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Antipsychotic use in older adults: Canadian best practices

Pathak, Sushila, MSN, NP; Duff, Elsie, PhD, NP

doi: 10.1097/01.NPR.0000532766.14251.c7
Feature: ANTIPSYCHOTIC MEDICATIONS

Abstract: Due to the physiologic changes of aging, managing behavioral issues and antipsychotic use is associated with adverse reactions that are more complex in older adults than in younger adults. Therefore, appropriate prescribing and evaluating the need to continue antipsychotics are necessary to enhance optimum patient outcomes. This article discusses best practice recommendations for NPs in Canada to help ensure safe use of antipsychotic medications in the older adult population.

Due to the physiologic changes of aging, managing behavioral issues and antipsychotic use is associated with adverse reactions that are more complex in older adults than in younger adults. Therefore, appropriate prescribing and evaluating the need to continue antipsychotics are necessary to enhance optimum patient outcomes. This article discusses best practice recommendations for NPs in Canada to help ensure safe use of antipsychotic medications in the older adult population.

Sushila Pathak is an NP at Shellbrook Primary Care Clinic, Saskatchewan Health Authority, Shellbrook, Saskatchewan, Canada.

Elsie Duff is an NP at Selkirk Quickcare and an instructor at Sask Polytech, Regina, Saskatchewan, Canada.

The authors have disclosed no financial relationships related to this article.

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Figure

An individual's health state is affected by age-related diminished physiologic functioning, functional decline, sensory impairment, frailty, and multiple disease comorbidities, increasing one's vulnerability for acute and end-of-life care.1 In older adults, even a minor disease process can lead to diminished physiologic functioning as well as major health deterioration.

In Canada, the older adult population is growing; the latest population estimates are approximately 2 million adults between ages 65 and 69, 3.8 million older adults between ages 70 and 89, and 300,000 over age 89.2 It is estimated that individuals age 85 years and older account for the fastest growing age-group in Canada, which reflects reduced premature deaths and extended life spans.1 Thus, the longevity and quality of living will be affected if not complemented with quality care.

Currently, 27.5% of older adults living in Canadian long-term-care facilities are on at least one antipsychotic medication, and of these, more than 30% have no clinical indication for their use.2 To address this problem, this article discusses best practice recommendations to help ensure safe use of antipsychotics in the older adult population.

NPs have the knowledge and expertise to select appropriate interventions for nonpharmacologic and pharmacologic management of patients to restore or maintain functional, physiologic, and mental stability.3,4 In Canada, NPs are RNs with graduate education who have the legal authority to prescribe antipsychotic medications to older adults.4,5 Accurately diagnosing and treating patients with mental illness in accordance with practice guidelines is an entry-level competency for NPs in Canada.4

Antipsychotic medications (formerly known as tranquilizers and neuroleptics) are used to reduce or relieve symptoms of psychosis.6 In practice, they are also used to stabilize moods and reduce anxiety, depression, agitation, and tics in Tourette syndrome.6 The therapeutic effect of antipsychotics is usually achieved between 4 and 6 weeks.6 Antipsychotics can help prevent exacerbation, persistence, and relapse of psychotic symptoms; however, they do not cure the underlying condition.7

Although antipsychotics are used to induce calmness and eliminate confusion in those with acute psychosis or delirium, the benefits are debatable due to the associated severe adverse reactions.8 Although atypical antipsychotics (AAPs) are known to have less adverse reactions as compared with their typical counterparts, the use of both types of antipsychotics in older adults has been disputed.1,6,8-12

The use of antipsychotics to treat behavioral symptoms in older adults has been limited due to the associated adverse reactions.9 Multiple disease comorbidities, antipsychotic use, and polypharmacy are factors responsible for negative health outcomes in older adults.13 Agencies worldwide issued warnings against antipsychotic use between 2002 and 2005—especially against use in older populations—as this patient population is the most vulnerable to adverse reactions.1,6,9

