risk of death higher for Benzos, antidepressants and typical antipsychotics then atypical antipsychotics

[Guest guest]

And atypical antipsychotics HAVE THE WARNING OF DEATH ON THEM!!

http://www.medscape.com/viewarticle/739729

Alternative Agents No Safer Than Atypicals in the Elderly

Fran Lowry

March 28, 2011 — Psychotropic agents, including benzodiazepines,

antidepressants, and conventional antipsychotic medications,

frequently used as an alternative to atypical antipsychotics, may

be no safer in vulnerable nursing home residents, according to a

new study published online March 28 in CMAJ.

"In the past, excessive and inappropriate prescribing of

psychotropic medications in nursing homes has primarily been

considered a marker of inadequate care. But now, evidence is

accumulating that the use of these medications may represent an

important drug safety issue as well," study investigator, Krista

F. Huybrechts, PhD, from Harvard Medical School, Boston, told Medscape

Medical News.

The safety of antipsychotic medications, such as risperidone,

olanzapine, and aripiprazole, in older adults has been called into

question, and as a result, advisories have been issued by the Food

and Drug Administration and Health Canada and black box warnings

have been added to the labels of both conventional and atypical

antipsychotics, said Dr. Huybrechts.

"Given this problematic safety record, physicians may

increasingly resort to alternative psychotropic agents also used

for the management of behavioral problems associated with

dementia," she said in an interview. "However, comparative safety

studies for these other psychotropic medication classes in this

patient population have not been conducted."

Filling the Research Gap

To address this research gap, she and her colleagues studied a

cohort of patients age 65 years or older who were admitted to a

nursing home between January 1, 1996, and March 31, 2006, and who

received a psychotropic drug within 90 days of admission.

Of the 10,900 patients in the study, 1942 received an atypical

antipsychotic, 1902 a conventional antipsychotic, 2169 an

antidepressant, and 4887 a benzodiazepine.

The researchers found that patients who used atypical

antipsychotics had more psychiatric comorbid conditions and used

more psychotropic drugs and drugs for dementia. They also had more

visits to psychiatrists. Compared with these patients, those who

used conventional antipsychotics had fewer comorbid conditions and

required less intensive care.

Patients who used antidepressants were sicker than those who used

atypical antipsychotics, with more circulatory system disease,

diabetes, chronic lung disease, and prior fractures.

Those who used benzodiazepines had more pre-existing

cardiovascular disease, diabetes, chronic lung disease, and

fractures than users of atypical antipsychotics but were in

slightly better health.

The study showed that the risk for death was higher among

patients taking conventional antipsychotics, antidepressants, and

benzodiazepines than in users of atypical antipsychotics.

Limitations

For conventional antipsychotics, the rate ratio (RR) was 1.47

(95% confidence interval [CI], 1.14 - 1.91). For antidepressants,

the RR was 1.20 (95% CI, 0.96 - 1.50).

The risk for femur fracture was also higher among patients

receiving conventional antipsychotics (RR, 1.61; 95% CI, 1.03 -

2.51) and antidepressants (RR, 1.29; 95% CI, 0.86 - 1.94).

For benzodiazepines, the RR for death was 1.28 (95% CI, 1.04 -

1.58). In addition, for patients given benzodiazepines for

anxiety, the RR for heart failure was 1.54 (95% CI, 0.89 - 2.67)

and for pneumonia, it was 0.85 (95% CI, 0.56 - 1.31).

Dr. Huybrechts acknowledged that her study has some limitations.

"As with any nonrandomized study, there is potential for residual

confounding. We used advanced methodological approaches to

minimize the potential for such confounding but this can never be

excluded.

"Also, owing to the limited cohort size, despite the

population-based nature of the study, we were unable to assess the

effect of individual drugs within a given class with or without

consideration of dose, and to study certain relevant subclasses,"

she said.

Close Monitoring Required

These emerging safety concerns underscore the importance of close

monitoring of these patients, "especially in the nursing home

environment, where patients tend to have a complex array of

medical illnesses and receive intense pharmacological therapy

often with only minimal physician input and supervision," she

said.

M. Lyness, MD, immediate past president of the American

Association for Geriatric Psychiatry and professor of psychiatry

at the University of Rochester Medical Center, Rochester, New

York, commented that the study is interesting but limited by its

observational design.

"It is likely that patients who received different classes of

medications had different types of severities of psychiatric and

general medical conditions, so it may be that those differences,

rather than the drugs themselves, were responsible for the higher

mortality rate seen in some patients," he told Medscape

Medical News.

