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Antipsikotikler yaşlı demanslıları öldürüyor

Arch. Intern. Med. (Antipsychotic Therapy and Short-term Serious Events in Older Adults With Dementia) son sayısında yayınlanan makalelerde yaşlılarda kısa süre antipsikotik kullanımının bile hastaların acil servislere kaldırılması ve ölüm gibi çok ciddi yan etkilere sebep olduğu ve bu bakımdan yaşlıkarda bu tip ilaçları kullanırken çok dikkatli olunması tavsie edildi.

Çalışmada 20.682 evinde yaşayan, 20.559 bakım evinde yaşayan hasta üzerinde retrospektif olarak yapıldı. Evinde yaşayan hastalara atipik antipisokotik verildiğinde 32 misli, bakım evinde kalanlara antipsikotik veridiğinde verilmeyenlere göre 3.8 misli çok ciddi yan etki ortaya çıktığı gösterildi.
 Daha önce yapılan araştırmalarda da benzer sonuçlar elde edilmişti ve FDA tarafından yaşlı demanslı hastalrada antipsikotik kullanımı kontrendşkasyon olarak kabul edilmesine rağmen Türkiyede bir sınırlama getirilmediği gibi atipik antipsikotiklerin demansta kullanımı geri ödeme kapsamına alınmıştı.
Konu ile ilgili bazı referanslar:
Antipsychotic Therapy and Short-term Serious Events in Older Adults With Dementia
Paula A. Rochon, MD, MPH, FRCPC; Sharon-Lise Normand, PhD; Tara Gomes, MHSc; Sudeep S. Gill, MD, MSc; Geoffrey M. Anderson, MD, PhD; Magda Melo, MSc; Kathy Sykora, MSc; Lorraine Lipscombe, MD, MSc; Chaim M. Bell, MD, PhD; Jerry H. Gurwitz, MD
Arch Intern Med. 2008;168(10):1090-1096.
Background  Antipsychotic therapy is widely used to treatbehavioral problems in older adults with dementia. Cohort studiesevaluating the safety of antipsychotic therapy generally focuson a single adverse event. We compared the rate of developingany serious event, a composite outcome defined as an event seriousenough to lead to an acute care hospital admission or deathwithin 30 days of initiating antipsychotic therapy, to betterestimate the overall burden of short-term harm associated withthese agents.
Methods  In this population-based, retrospective cohortstudy, we identified 20 682 matched older adults with dementialiving in the community and 20 559 matched individualsliving in a nursing home between April 1, 1997, and March 31,2004. Propensity-based matching was used to balance differencesbetween the drug exposure groups in each setting. To examinethe effects of antipsychotic drug use on the composite outcomeof any serious event we used a conditional logistic regressionmodel. We also estimated adjusted odds ratios using models thatincluded all covariates with a standard difference greater than0.10.
Results  Relative to those who received no antipsychotictherapy, community-dwelling older adults newly dispensed anatypical antipsychotic therapy were 3.2 times more likely (95%confidence interval, 2.77-3.68) and those who received conventionalantipsychotic therapy were 3.8 times more likely (95% confidenceinterval, 3.31-4.39) to develop any serious event during the30 days of follow-up. The pattern of serious events was similarbut less pronounced among older adults living in a nursing home.
Conclusions  Serious events, as indicated by a hospitaladmission or death, are frequent following the short-term useof antipsychotic drugs in older adults with dementia. Antipsychoticdrugs should be used with caution even when short-term therapyis being prescribed.

Author Affiliations: Departments of Medicine (Drs Rochon, Lipscombe, and Bell) and Health Policy, Management, and Evaluation (Drs Rochon, Anderson, and Bell), University of Toronto; Institute for Clinical Evaluative Sciences (Drs Rochon, Gill, Anderson, Lipscombe, and Bell and Mss Gomes, Melo, and Sykora); Kunin-Lunenfeld Applied Research Unit, Baycrest (Dr Rochon); Department of Medicine, Women's College Hospital (Dr Lipscombe); and Department of Medicine and Keenan Research Centre (Dr Bell), Li Ka Shing Knowledge Institute (Ms Melo), St Michael's Hospital, Toronto, Ontario, Canada; Department of Health Care Policy, Harvard Medical School, and Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts (Dr Normand); Queen's University, Kingston, Ontario, Canada (Dr Gill); and Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester (Dr Gurwitz).

