We need to understand why this practice continues despite the mortality risk.
Jenny McCleery and Robin Fox.
Responding to the above article BMJ 17 March, volume 344, p.7.
Disturbed demented patients remain a major concern whether resident in nursing homes or the long stay NHS wards since the behaviour per se if left uncontrolled would continue to be a mortality risk. For decades, the long standing treatment of disturbed behaviour benefitted from antipsychotic medication – the “major tranquillisers” whether phenothiazines or butyrophenones – initially in large mental asylums then later in district general hospitals and now nursing homes and the community in the current era of having additionally the atypical antipsychotics. Unfortunately continuous prescription of this drug group and with increasing doses invariably result in extra-pyramidal side-effects with physical and psychological disturbances (the latter sometimes referred to as psychological extra-pyramidal side effect ).
Experience in treating referred disturbed patients came from my consultant locums in the South of England and Wales after retiring from the NHS and Royal Navy and was guided by an article about raised serum prolactin levels during antipsychotic treatment 1. It stated that over-occupancy of dopaminergic receptors whilst patients were receiving antipsychotics could result in increased serum prolactin and extrapyramidal side effects.
Raised serum prolactin level, a side effect in itself, was not the cause of extra pyramidal signs and symptoms but was merely an indicator of its emergence. My purpose in treatment was to use this indicator to ensure uncomplicated outcome and particularly to avoid serious adverse risks. The observed disturbed patients on antipsychotic treatment during my locums were showing extra pyramidal side effects whilst mainly on conventional and some atypical antipschotics. Their behaviour benefitted by replacing the previously prescribed medication with quetiapine twice per day in graduated doses if necessary and coupled initially with semisodium valproate – the mood stabiliser by itself was reported to have benefits in disturbed behaviour 2. The treatment was monitored clinically by the serum prolactin levels.
Ironically, my investigations during a short locum were questioned citing several patients previously prescribed antipsychotics for longstanding disturbed behaviour without realising that the serum prolactin levels were raised which indicated to me the encroachment of extra pyramidal side effects underlying the adverse behaviour.
Psychiatry owes much to antipsychotics historically in treatment of disturbed demented patients who are now residing in nursing homes and at home. To pose the question as to the continuing practice of their use despite the mortality risk is to realise that the pharmacokinetics of the drug and the absence of not employing a cheap investigation measure were being clinically overlooked.
Competing interest : retired consultant psychiatrist with continuing interest in medicine.
References:
1 Relationship between Dopamine D2 Occupancy, Clinical Response, and Side Effects --- Shitij Kapur et al AJP 2000.
2 Sival R.C.et al Sodium Valproate in aggressive behaviour in dementia: a 12 week open label follow up study. Int. Geriatric Pscyhiatry2004: 19:203-312
Rapid Response:
Re: Antipsychotic prescribing in nursing homes
Antipsychotic prescribing in nursing homes.
We need to understand why this practice continues despite the mortality risk.
Jenny McCleery and Robin Fox.
Responding to the above article BMJ 17 March, volume 344, p.7.
Disturbed demented patients remain a major concern whether resident in nursing homes or the long stay NHS wards since the behaviour per se if left uncontrolled would continue to be a mortality risk. For decades, the long standing treatment of disturbed behaviour benefitted from antipsychotic medication – the “major tranquillisers” whether phenothiazines or butyrophenones – initially in large mental asylums then later in district general hospitals and now nursing homes and the community in the current era of having additionally the atypical antipsychotics. Unfortunately continuous prescription of this drug group and with increasing doses invariably result in extra-pyramidal side-effects with physical and psychological disturbances (the latter sometimes referred to as psychological extra-pyramidal side effect ).
Experience in treating referred disturbed patients came from my consultant locums in the South of England and Wales after retiring from the NHS and Royal Navy and was guided by an article about raised serum prolactin levels during antipsychotic treatment 1. It stated that over-occupancy of dopaminergic receptors whilst patients were receiving antipsychotics could result in increased serum prolactin and extrapyramidal side effects.
Raised serum prolactin level, a side effect in itself, was not the cause of extra pyramidal signs and symptoms but was merely an indicator of its emergence. My purpose in treatment was to use this indicator to ensure uncomplicated outcome and particularly to avoid serious adverse risks. The observed disturbed patients on antipsychotic treatment during my locums were showing extra pyramidal side effects whilst mainly on conventional and some atypical antipschotics. Their behaviour benefitted by replacing the previously prescribed medication with quetiapine twice per day in graduated doses if necessary and coupled initially with semisodium valproate – the mood stabiliser by itself was reported to have benefits in disturbed behaviour 2. The treatment was monitored clinically by the serum prolactin levels.
Ironically, my investigations during a short locum were questioned citing several patients previously prescribed antipsychotics for longstanding disturbed behaviour without realising that the serum prolactin levels were raised which indicated to me the encroachment of extra pyramidal side effects underlying the adverse behaviour.
Psychiatry owes much to antipsychotics historically in treatment of disturbed demented patients who are now residing in nursing homes and at home. To pose the question as to the continuing practice of their use despite the mortality risk is to realise that the pharmacokinetics of the drug and the absence of not employing a cheap investigation measure were being clinically overlooked.
Competing interest : retired consultant psychiatrist with continuing interest in medicine.
References:
1 Relationship between Dopamine D2 Occupancy, Clinical Response, and Side Effects --- Shitij Kapur et al AJP 2000.
2 Sival R.C.et al Sodium Valproate in aggressive behaviour in dementia: a 12 week open label follow up study. Int. Geriatric Pscyhiatry2004: 19:203-312
Yours truly
M.Cassim Khan MB, ChB, FRCPsych., DPM
Ret’d Consultant Psychiatrist.
Competing interests: No competing interests