"While this is a well-done study, with careful study measures and

a very large sample size, we can never be certain that they were

able to measure all the relevant differences between patients.

Therefore, I think this study should lead to further research on

the subject, but should not change clinical practice at this stage

of our knowledge."

Dr. Lyness added that use of any medications, psychiatric or

otherwise, in older persons should always be based on a careful

assessment of potential benefits and risks. "This study will not

change how I think about such considerations."

Urgent Need for Geriatric Psychiatrists

Unfortunately, most of the patients who have the greatest need

for such careful assessment will not have access to the people who

have the expertise to do the job. Ideally these would be geriatric

psychiatrists, or at the very least, doctors with a knowledge of

psychotropic drugs in the elderly.

"The people who are in the best position to treat these very

complicated cases are geriatric psychiatrists and psychiatrists

who are interested in treating behavior problems in older people,

but there are very few around," said P. Roca, MD, from

Sheppard Pratt Health System, Towson, land.

Dr. Roca, who is a geriatric psychiatrist, told Medscape

Medical News that the American Association of Geriatric

Psychiatry has about 1400 members and that there are only 55

trainees in geriatric psychiatry in the United States right now.

"We have an incredible workforce problem, so the vast majority of

these people in nursing homes with these kinds of problems are

being treated and medicated by people who are certainly not

psychiatrists. I would at least make the suggestion that if the

people who were advising about these medications in these settings

were the people who knew the most about them, then everybody would

be better off," he said.

The problem is only going to get worse, particularly as the

population is aging, and as dementia increases with age.

"The specialties that work a lot with older patients, especially

ones that tend to be lower paid, like geriatric psychiatry, do not

have hoards of people flocking to training," Dr. Roca noted.

"There are more and more people entering the age of risk, and

there are many in need of expert treatment, but there are not

going to be enough people to meet this need."

Dr. Roca said the message worth taking to heart from this study

is that "all psychotropic medications, and indeed all medications,

can have serious adverse side effects in elderly people and should

be prescribed only after an informed consent discussion that

includes considering the risks and costs of using these agents

versus the risks and costs of not using them."

Dr. Huybrechts, Dr. Lyness, and Dr. Roca have disclosed no

relevant financial relationships.

CMAJ. Published online March 28, 2011.

[Guest guest]

And atypical antipsychotics HAVE THE WARNING OF DEATH ON THEM!!

http://www.medscape.com/viewarticle/739729

Alternative Agents No Safer Than Atypicals in the Elderly

Fran Lowry

March 28, 2011 — Psychotropic agents, including benzodiazepines,

antidepressants, and conventional antipsychotic medications,

frequently used as an alternative to atypical antipsychotics, may

be no safer in vulnerable nursing home residents, according to a

new study published online March 28 in CMAJ.

"In the past, excessive and inappropriate prescribing of

psychotropic medications in nursing homes has primarily been

considered a marker of inadequate care. But now, evidence is

accumulating that the use of these medications may represent an

important drug safety issue as well," study investigator, Krista

F. Huybrechts, PhD, from Harvard Medical School, Boston, told Medscape

Medical News.

The safety of antipsychotic medications, such as risperidone,

olanzapine, and aripiprazole, in older adults has been called into

question, and as a result, advisories have been issued by the Food

and Drug Administration and Health Canada and black box warnings

have been added to the labels of both conventional and atypical

antipsychotics, said Dr. Huybrechts.

"Given this problematic safety record, physicians may

increasingly resort to alternative psychotropic agents also used

for the management of behavioral problems associated with

dementia," she said in an interview. "However, comparative safety

studies for these other psychotropic medication classes in this

patient population have not been conducted."

Filling the Research Gap

To address this research gap, she and her colleagues studied a

cohort of patients age 65 years or older who were admitted to a

nursing home between January 1, 1996, and March 31, 2006, and who

received a psychotropic drug within 90 days of admission.

Of the 10,900 patients in the study, 1942 received an atypical

antipsychotic, 1902 a conventional antipsychotic, 2169 an

antidepressant, and 4887 a benzodiazepine.

The researchers found that patients who used atypical

antipsychotics had more psychiatric comorbid conditions and used

more psychotropic drugs and drugs for dementia. They also had more

visits to psychiatrists. Compared with these patients, those who

used conventional antipsychotics had fewer comorbid conditions and

required less intensive care.

Patients who used antidepressants were sicker than those who used

atypical antipsychotics, with more circulatory system disease,

diabetes, chronic lung disease, and prior fractures.