Arch Gen Psychiatry. 2007 Nov;64(11):1259-68.
Cost-benefit analysis of second-generation antipsychotics and placebo in a randomized trial of the treatment of psychosis and aggression in Alzheimer disease.
Northeast Program Evaluation Center (182), VA Connecticut Health Care System, West Haven, Connecticut 06516, USA. [email protected]
CONTEXT: Second-generation antipsychotics (SGAs) are prescribed for psychosis, aggression, and agitation in Alzheimer disease (AD). OBJECTIVE: To conduct a cost-benefit analysis of SGAs and placebo (taken to represent a "watchful waiting" treatment strategy) for psychosis and aggression in outpatients with AD. DESIGN: Randomized placebo-controlled trial of alternative SGA initiation strategies. SETTING: Forty-two outpatient clinics. PARTICIPANTS: Outpatients with AD and psychosis, aggression, or agitation (N = 421). Intervention Participants were randomly assigned to treatment with olanzapine, quetiapine fumarate, risperidone, or placebo with the option of double-blind rerandomization to another antipsychotic or citalopram hydrobromide or open treatment over 9 months. MAIN OUTCOME MEASURES: Monthly interviews documented health service use and costs. The economic perspective addressed total health care and medication costs. Costs of study drugs were estimated from wholesale prices with adjustment for discounts and rebates. Quality-adjusted life-years (QALYs) were assessed with the Health Utilities Index Mark 3 and were supplemented with measures of functioning, activities of daily living, and quality of life. Primary analyses were conducted using all available data. Secondary analyses excluded observations after the first medication change (ie, phase 1 only). Cost-benefit analysis was conducted using the net health benefits approach in a sensitivity analysis in which QALYs were valued at $50,000 per year and $100,000 per year. RESULTS: Average total health costs, including medications, were significantly lower for placebo than for SGAs, by $50 to $100 per month. There were no differences between treatments in QALYs or other measures of function. Phase 1-only analyses were broadly similar. Net-benefit analysis showed greater net health benefits for placebo as compared with other treatments, with probabilities ranging from 50% to 90%. CONCLUSIONS: There were no differences in measures of effectiveness between initiation of active treatments or placebo (which represented watchful waiting) but the placebo group had significantly lower health care costs. TRIAL REGISTRATION: Identifier: NCT00015548.
 Ann Intern Med. 2007 Jun 5;146(11):775-86.
Antipsychotic drug use and mortality in older adults with dementia.
Queen's University, Kingston, Ontario, Canada.
BACKGROUND: Antipsychotic drugs are widely used to manage behavioral and psychological symptoms in dementia despite concerns about their safety. OBJECTIVE: To examine the association between treatment with antipsychotics (both conventional and atypical) and all-cause mortality. DESIGN: Population-based, retrospective cohort study. SETTING: Ontario, Canada. PATIENTS: Older adults with dementia who were followed between 1 April 1997 and 31 March 2003. MEASUREMENTS: The risk for death was determined at 30, 60, 120, and 180 days after the initial dispensing of antipsychotic medication. Two pairwise comparisons were made: atypical versus no antipsychotic use and conventional versus atypical antipsychotic use. Groups were stratified by place of residence (community or long-term care). Propensity score matching was used to adjust for differences in baseline health status. RESULTS: A total of 27,259 matched pairs were identified. New use of atypical antipsychotics was associated with a statistically significant increase in the risk for death at 30 days compared with nonuse in both the community-dwelling cohort (adjusted hazard ratio, 1.31 [95% CI, 1.02 to 1.70]; absolute risk difference, 0.2 percentage point) and the long-term care cohort (adjusted hazard ratio, 1.55 [CI, 1.15 to 2.07]; absolute risk difference, 1.2 percentage points). Excess risk seemed to persist to 180 days, but unequal rates of censoring over time may have affected these results. Relative to atypical antipsychotic use, conventional antipsychotic use was associated with a higher risk for death at all time points. Sensitivity analysis revealed that unmeasured confounders that increase the risk for death could diminish or eliminate the observed associations. LIMITATIONS: Information on causes of death was not available. Many patients did not continue their initial treatments after 1 month of therapy. Unmeasured confounders could affect associations. CONCLUSIONS: Atypical antipsychotic use is associated with an increased risk for death compared with nonuse among older adults with dementia. The risk for death may be greater with conventional antipsychotics than with atypical antipsychotics.
Am J Psychiatry. 2007 Oct;164(10):1568-76
Mortality risk in patients with dementia treated with antipsychotics versus other psychiatric medications.
Serious Mental Illness Treatment Research and Evaluation Center, Health Services Research and Development, VA Ann Arbor Healthcare System, Ann Arbor, Ann Arbor, MI 48109, USA. [email protected]
OBJECTIVE: Mortality rates in the year following new antipsychotic medication starts for neuropsychiatric symptoms of dementia were compared with rates after starts of other psychiatric medications. METHOD: The retrospective, cohort study used national data from the Department of Veterans Affairs (fiscal years 2001-2005) on patients older than 65 years who began outpatient treatment with psychiatric medication following a dementia diagnosis (N=10,615). Twelve-month mortality rates were compared in patients taking antipsychotics and those taking other psychiatric medications. The authors controlled for confounding by using multivariate models and propensity-scoring methods. Secondary analyses included a no-medication group and examination of mortality causes. RESULTS: All groups taking antipsychotics had significantly higher mortality rates (22.6%-29.1%) than patients taking nonantipsychotic medications (14.6%). Adjusted mortality risks for atypicals and for combined atypical and conventional antipsychotics were similar to those for conventional antipsychotics. The mortality risk was significantly lower for nonantipsychotic medications than conventional antipsychotics. Except for anticonvulsants, the adjusted risks for all individual classes of nonantipsychotics were significantly lower than the risk for antipsychotics. Mortality risks did not change over 12 months. The proportions of patients taking antipsychotics who died from cerebrovascular, cardiovascular, or infectious causes were not higher than rates for those taking nonantipsychotic psychiatric medications. CONCLUSIONS: Antipsychotic medications taken by patients with dementia were associated with higher mortality rates than were most other medications used for neuropsychiatric symptoms. The association between mortality and antipsychotics is not well understood and may be due to a direct medication effect or the pathophysiology underlying neuropsychiatric symptoms that prompt antipsychotic use.