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2006 HSR&D National Meeting Abstract

1069 — The Use of Antipsychotics in Dementia: Is There An Increased Risk of Mortality?

Author List:
Valenstein M (SMITREC)
McCarthy J (SMITREC)
Ganoczy D (SMITREC)

Psychiatric symptoms are common among patients with dementia and associated with poor outcomes, including nursing home placement. Studies indicate clinically modest but significant reductions in psychiatric symptoms with antipsychotics. However, a recent FDA advisory warned of increased mortality risk with use of second-generation antipsychotics (SGAs) in patients with dementia, raising questions regarding the common clinical practice of using these agents to treat secondary psychiatric symptoms.

We used national VA data to compare 12-month mortality in 12,906 patients with dementia aged >65 years with new psychiatric medication starts in FY 2002 and 2003 of: 1) first-generation antipsychotics (FGAs), 2) SGAs, or 3) other psychiatric medications (OPMs).

Among the sample, 55% (n=7113) were started on OPMs; 39% (n=5062) were started on SGAs; 4% (n=474) on FGAs; and 2% (n=257) on FGAs and SGAs. A new start of any type of antipsychotic was predictive of mortality (all p<0.0001) compared to a new start of OPMs. Age and medical comorbidity were also associated with mortality (both p<0.0001). Additional separate models controlled for specific comorbidity indicators (vascular, pulmonary and renal disease, diabetes, and delirium). In the first four comorbidity models, antipsychotic use remained predictive of mortality risk {odds ratios (ORs) between 2.2-2.3 for FGAs, and 1.7 for SGAs}. Initial antipsychotic prescription at inpatient hospital discharge was significantly related to a delirium diagnosis in the prior 6 months, as well as being predictive of mortality. Adding indicators for prescription at inpatient discharge or delirium diagnosis, resulted in smaller ORs for mortality associated with FGAs (OR=2.0) and SGAs (OR=1.5).

In veterans with dementia, both first and second-generation antipsychotics were associated with increased mortality compared with other psychiatric medications. Findings relating antipsychotic prescription on discharge, delirium diagnosis, and mortality may suggest that the antipsychotic-mortality association is partly related to use of these agents in delirium, a syndrome with significant morbidity/mortality. Further analyses will examine the specific time period of mortality risk and causes of death among users of antipsychotics versus those using other psychiatric medications.

Based on these results and current expert recommendations, clinical decision-making regarding antipsychotic agents in veterans with dementia should be made on a case-by-case basis.

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