Those who used benzodiazepines had more pre-existing

cardiovascular disease, diabetes, chronic lung disease, and

fractures than users of atypical antipsychotics but were in

slightly better health.

The study showed that the risk for death was higher among

patients taking conventional antipsychotics, antidepressants, and

benzodiazepines than in users of atypical antipsychotics.

Limitations

For conventional antipsychotics, the rate ratio (RR) was 1.47

(95% confidence interval [CI], 1.14 - 1.91). For antidepressants,

the RR was 1.20 (95% CI, 0.96 - 1.50).

The risk for femur fracture was also higher among patients

receiving conventional antipsychotics (RR, 1.61; 95% CI, 1.03 -

2.51) and antidepressants (RR, 1.29; 95% CI, 0.86 - 1.94).

For benzodiazepines, the RR for death was 1.28 (95% CI, 1.04 -

1.58). In addition, for patients given benzodiazepines for

anxiety, the RR for heart failure was 1.54 (95% CI, 0.89 - 2.67)

and for pneumonia, it was 0.85 (95% CI, 0.56 - 1.31).

Dr. Huybrechts acknowledged that her study has some limitations.

"As with any nonrandomized study, there is potential for residual

confounding. We used advanced methodological approaches to

minimize the potential for such confounding but this can never be

excluded.

"Also, owing to the limited cohort size, despite the

population-based nature of the study, we were unable to assess the

effect of individual drugs within a given class with or without

consideration of dose, and to study certain relevant subclasses,"

she said.

Close Monitoring Required

These emerging safety concerns underscore the importance of close

monitoring of these patients, "especially in the nursing home

environment, where patients tend to have a complex array of

medical illnesses and receive intense pharmacological therapy

often with only minimal physician input and supervision," she

said.

M. Lyness, MD, immediate past president of the American

Association for Geriatric Psychiatry and professor of psychiatry

at the University of Rochester Medical Center, Rochester, New

York, commented that the study is interesting but limited by its

observational design.

"It is likely that patients who received different classes of

medications had different types of severities of psychiatric and

general medical conditions, so it may be that those differences,

rather than the drugs themselves, were responsible for the higher

mortality rate seen in some patients," he told Medscape

Medical News.

"While this is a well-done study, with careful study measures and

a very large sample size, we can never be certain that they were

able to measure all the relevant differences between patients.

Therefore, I think this study should lead to further research on

the subject, but should not change clinical practice at this stage

of our knowledge."

Dr. Lyness added that use of any medications, psychiatric or

otherwise, in older persons should always be based on a careful

assessment of potential benefits and risks. "This study will not

change how I think about such considerations."

Urgent Need for Geriatric Psychiatrists

Unfortunately, most of the patients who have the greatest need

for such careful assessment will not have access to the people who

have the expertise to do the job. Ideally these would be geriatric

psychiatrists, or at the very least, doctors with a knowledge of

psychotropic drugs in the elderly.

"The people who are in the best position to treat these very

complicated cases are geriatric psychiatrists and psychiatrists

who are interested in treating behavior problems in older people,

but there are very few around," said P. Roca, MD, from

Sheppard Pratt Health System, Towson, land.

Dr. Roca, who is a geriatric psychiatrist, told Medscape

Medical News that the American Association of Geriatric

Psychiatry has about 1400 members and that there are only 55

trainees in geriatric psychiatry in the United States right now.

"We have an incredible workforce problem, so the vast majority of

these people in nursing homes with these kinds of problems are

being treated and medicated by people who are certainly not

psychiatrists. I would at least make the suggestion that if the

people who were advising about these medications in these settings

were the people who knew the most about them, then everybody would

be better off," he said.

The problem is only going to get worse, particularly as the

population is aging, and as dementia increases with age.

"The specialties that work a lot with older patients, especially

ones that tend to be lower paid, like geriatric psychiatry, do not

have hoards of people flocking to training," Dr. Roca noted.

"There are more and more people entering the age of risk, and

there are many in need of expert treatment, but there are not

going to be enough people to meet this need."

Dr. Roca said the message worth taking to heart from this study

is that "all psychotropic medications, and indeed all medications,

can have serious adverse side effects in elderly people and should

be prescribed only after an informed consent discussion that

includes considering the risks and costs of using these agents

versus the risks and costs of not using them."

Dr. Huybrechts, Dr. Lyness, and Dr. Roca have disclosed no

relevant financial relationships.

