Les antipsychotiques donnés dans les maisons de retraite aggravent le comportement et les risques pour la santé

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Antipsychotics in Nursing Homes Worsen Behavior and Health Risks

Analysis by Dr. Joseph Mercola 8 janvier 2025

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Story at-a-glance

• A significant number of long-term care (LTC) residents are prescribed antipsychotics, often off-label for dementia-related symptoms, despite associated risks like cardiovascular events and increased mortality
• Antipsychotic use in LTC residents is linked to a 27% increase in worsening behavioral symptoms, highlighting the importance of prioritizing nonpharmacological treatments
• Research shows that conventional antipsychotics carry significantly higher risks than atypical ones, with a 25% increased risk of bacterial infections, 23% higher risk of heart attacks and 29% greater chance of hip fractures
• A study of nursing homes found that facilities served by certain psychiatric consultant groups had antipsychotic prescribing rates as high as 26.4%, while others maintained rates as low as 12.2%, indicating that consultant practices significantly influence medication use
• Optimizing nutrition, eliminating seed oils and toxins and supporting cellular health through targeted interventions offer safer alternatives for targeting the underlying factors driving many symptoms in nursing home residents

Alzheimer's disease and related dementias (ADRD) are progressive neurological disorders that impair memory, thinking and behavior. This means individuals with ADRD experience a decline in their cognitive functions, making daily tasks increasingly challenging.

Common symptoms include memory loss, confusion, difficulty communicating and changes in mood or behavior. As the disease advances, patients require comprehensive care to manage their symptoms and maintain their quality of life.

Managing ADRD often involves the use of antipsychotic medications to control behavioral symptoms such as agitation, aggression and hallucinations. However, these medications carry significant risks, including increased mortality, falls and cardiovascular events. Despite these dangers, antipsychotic use remains prevalent among older adults with dementia, raising concerns about patient safety and the appropriateness of such treatments.

In a study published in the Journal of the American Geriatrics Society, researchers analyzed data from 1,289,401 community-dwelling older adults with ADRD. They found that antipsychotic use declined from 11.4% in July 2010 to 9.0% in December 2017.¹

Despite the implementation of two Centers for Medicare & Medicaid Services (CMS) policies aimed at reducing antipsychotic use in nursing homes, these initiatives did not lead to a further decrease in the community setting. Additionally, the study revealed that anticonvulsant and antidepressant use increased during the same period, highlighting likely substitution effects and the need for careful monitoring of all psychotropic medications.

Off-Label Use of Antipsychotics in Nursing Homes Poses Significant Risks

The continued use of antipsychotics in community-dwelling ADRD patients poses several challenges. Beyond the immediate health risks, there is a concern that these medications may exacerbate behavioral problems rather than alleviate them. Furthermore, the increase in other psychotropic medications suggests that efforts to reduce antipsychotic use alone is not be sufficient to improve patient outcomes.

Comprehensive strategies that monitor and assess the appropriateness of all psychotropic treatments are essential to ensure the safety and well-being of individuals living with dementia. Antipsychotic medications are frequently prescribed in nursing homes to manage behavioral symptoms in dementia patients. However, these drugs are often used off-label, which means they are prescribed for conditions not specifically approved by regulatory agencies.

This practice raises significant safety concerns, as antipsychotics are linked to serious health risks. Despite these dangers, they remain a common treatment option, often overshadowing nonpharmacological approaches that are safer and more effective. The underlying causes of behavioral symptoms in dementia are complex. Factors such as cognitive decline, environmental stressors and unmet needs all contribute to these symptoms.

Cognitive decline, a hallmark of dementia, leads to confusion and frustration, which may manifest as agitation or aggression. Environmental stressors, like changes in routine or unfamiliar surroundings, exacerbate these behaviors. Additionally, unmet needs, such as pain or discomfort, also trigger behavioral symptoms, as individuals with dementia may struggle to communicate their needs effectively.

These underlying causes lead to behavioral symptoms through a combination of neurological and psychological mechanisms. Cognitive decline affects your brain's ability to process information and regulate emotions, resulting in increased irritability and aggression. Environmental stressors often overwhelm an individual's coping mechanisms, leading to heightened anxiety and agitation.

