One in three people in residential care homes over the age of 75 receive an antipsychotic against hallucinations and delusions, including many patients with dementia. However, the medication is often used incorrectly or without any scientific basis.
Following several suspicious deaths in a residential care home in the municipality of Oostrozebeke in the West Flanders province last month, VRT's investigative 'Pano' television programme has started looking deeper into how the medication is administered in these centres.
One in three over-75s living in residential care homes receives such medicines, according to figures collected by the various health insurance funds. These include the well-known antipsychotic Haldol, but also drugs such as Risperdal and Quetiapine, which were initially used in psychiatry, against psychoses or delusions, geriatrician Mirko Petrovic (University of Ghent) told VRT.
“But in practice, they are also often used for people with dementia when they show behavioural disorders," he said, explaining that this can be helpful for some of them if the disease causes them to hallucinate or become physically aggressive. "For the milder symptoms of this disease, there is insufficient evidence that antipsychotics work."
No scientific grounds
Therefore, the medication is sometimes prescribed for symptoms for which they are not actually intended, Petrovic said. "At the moment, the use in these patients is really too high."
However, medication against psychosis is of no use against other common symptoms of dementia patients, such as wandering behaviour, running away and shouting. "There is no scientific evidence for that. With such difficult-to-manage behaviour, we first have to look at solutions without drugs."
Of all over-75s in residential care homes, about 10% to 15% really need such an antipsychotic, explained Jan De Lepeleire, emeritus Professor of family medicine at KU Leuven. "One is three is a lot. And its use should not be for the long term, but for a short, defined period."
Additionally, figures from the Intermutual Agency show that for 41% of elderly people receiving the medication, treatment lasted longer than six months – which leads to more severe side effects.
'Stop date'
“With long-term use, there is no evidence that the drug still works for symptoms such as delusions and physical aggression. This means that for the elderly, only the side effects remain: an increased risk of stroke, falls and fractures, cardiac arrhythmias and even higher risk of hospitalisation or death," said Petrovic.
“If the treatment lasts longer than three months, the risk of death increases by 1.5 to two times.”
That is why both doctors are arguing for a "stop date" for these kinds of medicines. "When such a treatment is started, you have to immediately look ahead to the end. Every cure has a duration, so to speak. It should certainly not be longer than three months," said Petrovic.
"Such a 'stop date' has always been our advice," added De Lepeleire. "Over time, people no longer know why and by whom the treatment was started. We need to break that pattern.”
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However, he does recognise that there is a difference between theory and practice. It is not always easy to neatly delineate symptoms in boxes, for which antipsychotics are or are not appropriate.
"Additionally, it often concerns people with multiple disorders, making situations very subjective. What is difficult behaviour for me may not be for someone else."
Patients with dementia cannot always name their complaints themselves, but instruments to measure those symptoms can help, Petrovic said. "So one always has to weigh up: what still has an advantage for the patient, and what are the disadvantages? One has to look at patients individually."
And most importantly, he added, "restless behaviour should always be treated without medication first."