CMAJ. Published online March 28, 2011.

[Guest guest]

And atypical antipsychotics HAVE THE WARNING OF DEATH ON THEM!!

http://www.medscape.com/viewarticle/739729

Alternative Agents No Safer Than Atypicals in the Elderly

Fran Lowry

March 28, 2011 — Psychotropic agents, including benzodiazepines,

antidepressants, and conventional antipsychotic medications,

frequently used as an alternative to atypical antipsychotics, may

be no safer in vulnerable nursing home residents, according to a

new study published online March 28 in CMAJ.

"In the past, excessive and inappropriate prescribing of

psychotropic medications in nursing homes has primarily been

considered a marker of inadequate care. But now, evidence is

accumulating that the use of these medications may represent an

important drug safety issue as well," study investigator, Krista

F. Huybrechts, PhD, from Harvard Medical School, Boston, told Medscape

Medical News.

The safety of antipsychotic medications, such as risperidone,

olanzapine, and aripiprazole, in older adults has been called into

question, and as a result, advisories have been issued by the Food

and Drug Administration and Health Canada and black box warnings

have been added to the labels of both conventional and atypical

antipsychotics, said Dr. Huybrechts.

"Given this problematic safety record, physicians may

increasingly resort to alternative psychotropic agents also used

for the management of behavioral problems associated with

dementia," she said in an interview. "However, comparative safety

studies for these other psychotropic medication classes in this

patient population have not been conducted."

Filling the Research Gap

To address this research gap, she and her colleagues studied a

cohort of patients age 65 years or older who were admitted to a

nursing home between January 1, 1996, and March 31, 2006, and who

received a psychotropic drug within 90 days of admission.

Of the 10,900 patients in the study, 1942 received an atypical

antipsychotic, 1902 a conventional antipsychotic, 2169 an

antidepressant, and 4887 a benzodiazepine.

The researchers found that patients who used atypical

antipsychotics had more psychiatric comorbid conditions and used

more psychotropic drugs and drugs for dementia. They also had more

visits to psychiatrists. Compared with these patients, those who

used conventional antipsychotics had fewer comorbid conditions and

required less intensive care.

Patients who used antidepressants were sicker than those who used

atypical antipsychotics, with more circulatory system disease,

diabetes, chronic lung disease, and prior fractures.

Those who used benzodiazepines had more pre-existing

cardiovascular disease, diabetes, chronic lung disease, and

fractures than users of atypical antipsychotics but were in

slightly better health.

The study showed that the risk for death was higher among

patients taking conventional antipsychotics, antidepressants, and

benzodiazepines than in users of atypical antipsychotics.

Limitations

For conventional antipsychotics, the rate ratio (RR) was 1.47

(95% confidence interval [CI], 1.14 - 1.91). For antidepressants,

the RR was 1.20 (95% CI, 0.96 - 1.50).

The risk for femur fracture was also higher among patients

receiving conventional antipsychotics (RR, 1.61; 95% CI, 1.03 -

2.51) and antidepressants (RR, 1.29; 95% CI, 0.86 - 1.94).

For benzodiazepines, the RR for death was 1.28 (95% CI, 1.04 -

1.58). In addition, for patients given benzodiazepines for

anxiety, the RR for heart failure was 1.54 (95% CI, 0.89 - 2.67)

and for pneumonia, it was 0.85 (95% CI, 0.56 - 1.31).

Dr. Huybrechts acknowledged that her study has some limitations.

"As with any nonrandomized study, there is potential for residual

confounding. We used advanced methodological approaches to

minimize the potential for such confounding but this can never be

excluded.

"Also, owing to the limited cohort size, despite the

population-based nature of the study, we were unable to assess the

effect of individual drugs within a given class with or without

consideration of dose, and to study certain relevant subclasses,"

she said.

Close Monitoring Required

These emerging safety concerns underscore the importance of close

monitoring of these patients, "especially in the nursing home

environment, where patients tend to have a complex array of

medical illnesses and receive intense pharmacological therapy

often with only minimal physician input and supervision," she

said.

M. Lyness, MD, immediate past president of the American

Association for Geriatric Psychiatry and professor of psychiatry

at the University of Rochester Medical Center, Rochester, New

York, commented that the study is interesting but limited by its

observational design.

"It is likely that patients who received different classes of

medications had different types of severities of psychiatric and

general medical conditions, so it may be that those differences,

rather than the drugs themselves, were responsible for the higher

mortality rate seen in some patients," he told Medscape

Medical News.

