Elderly patients over-prescribed antipsychotic drugs

New York Post
Friday, December 02, 2011

In the United States, elderly patients with dementia are too often prescribed antipsychotic drugs to calm their disruptive behavior, a costly and risky practice that should end, experts said Wednesday
Instead, more care should be taken to determine why dementia patients may be acting up and treat those underlying causes, lawmakers were told at a hearing of the Senate Committee on Aging.
"As the baby boomer generation ages, it is imperative to address the overuse and misuse of antipsychotic drugs among nursing home patients," said Daniel Levinson, Health and Human Services Inspector General.

Levinson said recent government audits have raised concerns about the use of antipsychotics by elderly people with dementia in nursing homes, raising their risk of death and wasting money for the US healthcare system.
For instance, more than half of such prescriptions were wrongly paid for in 2007 by government Medicare because the patients did not exhibit symptoms of schizophrenia or bipolar disorder, amounting to about 230 million dollars in waste.
One audit showed 14 percent of nursing home residents had Medicare claims for antipsychotic drugs, he said.
But another panel member, Toby Edelman, senior policy attorney in the office of the Center for Medicare Advocacy, said that audit's estimate was low because it only included some kinds of anti-psychotics.
"Nursing facilities' self-reported data indicate that in the third quarter of 2010, 26.2 percent of residents had received antipsychotic drugs in the previous seven days. That is approximately 350,000 individuals," she said.
"Facilities reported they gave antipsychotic drugs to many residents who did not have a psychosis, including 40 percent of patients at high risk because of behavior issues."
Edelman also pointed out that this issue is far from new, and that the same Senate committee had issued a report on the misuse of drugs in nursing homes back in 1975, and held a workshop on the topic two decades ago.
The practice persists, even though it is against federal law, because of serious understaffing in nursing facilities, high turnover of staff, and "aggressive off-label marketing of anti-psychotic drugs," she said.
The pharmaceutical giant Eli Lilly in 2009 paid a nearly 1.5 billion dollar settlement, in which it admitted no wrongdoing, for off-label promotion of its drug Zyprexa as a treatment for dementia. The drug is FDA-approved for bipolar disorder and schizophrenia.
According to Tom Hlavacek, executive director at Alzheimer's Association's southeastern Wisconsin chapter, elderly people with dementia are sometimes prescribed these potent drugs for behaviors that have other causes.
Urinary tract infections, tooth decay, arthritic pain, or simply moving a patient from one place to another can lead to agitated behaviors.
"Our experience indicates that these care transitions can exacerbate behaviors and often lead to escalating drug treatments," he told lawmakers.
Experts said solutions could include creating stronger penalties for inappropriate prescribing, and a renewed focus on trying non-pharmacological approaches to a problem first.
"Most doctors treat unwelcome behavior in all settings as a disease that requires medication. These drugs are used as chemical restraints," said Jonathan Evans, a doctor who specializes in caring for frail elders.
"Behavior is not a disease. Behavior is communication. And in people who have lost the ability to communicate with words, the only way to communicate is through behavior," he added.
"Good care demands we figure out what they are telling us and help them."

Confusing Medical Ailments with Mental Illness

WALL STREET JOURNAL online
August 9, 2011

An elderly woman's sudden depression turns out to be a side effect of her high blood-pressure medication.
A new mother's exhaustion and disinterest in her baby seem like postpartum depression—but actually signal a postpartum thyroid imbalance that medication can correct.
A middle-aged manager has angry outbursts at work and frequently feels "ready to explode." A brain scan reveals temporal-lobe seizures, a type of epilepsy that can be treated with surgery or medication.
More than 100 medical disorders can masquerade as psychological conditions, according to Harvard psychiatrist Barbara Schildkrout, who cited these examples among others in "Unmasking Psychological Symptoms," a book aimed at helping therapists broaden their diagnostic skills.

Different Diagnoses

More than 100 medical disorders can masquerade as psychological conditions or contribute to them, complicating treatment decisions.

WHAT SEEMS LIKE ...	MAY ACTUALLY BE ...
Depression	Underactive thyroid; low vitamin D or B-12 or folate; diabetes; hormonal changes; heart disease; Lyme disease; lupus; head trauma, sleep disorders; some cancers and cancer drugs
Anxiety	Overactive thyroid; respiratory problems; very low blood pressure; concussion; anaphylactic shock
Irritability	Brain injury; temporal lobe epilepsy;  disease and early stage dementia; parasitic infection; hormonal changes
Hallucinations	Epilepsy; brain tumor; fever; narcolepsy; substance abuse
Cognitive changes	Brain injury or infection; Alzheimer's; Parkinson's; liver failure; mercury or lead poisoning
Psychosis	Venereal disease; brain tumors and cysts; stroke; epilepsy; steroids; substance abuse