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The use of antipsychotics for nonpsychotic behavior is considered off-label use and poses legal implications.9,13 The use of antipsychotic medications in the absence of a clear diagnostic indication has risen multiple folds, and patients age 65 years and older are at a greater risk than any other age-group for adverse drug reactions due to antipsychotic polypharmacy, off-label prescription, and underdiagnosis of mental illnesses.12,14

Although AAPs have a better safety profile as compared with typical antipsychotics (TAPs), indiscriminate prescribing is not justifiable. The safety of TAPs and AAPs should be investigated, evaluated, and discussed before initiating the treatment, as older adults are likely at risk for exposure to antipsychotics in primary care settings even before moving to long-term-care facilities.13

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Indications for antipsychotic medications

Schizophrenia and psychotic disorders affect approximately 1% of the population and are among the major causes of disability worldwide.14 NPs play an essential role in prescribing antipsychotic medications given the optimum evidence-based care in managing mental illnesses and for psychotic disorders. One prescribing strategy to reduce drug-drug interaction, polypharmacy, and adverse reactions is to consider the risk of schizophrenia and psychotic disorder relapse relative to other patient outcomes.10,15 That is, if a relapse is not severe and the adverse reactions are disabling, patients may prefer relapse over antipsychotic medications.15 Additionally, documenting the mental health diagnosis of patients, starting patients on oral antipsychotics to ascertain tolerability, and conducting a monthly medication review are needed.14 NPs can use the following indication for antipsychotics when working with older adults.

Confirmed mental health diagnosis. Antipsychotics are used to treat confirmed mental health diagnoses, such as schizophrenia, mania in bipolar disorder, and as adjunctive treatment for major depressive disorder in adult patients unresponsive to prior antidepressant treatments (see Antipsychotic usage). The use of antipsychotics is indicated for managing acute symptoms or as a long-term therapy for a specific mental health diagnosis. For example, the long-acting injection form of risperidone is well tolerated and considered safe in older adults with psychosis. Nevertheless, the NP should consider the efficacy of each antipsychotic and prescribe accordingly to treat different diseases that may coexist in the older adult population.9,10,14,16

Severe psychoses, delusions, and hallucinations. Symptom severity is evaluated based on the degree of danger, suffering, or excess disability. To identify the actual nature of psychological disturbance versus physiologic or medical deterioration, it is important that hallucinations are distinguished from a patient's language difficulty and visual or auditory misperceptions.6 Understanding the normal differences in human physiology and changes associated with aging is required to help NPs provide timely care.

A new onset of delusions or hallucinations should alert NPs to investigate for delirium.6 If suspected, the short-term use of an AAP is usually the preferred choice of treatment. NPs should adhere strictly to prescribing low-dose monotherapy to older adults with delirium, as monotherapy with the lowest effective antipsychotic dose is the mainstay treatment for delirium.6,14,17

Injury risk for older adults. Antipsychotics are preferred for the management of neuropsychiatric symptoms in patients with dementia despite safety concerns.10 If the patient evaluation indicates behavior that is likely to cause self-harm or harm to others, and if the nonpharmacologic approaches for the prevention and management of neuropsychiatric symptoms have been ineffective, short-term antipsychotic treatment for 3 to 6 months with AAPs is approved for the symptomatic management of aggressive or psychotic behavior in Canada.13,18 Treatment of behavioral symptoms associated with delirium or dementia with antipsychotics is FDA off-label use in the United States.17

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Consequences of antipsychotic polypharmacy

Antipsychotic polypharmacy is defined as the use of two or more antipsychotics for managing refractory and significant residual psychotic signs and symptoms.9,15,16,19 The maintenance of long-term chronic use of antipsychotic polypharmacy reduces brain volume and weight.15

Furthermore, antipsychotic polypharmacy, regardless of age-group, is likely to cause higher rates of drug-drug interactions, adverse reactions, and an increase in healthcare costs.9 Antipsychotic monotherapy has shown to increase functional improvements, reduce adverse reactions and associated healthcare costs, and induce positive effects on cognition in older adults.9 For example, the use of risperidone or other AAPs as monotherapy is well tolerated and considered safer than TAP monotherapy and/or polypharmacy in older adults with chronic schizophrenia.9,16