"While this is a well-done study, with careful study measures and

a very large sample size, we can never be certain that they were

able to measure all the relevant differences between patients.

Therefore, I think this study should lead to further research on

the subject, but should not change clinical practice at this stage

of our knowledge."

Dr. Lyness added that use of any medications, psychiatric or

otherwise, in older persons should always be based on a careful

assessment of potential benefits and risks. "This study will not

change how I think about such considerations."

Urgent Need for Geriatric Psychiatrists

Unfortunately, most of the patients who have the greatest need

for such careful assessment will not have access to the people who

have the expertise to do the job. Ideally these would be geriatric

psychiatrists, or at the very least, doctors with a knowledge of

psychotropic drugs in the elderly.

"The people who are in the best position to treat these very

complicated cases are geriatric psychiatrists and psychiatrists

who are interested in treating behavior problems in older people,

but there are very few around," said P. Roca, MD, from

Sheppard Pratt Health System, Towson, land.

Dr. Roca, who is a geriatric psychiatrist, told Medscape

Medical News that the American Association of Geriatric

Psychiatry has about 1400 members and that there are only 55

trainees in geriatric psychiatry in the United States right now.

"We have an incredible workforce problem, so the vast majority of

these people in nursing homes with these kinds of problems are

being treated and medicated by people who are certainly not

psychiatrists. I would at least make the suggestion that if the

people who were advising about these medications in these settings

were the people who knew the most about them, then everybody would

be better off," he said.

The problem is only going to get worse, particularly as the

population is aging, and as dementia increases with age.

"The specialties that work a lot with older patients, especially

ones that tend to be lower paid, like geriatric psychiatry, do not

have hoards of people flocking to training," Dr. Roca noted.

"There are more and more people entering the age of risk, and

there are many in need of expert treatment, but there are not

going to be enough people to meet this need."

Dr. Roca said the message worth taking to heart from this study

is that "all psychotropic medications, and indeed all medications,

can have serious adverse side effects in elderly people and should

be prescribed only after an informed consent discussion that

includes considering the risks and costs of using these agents

versus the risks and costs of not using them."

Dr. Huybrechts, Dr. Lyness, and Dr. Roca have disclosed no

relevant financial relationships.

CMAJ. Published online March 28, 2011.

[Guest guest]

And atypical antipsychotics HAVE THE WARNING OF DEATH ON THEM!!

http://www.medscape.com/viewarticle/739729

Alternative Agents No Safer Than Atypicals in the Elderly

Fran Lowry

March 28, 2011 — Psychotropic agents, including benzodiazepines,

antidepressants, and conventional antipsychotic medications,

frequently used as an alternative to atypical antipsychotics, may

be no safer in vulnerable nursing home residents, according to a

new study published online March 28 in CMAJ.

"In the past, excessive and inappropriate prescribing of

psychotropic medications in nursing homes has primarily been

considered a marker of inadequate care. But now, evidence is

accumulating that the use of these medications may represent an

important drug safety issue as well," study investigator, Krista

F. Huybrechts, PhD, from Harvard Medical School, Boston, told Medscape

Medical News.

The safety of antipsychotic medications, such as risperidone,

olanzapine, and aripiprazole, in older adults has been called into

question, and as a result, advisories have been issued by the Food

and Drug Administration and Health Canada and black box warnings

have been added to the labels of both conventional and atypical

antipsychotics, said Dr. Huybrechts.

"Given this problematic safety record, physicians may

increasingly resort to alternative psychotropic agents also used

for the management of behavioral problems associated with

dementia," she said in an interview. "However, comparative safety

studies for these other psychotropic medication classes in this

patient population have not been conducted."

Filling the Research Gap

To address this research gap, she and her colleagues studied a

cohort of patients age 65 years or older who were admitted to a

nursing home between January 1, 1996, and March 31, 2006, and who

received a psychotropic drug within 90 days of admission.

Of the 10,900 patients in the study, 1942 received an atypical

antipsychotic, 1902 a conventional antipsychotic, 2169 an

antidepressant, and 4887 a benzodiazepine.

The researchers found that patients who used atypical

antipsychotics had more psychiatric comorbid conditions and used

more psychotropic drugs and drugs for dementia. They also had more

visits to psychiatrists. Compared with these patients, those who

used conventional antipsychotics had fewer comorbid conditions and

required less intensive care.

Patients who used antidepressants were sicker than those who used

atypical antipsychotics, with more circulatory system disease,

diabetes, chronic lung disease, and prior fractures.