Source: WSJ reporting

Studies have suggested that medical conditions may cause mental-health issues in as many as 25% of psychiatric patients and contribute to them in more than 75%.
Untangling cause and effect can challenge even seasoned clinicians, and the potential for missed diagnoses is growing these days, said Dr. Schildkrout, who has more than 25 years of clinical practice in the Boston area. Most mental-health counselors rely on primary-care doctors to spot medical issues, but those physicians are increasingly time-pressed and may not know their patients well. Neither do the psychiatrists who mainly write prescriptions and see patients only briefly, she said in an interview.
Common culprits include under- or over-active thyroid glands, which can cause depression and anxiety, respectively. Deficiencies of vitamins D, B-12 and folate, as well as hormonal changes and sleep disorders have also been linked to depression.
Diabetes, lupus and Lyme disease can have a variety of psychiatric symptoms, as can mercury and lead poisoning and sexually transmitted diseases. Many medications also list mood changes among their side effects, and substance abuse is notorious for causing psychiatric problems.
Some underlying conditions are readily treatable. Others, such as Alzheimer's and Parkinson's disease and some brain tumors, are not. But a correct diagnosis can save months or years of frustration and ineffective treatment.
In some cases, a psychological problem is just the first sign of a serious medical issue. "Depression predicts heart disease and heart disease predicts depression," said Gary Kennedy, director of the geriatric psychiatry at Montefiore Medical Center in Bronx, N.Y.
About one-third of people who have their first episode of depression after age 55 have changes in brain circuits that are associated with hypertension, diabetes and heart attacks. Such patients are usually apathetic, have difficulty with executive planning and don't respond well to antidepressants. Making sure their blood pressure and blood-sugar levels are on target is crucial, though medical and psychotherapy may be needed as well, Dr. Kennedy said.
Recognizing an underlying medical condition can be particularly difficult when there is also a psychological explanation for a patient's dark moods. For example, victims of domestic violence are often anxious, depressed and withdrawn—but mild brain injury could be causing such symptoms, too.

Warning Signs

When to suspect a mental problem may be medical:
• Sudden change in mood or personality
• History of head trauma
• Depression that occurs for the first time after age 55
• Recent travel or exposure to infections
• Any rash, swelling, drooping eyelid; facial tic
• Standard medication or therapy isn't effective

Similarly, a former college athlete who becomes angry and irritable in his 40s could be suffering a midlife crisis—or delayed reaction to head injuries sustained decades earlier. "We now know that multiple concussions can have a sleeper effect for years. Then one day, out of the blue, you start acting explosive and depressed," due to a brain swelling known as chronic trauma encephalopathy, said Jerrold Pollak, a neuropsychologist at Seacoast Mental Health Center in Portsmouth, N.H., and lead author of an article on distinguishing mental from medical disorders in the Journal of Clinical Psychology Practice this spring.
If the head-injury diagnosis is missed, Dr. Pollak added, the patient could be in psychotherapy for months, "thinking that he has trouble with his father or feels like a failure for not becoming a pro athlete."
Giving every patient who seeks psychological help a brain scan first would be prohibitively expensive and likely yield many confusing results. But experts say mental-health counselors should ask patients about their medical histories as well as emotional issues, and make sure they've had a recent physical exam.
Tell-tale signs of underlying medical problems include significant changes in energy, weight, appetite or sleep, which could be due to an endocrine disorder. Sudden changes in mood or personality, visual hallucinations and alternations in smell, taste or tactile senses could signal a brain tumor or other abnormality.
Sometimes a single physical sign can broaden a clinician's diagnostic thinking. Manhattan psychiatrist Drew Ramsey recalled that early in his career, he examined a patient with daily panic attacks and noticed a swelling on her shins, a classic sign of Graves' disease, a form of overactive thyroid that can cause severe anxiety.
Like other psychiatrists, Dr. Ramsey said he always takes a medical history and orders blood tests for patients. He found that one was anemic and improved markedly when meat was added to her diet. Another who was depressed and drinking heavily was low on vitamins D and B-12.
Similarly, Dr. Schildkrout once treated a 50-year-old woman for mood swings and noticed a slight slurring to her speech. While it could have been dismissed as ill-fitting dentures, it turned out to be the first sign of amyotrophic lateral sclerosis, which also causes severe fatigue and odd jags of laughing and crying in its early stages.
Some patients may benefit from both psychological counseling and medical help. Therapists need not turn patients away while medical issues are being explored, experts say. "Clinicians can say, 'While we work on these issues, let's also discuss any possible medical conditions that could be contributing, so we can at least rule them out,"' Dr. Pollak said.
Finally clarifying a diagnosis can be a relief to clinicians and patients—particularly when therapy hasn't been working or patients have spent years blaming themselves. "When you find the right diagnosis, not only is there appropriate treatment, but it can make a dramatic improvement in terms of healing their self esteem," Dr. Schildkrout said.
—Email HealthJournal@wsj.com

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