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The recent warning by the US Food and Drug Administration about the
adverse effects of atypical antipsychotics in the elderly is too little,
too late. It has been known for decades that use of these drugs is ill-
advised in a population with altered ability to metabolize and excrete
them, as well as no identified psychiatric reason for their use. The
increase in respiratory infections can be accounted for as follows.
The elderly have a reduced ability to tolerate anticholinergic drugs in
general. (1) The neuroleptics/antipsychotics are well known for their
ability to cause dyskinesias, among them tardive dyskinesia and
extrapyramidal syndrome ( 2, 3, 4, 5, 6). When added to the parkinsonism
that develops in the natural history of many of the dementing illnesses,
this tendency can be lethal.
The adverse effects of these drugs include, in addition to dyskinesias:
xerostomia, oropharyngeal deglutition disorders, esophageal dysfunction,
taste and olfactory alterations and anorexia . Xerostomia, with a
reduction in the amount of saliva swallowed, may cause or exacerbate
gastroesophageal reflux ( 7, 8, 9 ). This reflux, occurring often during
sleep, and unwitnessed, is the first step in the development of aspiration
pneumonitis, often followed within days by a secondary bacterial infection
in a population that is well known to be frail, malnourished,dehydrated
and lacking resistance to infection. Generally, the chronic aspiration of
food, fluid and saliva in a well nourished and adequately hydrated
patient, is tolerated and handled by the lungs’ scavenging system (10). In
the population under discussion, it is not.
The well recognized eating and swallowing impairments as well as
dependence on others for feeding in patients with a dementing illness are
exacerbated if not caused by the use of both “traditional” and atypical
antipsychotic medications.
1. Feinberg M . The problems of anticholinergic adverse effects in
older patients. Drugs Aging, 3(4):335-48 1993
2. Hughes TA; Shone G; Lindsay G; Wiles CM. Severe dysphagia associated
with major tranquillizer treatment.Postgrad Med J, 70:581-583 1994
3. Jeste DV; Lacro JP; Palmer B; Rockwell E; Harris MJ; Caligiuri MP .
Incidence of tardive dyskinesia in early stages of low-dose treatment with
typical neuroleptics in older patients. Am J Psychiatry, 156(2):309-11
1999
4. Kruk J; Sachdev P; Singh S . Neuroleptic-induced respiratory
dyskinesia.
J Neuropsychiatry Clin Neurosci, 7:223-9 1995
5. Gardos G; Cole JO. The evaluation and treatment of neuroleptic-induced
movement disorders.Harv Rev Psychiatry, 3:130-139.1995
6. Williams BR, Nichol MB, Lowe B, Yoon PS, McCombs JS, Margolies J
Medication use in residential care facilities for the elderly. Ann
Pharmacother 1999;33:149-55
7. Crockett DN. Xerostomia: the missing diagnosis? Aust Dent J, 38:114-
118.1993.
8. Henkin RI . Drug-induced taste and smell disorders. Incidence,
mechanisms and management related primarily to treatment of sensory
receptor dysfunction.Drug Saf, 11:318-377 1994
9. Meyer D; Hartmann K; Kuhn M . Drug-induced taste disorders. Schweiz
Rundsch Med Prax, 85:1468-1472 1996k, P. E. N Engl J Med 2001;344:665-671
10. Marik PE. Aspiration pneumonia and aspiration pneumonitis. NEJM 344:
655- 671. 2001
Antipsychotics, adverse effects and dementing illness
The recent warning by the US Food and Drug Administration about the
adverse effects of atypical antipsychotics in the elderly is too little,
too late. It has been known for decades that use of these drugs is ill-
advised in a population with altered ability to metabolize and excrete
them, as well as no identified psychiatric reason for their use. The
increase in respiratory infections can be accounted for as follows.
The elderly have a reduced ability to tolerate anticholinergic drugs in
general. (1) The neuroleptics/antipsychotics are well known for their
ability to cause dyskinesias, among them tardive dyskinesia and
extrapyramidal syndrome ( 2, 3, 4, 5, 6). When added to the parkinsonism
that develops in the natural history of many of the dementing illnesses,
this tendency can be lethal.
The adverse effects of these drugs include, in addition to dyskinesias:
xerostomia, oropharyngeal deglutition disorders, esophageal dysfunction,
taste and olfactory alterations and anorexia . Xerostomia, with a
reduction in the amount of saliva swallowed, may cause or exacerbate
gastroesophageal reflux ( 7, 8, 9 ). This reflux, occurring often during
sleep, and unwitnessed, is the first step in the development of aspiration
pneumonitis, often followed within days by a secondary bacterial infection
in a population that is well known to be frail, malnourished,dehydrated
and lacking resistance to infection. Generally, the chronic aspiration of
food, fluid and saliva in a well nourished and adequately hydrated
patient, is tolerated and handled by the lungs’ scavenging system (10). In
the population under discussion, it is not.
The well recognized eating and swallowing impairments as well as
dependence on others for feeding in patients with a dementing illness are
exacerbated if not caused by the use of both “traditional” and atypical
antipsychotic medications.
1. Feinberg M . The problems of anticholinergic adverse effects in
older patients. Drugs Aging, 3(4):335-48 1993
2. Hughes TA; Shone G; Lindsay G; Wiles CM. Severe dysphagia associated
with major tranquillizer treatment.Postgrad Med J, 70:581-583 1994
3. Jeste DV; Lacro JP; Palmer B; Rockwell E; Harris MJ; Caligiuri MP .
Incidence of tardive dyskinesia in early stages of low-dose treatment with
typical neuroleptics in older patients. Am J Psychiatry, 156(2):309-11
1999
4. Kruk J; Sachdev P; Singh S . Neuroleptic-induced respiratory
dyskinesia.
J Neuropsychiatry Clin Neurosci, 7:223-9 1995
5. Gardos G; Cole JO. The evaluation and treatment of neuroleptic-induced
movement disorders.Harv Rev Psychiatry, 3:130-139.1995
6. Williams BR, Nichol MB, Lowe B, Yoon PS, McCombs JS, Margolies J
Medication use in residential care facilities for the elderly. Ann
Pharmacother 1999;33:149-55
7. Crockett DN. Xerostomia: the missing diagnosis? Aust Dent J, 38:114-
118.1993.
8. Henkin RI . Drug-induced taste and smell disorders. Incidence,
mechanisms and management related primarily to treatment of sensory
receptor dysfunction.Drug Saf, 11:318-377 1994
9. Meyer D; Hartmann K; Kuhn M . Drug-induced taste disorders. Schweiz
Rundsch Med Prax, 85:1468-1472 1996k, P. E. N Engl J Med 2001;344:665-671
10. Marik PE. Aspiration pneumonia and aspiration pneumonitis. NEJM 344:
655- 671. 2001
Competing interests:
None declared
Competing interests: No competing interests