In fact, the combination of antipsychotics may actually increase extrapyramidal symptoms and cause hyperprolactinemia, sexual dysfunction, sedation, cognitive impairment, hyperlipidemia, and metabolic syndrome.15 Therefore, antipsychotic polypharmacy is advised only for the treatment of schizophrenia and serious mental illness after little or no response with monotherapy.16

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Adverse reactions

The high risk-to-benefit ratio of TAP medications in older adults is well documented, with an increased mortality risk and disabling behaviors.1,9,14 AAPs are also associated with an increased risk of clinically significant adverse reactions (see Antipsychotics: Adverse reactions in older adults). The aforementioned adverse reactions are dependent on variables such as lifestyle, comorbidities, and the type of antipsychotic, such as risperidone or quetiapine, which are known to cause low to moderate levels of weight gain.9

Moreover, these adverse reactions become multifold when older adults are prescribed multiple medications, increasing the risk of drug-drug interactions. For example, aripiprazole interacts with medications that are inducers or inhibitors of cytochrome P 450 (CYP 450) 3A4 and CYP2D6 enzymes.9 Likewise, when considering discontinuation of these drugs, a careful evaluation and appropriate measures must be taken to ameliorate the significant and debilitating withdrawal effects in older adults.14

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Special care is required for older patients with one or more problems, as AAPs mimic anticholinergic effects. Furthermore, the long-term antipsychotic use has been associated with extrapyramidal symptoms, which can increase a patient's risk of tremor and muscle rigidity.20 While extrapyramidal symptoms are common with TAPs, AAPs are also associated with orthostatic hypotension, QT interval prolongation, tachycardia, and weight gain.10,14

Antipsychotics negatively impact an older adults' activity of daily living, cognition, behavioral and psychological symptoms, blood glucose level, and BP.21,23,24 Regardless of the dose and duration of the antipsychotic used, antipsychotics—particularly TAPs—are associated with disruptive adverse reactions and higher mortality.13 Researchers also identified the positive correlation between antipsychotic use and verbally disruptive attention-seeking behavior, restlessness, disoriented symptoms, and passiveness in patients. Although evidence on the antipsychotic efficacy in managing these behaviors is limited, antipsychotic medication-induced psychosis, polypharmacy, and increased hospitalizations and financial burden were found to be statistically significant.11,13,23

Falls and frailty are associated with polypharmacy, which is commonly seen among patients using antipsychotics and cardiovascular drugs.11,14 Antipsychotics are one of the major drug categories that increase the risk of falls and are known to cause sedation, orthostatic hypotension, severe dizziness, and fatigue, resulting in confusion, fractures, and hospitalization.11,21 The risk of falls increases among those who have gait and balance issues.

In a study of major cardiovascular events and noncardiovascular mortality associated with antipsychotic medication, there is an increased incidence rate of cardiovascular events with AAP and TAP use regardless of a patient's dementia status.23 The results were significant for older adults with established cardiovascular disease during the first month of initiating the medication, with a subsequent decline thereafter in long-term users.23

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Implications for NPs

Older adults make up a substantial proportion of the total Canadian population, and this growing demographic puts a significant burden on the Canadian healthcare system.5 Although antipsychotics are effective in limiting psychotic symptoms, preventing relapses, and reducing disability in those affected by mental illnesses, NPs must recognize the limitations, current evidence, and indications while prescribing antipsychotics.

Older adults with psychotic behaviors are treated with antipsychotic medications across all settings. Understanding the benefits versus risks of antipsychotic medication, based on the current, evidence-based, clinical practice guidelines, is crucial to ensure safe patient care. NPs must use their clinical judgment in conjunction with the practice guidelines to assess, diagnose, and manage older adults with mental illness. Based on the guidelines, it is essential that NPs consider the need of antipsychotics for lifelong use among patients with confirmed mental illness diagnoses.9,14

The best practice guidelines for managing older adults' mental health suggest NPs and the interdisciplinary team participate in collaborative practice and promote monthly medication reviews to discuss treatment.14 NPs should note when to use antipsychotics and identify the benefits antipsychotics have in managing those with serious mental health issues.14 Similarly, it is also important for NPs to distinguish hallucinations caused by physiologic challenges experienced by older adults, such as language difficulties and visual or auditory misperceptions from those of psychiatric origin.

