Map of life expectancy at birth from Global Education Project.

Thursday, August 09, 2007

God Damn the Pusher

Okay, it's a day late, but I promised one of those rare personal anecdotes. My father has dementia, now very advanced, but just a few months ago he could still communicate pretty well and enjoy some activities. He was in an assisted living facility due to a lot of need for help with activities of daily living.

One day my mother went to visit him and found him slouched in a chair, drooling, and unable to walk. She thought he'd had a stroke. Then they told her they had given him a new medication, called aripiprazole, so she called me up to ask if I thought that might have anything to do with his setback.

Ahh, yeah, maybe. It's an antipsychotic. The side effects include increased salivation and asthenia, i.e. weakness, lack of energy or strength. And oh yeah, there's this little, its bitsy, teeny weeny insignificant BLACK BOX WARNING:


Increased Mortality in Elderly Patients with Dementia-Related Psychosis

Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks) in these patients revealed a risk of death in the drug-treated patients of between 1.6 to 1.7 times that seen in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature. ABILIFY (aripiprazole) is not approved for the treatment of patients with dementia-related psychosis.

And oh yeah -- there are no trials that have shown that this stuff has any beneficial effect in people with dementia-related psychosis. Did my father even have dementia-related "psychosis"? He was back in his navy days, and he thought he was on a ship. I don't know whether that's "psychosis" or not, but who cares? I particularly like the brand name, don't you? "Abilify." It is to laugh. So they took him off the drugs and the problems immediately cleared up.

Anyway, he kept declining of course so my mother eventually moved him to a nursing home. After a couple of weeks, she went to visit him and found him, yup, slouched in a chair, unable to walk, and drooling. She went to the nurse and yup, sure enough, they'd given him Abilify. But they didn't do it to abilify him, they did it to disabilify him. He was going into the physical therapy room, they told her, and they didn't want him wandering around like that. And yes, a physician wrote the prescription in both cases.

Now here's a little primer in medical ethics:

1) Physicians are to act in the best interest of the patient. You don't write prescriptions to zonk people out in order to make life more convenient for nursing home staff.
2) Medical treatment requires informed consent. In this case, because my father is incompetent, my mother has a signed health care proxy and a power of attorney. They gave him this drug without even telling her, let alone asking.
3) Physicians are supposed to be diligent and keep themselves well informed about the conditions they treat and the treatments they use. In other words, Read the Fucking Label.

Atypical antipsychotics have never been shown to be efficacious, and have never been approved, for use in people with dementia. So why are they prescribed for that purpose? Because drug companies send good looking young people around to doctors' offices who tell them it's a good idea.

Finally, although I admittedly have a small sample, this happened twice to one man in the space of a few months, so do you think maybe it happens a lot, like routinely? Maybe. My mother wrote a letter to the nursing home staff telling them never to do it again, and they were taken aback and non-plussed. They were supposed to get informed consent for treatment? They were supposed to prescribe drugs for the benefit of patients? These were highly unusual demands.

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