The diagnosis of behavioral symptoms in dementia often falls short due to a lack of standardized assessment tools and the complexity of the symptoms themselves. Many assessment tools rely on caregiver reports, which are influenced by personal biases or a lack of understanding of dementia-related behaviors.

Furthermore, the complexity of the symptoms, which often fluctuate in intensity and frequency, makes it difficult to capture an accurate picture of the individual's condition. These challenges highlight the need for improved diagnostic methods that provide a more comprehensive understanding of behavioral symptoms in dementia.

Antipsychotics Worsen Behavioral Issues in Nursing Homes

A study investigated the impact of antipsychotic medications on behavioral symptoms in long-term care (LTC) residents. Researchers sought to determine whether the use of these drugs was associated with the worsening of behaviors over time. The study included a vast population of 494,215 LTC residents from various provinces and territories in Canada.

Among these participants, 26.4% were using antipsychotics at the start of the study, and 17.9% experienced worsening behavior during the follow-up period.² The population studied consisted of adults aged 18 and older residing in LTC facilities who did not exhibit severe aggressive behavior at the beginning of the study.

The findings revealed a significant connection between the use of antipsychotic medications and an increase in problematic behaviors. Specifically, those who were prescribed antipsychotics had a 27% higher chance of experiencing worsening behavioral symptoms compared to those who did not use these medications.³

The research utilized sophisticated statistical methods, including propensity score matching and weighted regression models, to ensure that the results were robust and accounted for various confounding factors. Regardless of the method used, the association between antipsychotic use and deteriorating behavior remained consistent. This consistency across different analytical approaches strengthens the reliability of the findings.⁴

The study also explored the biological mechanisms underlying these adverse effects. Antipsychotics cause extrapyramidal symptoms, such as tremors, rigidity and muscle spasms, which exacerbate existing behavioral issues in patients. Additionally, the anticholinergic properties of these drugs lead to sedation, delirium and impaired cognitive function, further contributing to the worsening of behavioral symptoms.⁵

Despite efforts over the past three decades to reduce the chronic use of antipsychotics in nursing homes, these medications are still frequently prescribed off-label to manage behavioral and psychological symptoms of dementia (BPSD). The study highlighted that even though some physicians believe antipsychotics are effective for BPSD, the risks often outweigh the benefits.

More than 40% of patients treated with atypical antipsychotics for up to two weeks experienced worsening behavioral symptoms, indicating that these drugs might not only be ineffective but also harmful.⁶ The research underscores the importance of cautious use of antipsychotics in LTC facilities.

Given the significant association between antipsychotic use and increased behavioral problems, health care providers are encouraged to prioritize nonpharmacological approaches to care. Strategies such as behavioral therapies, environmental modifications and personalized care plans offer safer and more effective alternatives for managing BPSD.⁷

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Psychiatric Consultant Groups Significantly Influence Antipsychotic Prescribing in Nursing Homes

A separate study investigated the impact of psychiatric consultant groups on the prescription rates of antipsychotic medications in nursing homes. The research aimed to determine whether different psychiatric consultant groups are associated with varying levels of antipsychotic prescriptions, independent of resident demographics and facility characteristics.⁸

By analyzing data from numerous nursing homes, the study sought to uncover patterns that could inform better prescribing practices and improve patient care.

The study population consisted of residents from 60 nursing homes, each served by one of seven distinct psychiatric consultant groups. These facilities varied widely in terms of resident case-mix and overall quality, providing a comprehensive overview of prescribing trends across different settings.⁹

The primary finding revealed that psychiatric consultant groups have a significant influence on the prevalence of antipsychotic medication use within these facilities, even after accounting for the unique characteristics of each nursing home.¹⁰

One notable observation was that the overall mean facility-level antipsychotic prescribing rate was 19.2%.¹¹ However, this average masked substantial variations between different consultant groups. For instance, the mean prevalence of antipsychotic prescribing ranged from 12.2% in the lowest-ranked consultant group to 26.4% in the highest-ranked group.¹²

This wide disparity indicates that the practices and recommendations of psychiatric consultants play a significant role in determining whether residents are prescribed these medications.

