      
   “Sometimes, it’s enough to take the edge off the behavioral problems,   
   so the family and patient can live with it and you don’t expose people   
   to much risk,” said Dr. Gary J. Kennedy, director of geriatric   
   psychiatry at the Montefiore Medical Center in the Bronx.   
   Other experts cite a lack of research backing these drugs for   
   behavioral problems.   
      
   If patients begin showing behavioral symptoms of dementia, doctors   
   said, they should have complete medical and psychiatric workups first,   
   especially if symptoms develop suddenly.   
      
   “Just because someone is 95 does not mean one should not do a workup,   
   especially if she’s been healthy,” Dr. Kennedy said.   
      
   Common causes of the symptoms include ministrokes, reparable brain   
      
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    * Origin: you cannot sedate... all the things you hate (1:229/2)