Careful evaluation as to whether hallucinations or delusions are distressing to the patient and taking appropriate measures to prevent an individual with delirium from endangering himself or herself or others is crucial.10,17 Since delirium may be caused by the use of antipsychotic medications in patients with behavior issues, close observation and discontinuation of medications must be considered if the treatment fails. Therefore, the NP can start a patient on an antipsychotic medication for nonpsychotic mental illness only if and when a patient with chronic conditions (such as dementia and Parkinson disease) develops psychosis and nondrug options have not worked.14 Otherwise, the NP should consider supportive and nonrestrictive alternative intervention for reducing the patient's psychosis and polypharmacy.

NPs are in a unique position to strike a balance between safety and oversedation in older adults when initiating or augmenting psychotropic medications.3 It is crucial that NPs assess the behaviors of older adults and take patient-specific treatment approaches first.17 Identifying whether there are underlying causes for a patient's agitation is important. Knowing if a patient has any underlying pain, constipation, or other medical issues will help NPs take a collaborative approach in identifying, assessing, and managing the psychiatric issues as well as behavior and physical symptoms.

NPs should assess for the change in frequency and intensity of the behaviors in their patients during follow-up visits.3,14 Discussing response to therapy with the patient and family will assist in establishing trust. NPs may need to strategically plan and communicate with an interdisciplinary team to help a patient who is reluctant to stop antipsychotic use make an informed decision.

NPs must critically analyze and reduce polypharmacy in older adults because degeneration in behaviors with long-term use of antipsychotics occurs.13,18 In addition, there is a lack of evidence on the choice of an antipsychotic for a given mental illness or behavioral issues. Behavior monitoring for a minimum of 2 weeks after antipsychotic initiation or dose adjustment is recommended.6 NPs are advised to discontinue the medication if no improvement occurs in the patient's behaviors or symptoms with antipsychotic treatment.1,2

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Conclusion

Antipsychotic use is associated with polypharmacy and adverse reactions in older adults. NPs play a vital role in managing the health of older adult Canadians with ongoing assessment, monitoring, and evaluation of their antipsychotic use. Antipsychotic medications can successfully reduce psychosis and help manage severe mental issues to promote quality of life and safe patient care in older adults. However, caution must be used by NPs when prescribing antipsychotics to older adults who are vulnerable to the adverse reactions, given the variability of findings identified. NPs should use their clinical reasoning and evidence to prescribe or deprescribe antipsychotic medications in older adults to meet the needs of individual patients.

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REFERENCES

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13. Alberta Health Services (AHS). Clinical indications for prescribing antipsychotic medication. 2016. http://www.albertahealthservices.ca/assets/about/scn/ahs-scn-srs-aua-prescribing-antipsychotic.pdf.
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19. Burghart MS. Antipsychotic polypharmacy and joint commission quality measures: implications to the psychiatric pharmacist. Mental Health Clinician. 2013;3(1):10–12.
20. Kohen I, Lester PE, Lam S. Antipsychotic treatments for the elderly: efficacy and safety of aripiprazole. Neuropsychiatr Dis Treat. 2010;6:47–58.
21. Gustafsson M, Sandman PO, Karlsson S, Gustafson Y, Lövheim H. Association between behavioral and psychological symptoms and psychotropic drug use among old people with cognitive impairment living in geriatric care settings. Int Psychogeriatr. 2013;25(9):1415–1423.
22. Gellad WF, Aspinall SL, Handler SM, et al Use of antipsychotics among older residents in VA nursing homes. Med Care. 2012;50(11):954–960.
    23. Sahlberg M, Holm E, Gislason GH, Køber L, Torp-Pedersen C, Andersson C. Association of selected antipsychotic agents with major adverse cardiovascular events and noncardiovascular mortality in elderly persons. J Am Heart Assoc. 2015;4(9):e001666.
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    Keywords:

    adverse reactions; antipsychotic medications; NPs; older adults; polypharmacy

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