All nursing homes served by the highest-ranked consultant group exhibited antipsychotic prescribing levels that exceeded the study's overall mean.¹³ Specifically, half of these facilities surpassed the predicted usage for on-label indications, suggesting a tendency to prescribe antipsychotics beyond what is medically necessary.¹⁴

In contrast, most facilities associated with the lowest-ranked consultant group maintained antipsychotic prescribing rates below both the overall study mean and the predicted benchmarks.¹⁵ This stark contrast underscores the variability in prescribing practices driven by different consultant groups.

Preliminary evidence from the study suggests that the influence of psychiatric consultant groups on antipsychotic prescribing is independent of resident case-mix and facility characteristics.¹⁶ This means that regardless of the demographics or specific health conditions of the residents, the consultant group itself is a key determinant in how frequently antipsychotics are prescribed.

Nursing Homes Often Rely on Antipsychotic Drugs to Treat Mental Health Issues

Federal regulations mandate that nursing homes in the U.S. have psychiatric services available to meet residents' mental health and psychosocial needs.¹⁷ Despite this requirement, the study found that dementia-related behaviors remain the predominant challenge in most nursing homes, with a significant proportion of residents also suffering from psychotic or mood disorders.¹⁸

This dual burden often overwhelms facility staff, who are not typically adequately trained to address these complex mental health issues without relying heavily on antipsychotic medications.¹⁹

The study further revealed that financial constraints impede the ability of psychiatric and psychological consultants to provide behavior-based, nonpharmacologic interventions.²⁰ As a result, nursing home staff frequently depend on expert mental health consultation to manage residents with dementia and other mental health conditions.²¹

This reliance on consultants inadvertently leads to higher rates of antipsychotic prescribing, especially in facilities where nondrug interventions are not sufficiently available or affordable.²²

The research indicated that antipsychotic prescribing rates were influenced by the specific characteristics of the residents, such as the presence of dementia-related behavioral symptoms, which varied across different facilities.²³

For instance, facilities with a higher prevalence of residents with dementia-related behavioral symptoms experienced increased antipsychotic use, highlighting the need for tailored interventions based on resident needs.²⁴ This indicates that psychiatric consultants may adjust their prescribing practices in response to the specific mental health profiles of the populations they serve.²⁵

Moreover, the quality and resources of the nursing homes themselves played a role in antipsychotic prescribing.²⁶ Facilities with comprehensive assessments and monitoring systems generally had better outcomes in managing behavioral symptoms, suggesting that well-supported nursing homes reduce reliance on antipsychotic medications.²⁷

Conversely, facilities lacking adequate resources and support systems were more likely to rely on antipsychotic medications, emphasizing the need for enhanced support and training for staff in these settings.²⁸ The study concluded that psychiatric consultant groups significantly impact antipsychotic prescribing levels in nursing homes, independent of resident demographics and facility characteristics.²⁹

Conventional Antipsychotics Pose Higher Risks Than Atypical Ones in Nursing Home Residents

A cohort study examined the safety of conventional versus atypical antipsychotic medications among residents in nursing homes.³⁰ The research aimed to determine which type of antipsychotic posed greater health risks, focusing specifically on major medical events such as infections, heart attacks and fractures.

By analyzing a large population of nursing home residents, the study provided valuable insights into the comparative dangers associated with these commonly prescribed medications.

The study included nearly 83,959 residents aged 65 and older who began antipsychotic treatment during their stay in nursing homes.³¹ These participants were selected from various facilities across 45 states, ensuring a diverse and comprehensive sample. The findings revealed significant differences in the safety profiles of conventional and atypical antipsychotics.