Those who used benzodiazepines had more pre-existing

cardiovascular disease, diabetes, chronic lung disease, and

fractures than users of atypical antipsychotics but were in

slightly better health.

The study showed that the risk for death was higher among

patients taking conventional antipsychotics, antidepressants, and

benzodiazepines than in users of atypical antipsychotics.

Limitations

For conventional antipsychotics, the rate ratio (RR) was 1.47

(95% confidence interval [CI], 1.14 - 1.91). For antidepressants,

the RR was 1.20 (95% CI, 0.96 - 1.50).

The risk for femur fracture was also higher among patients

receiving conventional antipsychotics (RR, 1.61; 95% CI, 1.03 -

2.51) and antidepressants (RR, 1.29; 95% CI, 0.86 - 1.94).

For benzodiazepines, the RR for death was 1.28 (95% CI, 1.04 -

1.58). In addition, for patients given benzodiazepines for

anxiety, the RR for heart failure was 1.54 (95% CI, 0.89 - 2.67)

and for pneumonia, it was 0.85 (95% CI, 0.56 - 1.31).

Dr. Huybrechts acknowledged that her study has some limitations.

"As with any nonrandomized study, there is potential for residual

confounding. We used advanced methodological approaches to

minimize the potential for such confounding but this can never be

excluded.

"Also, owing to the limited cohort size, despite the

population-based nature of the study, we were unable to assess the

effect of individual drugs within a given class with or without

consideration of dose, and to study certain relevant subclasses,"

she said.

Close Monitoring Required

These emerging safety concerns underscore the importance of close

monitoring of these patients, "especially in the nursing home

environment, where patients tend to have a complex array of

medical illnesses and receive intense pharmacological therapy

often with only minimal physician input and supervision," she

said.

M. Lyness, MD, immediate past president of the American

Association for Geriatric Psychiatry and professor of psychiatry

at the University of Rochester Medical Center, Rochester, New

York, commented that the study is interesting but limited by its

observational design.

"It is likely that patients who received different classes of

medications had different types of severities of psychiatric and

general medical conditions, so it may be that those differences,

rather than the drugs themselves, were responsible for the higher

mortality rate seen in some patients," he told Medscape

Medical News.

"While this is a well-done study, with careful study measures and

a very large sample size, we can never be certain that they were

able to measure all the relevant differences between patients.

Therefore, I think this study should lead to further research on

the subject, but should not change clinical practice at this stage

of our knowledge."

Dr. Lyness added that use of any medications, psychiatric or

otherwise, in older persons should always be based on a careful

assessment of potential benefits and risks. "This study will not

change how I think about such considerations."

Urgent Need for Geriatric Psychiatrists

Unfortunately, most of the patients who have the greatest need

for such careful assessment will not have access to the people who

have the expertise to do the job. Ideally these would be geriatric

psychiatrists, or at the very least, doctors with a knowledge of

psychotropic drugs in the elderly.

"The people who are in the best position to treat these very

complicated cases are geriatric psychiatrists and psychiatrists

who are interested in treating behavior problems in older people,

but there are very few around," said P. Roca, MD, from

Sheppard Pratt Health System, Towson, land.

Dr. Roca, who is a geriatric psychiatrist, told Medscape

Medical News that the American Association of Geriatric

Psychiatry has about 1400 members and that there are only 55

trainees in geriatric psychiatry in the United States right now.

"We have an incredible workforce problem, so the vast majority of

these people in nursing homes with these kinds of problems are

being treated and medicated by people who are certainly not

psychiatrists. I would at least make the suggestion that if the

people who were advising about these medications in these settings

were the people who knew the most about them, then everybody would

be better off," he said.

The problem is only going to get worse, particularly as the

population is aging, and as dementia increases with age.

"The specialties that work a lot with older patients, especially

ones that tend to be lower paid, like geriatric psychiatry, do not

have hoards of people flocking to training," Dr. Roca noted.

"There are more and more people entering the age of risk, and

there are many in need of expert treatment, but there are not

going to be enough people to meet this need."

Dr. Roca said the message worth taking to heart from this study

is that "all psychotropic medications, and indeed all medications,

can have serious adverse side effects in elderly people and should

be prescribed only after an informed consent discussion that

includes considering the risks and costs of using these agents

versus the risks and costs of not using them."

Dr. Huybrechts, Dr. Lyness, and Dr. Roca have disclosed no

relevant financial relationships.

CMAJ. Published online March 28, 2011.