Specifically, those taking conventional antipsychotics faced higher risks of bacterial infections, heart attacks and hip fractures compared to those on atypical antipsychotics.³² The study found that conventional antipsychotics were linked to a 25% higher risk of developing bacterial infections and a 23% increased risk of experiencing a heart attack.³³ Additionally, residents using these conventional medications had a 29% higher chance of suffering hip fractures.³⁴

Furthermore, the research highlighted that the variability among atypical antipsychotic agents was minimal, with slight differences noted in specific risks. For instance, olanzapine and quetiapine demonstrated a somewhat lower risk of cerebrovascular events compared to other atypical drugs.³⁵

The study also observed a dose-response relationship, where higher doses of antipsychotic medications correlated with increased risks of adverse events.³⁶ This means that residents on higher doses of these drugs were more likely to experience serious health complications.

Natural Solutions to Address Behavioral Issues in Nursing Homes

Research indicates that antipsychotic medications often exacerbate behavioral symptoms in nursing home residents. Instead of depending on these drugs as a primary response, several evidence-based strategies address the root causes of agitation and behavioral challenges by focusing on nutrition, toxin elimination and cellular health.

1. Optimize nutrition for cellular energy — Ensure residents consume 200 to 350 grams of targeted carbohydrates daily, tailored to individual microbiomes and activity levels. Incorporate whole fruits with pulp and gradually introduce complex carbohydrates and starches to support gut health and cellular energy production.

Maintain protein intake at 0.8 grams per pound of lean body mass, with one-third of protein derived from collagen-rich sources to support muscle mass and metabolic function.

2. Eliminate harmful foods and toxins — Remove seed oils, found in most processed foods, from your diet. These oils are rich in linoleic acid (LA), which disrupts cellular health when consumed in excess. Avoid nuts, seeds and their derivatives as well to reduce LA intake. It's also advisable to avoid dining out, since most restaurants use seed oils in their cooking, sauces and dressings.

Additionally, limit your consumption of chicken and pork, which are typically high in LA. Overall, ensure that all food offerings are free from ultraprocessed ingredients and harmful additives to promote optimal metabolic health.

3. Support mitochondrial function and cellular health — The primary reason why excess LA is harmful to your health is because it disrupts your cellular powerhouses — the mitochondria. Think of mitochondria as tiny energy factories in your cells that produce adenosine triphosphate (ATP), the essential fuel that keeps your cells running and repairing themselves.

Without energy, your cells can't repair and regenerate themselves. So, the fundamental issue underlying most chronic disease is that your cells are not producing enough energy. In addition to LA, exposure to synthetic endocrine-disrupting chemicals (EDCs), estrogen and pervasive electromagnetic fields (EMFs) also impair your cells' ability to generate energy efficiently.

This energy deficit makes it challenging to sustain the oxygen-free gut environment necessary for beneficial bacteria like Akkermansia to flourish, further complicating the problem.

Further, a lack of cellular energy creates an environment in the gut that favors endotoxin-producing bacteria, damaging mitochondria, triggering insulin resistance and creating a vicious cycle of worsening health. By tackling the "Four E's" — excess LA, estrogens (xenoestrogens found in everyday items like plastic), electromagnetic fields and endotoxins — you restore you cellular energy and start down the path toward optimal health.

In addition, incorporate supplements such as magnesium threonate to support mitochondrial energy production, and ensure adequate intake of vitamins D3 and K2 to enhance bone and cardiovascular health. Safe sun exposure is the best way to boost vitamin D levels, but peak sunlight hours should be avoided until residents have been free from seed oils for six months.

4. Implement comprehensive toxin elimination — Reduce exposure to environmental toxins such as glyphosate and heavy metals by sourcing food and supplements from clean, reputable sources. Use natural, toxin-free personal care and cleaning products within the nursing home environment to create a healthier setting for residents.

By integrating these nutritional and lifestyle-based approaches, nursing homes start to address the underlying factors driving behavioral issues in residents, fostering a healthier and more balanced environment without the detrimental effects of antipsychotic medications.

- Sources and References

• ¹ Journal of the American Geriatrics Society September 6, 2024
• ^{2, 3, 4, 5, 6, 7} Journal of the American Medical Directors Association, November 2024, Volume 25, Issue 11, 105255
• ^{8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29} Med Care March 2014, Volume 52, Issue 3, 267-271
• ^{30, 31, 32, 33, 34, 35, 36} Journal of the American Geriatrics Society, March 2012, Volume 60, Issue 3, 420-429