Expert Study: Elderly patients in USA are over prescribed anti-psychotic drugs.

In the United States, elderly patients with dementia are too often prescribed anti-psychotic drugs to calm their disruptive behavior, a costly and risky practice that should end, experts said Wednesday.

Instead, more care should be taken to determine why dementia patients may be acting up and treat those underlying causes, lawmakers were told at a hearing of the Senate Committee on Aging.

"As the baby boomer generation ages, it is imperative to address the overuse and misuse of antipsychotic drugs among nursing home patients," said Daniel Levinson, Health and Human Services Inspector General.

Levinson said recent government audits have raised concerns about the use of antipsychotics by elderly people with dementia in nursing homes, raising their risk of death and wasting money for the US healthcare system.

For instance, more than half of such prescriptions were wrongly paid for in 2007 by government Medicare because the patients did not exhibit symptoms of schizophrenia or bipolar disorder, amounting to about 230 million dollars in waste.

One audit showed 14 percent of nursing home residents had Medicare claims for antipsychotic drugs, he said.

But another panel member, Toby Edelman, senior policy attorney in the office of the Center for Medicare Advocacy, said that audit's estimate was low because it only included some kinds of anti-psychotics.

"Nursing facilities' self-reported data indicate that in the third quarter of 2010, 26.2 percent of residents had received antipsychotic drugs in the previous seven days. That is approximately 350,000 individuals," she said.

"Facilities reported they gave antipsychotic drugs to many residents who did not have a psychosis, including 40 percent of patients at high risk because of behavior issues."

Edelman also pointed out that this issue is far from new, and that the same Senate committee had issued a report on the misuse of drugs in nursing homes back in 1975, and held a workshop on the topic two decades ago.

The practice persists, even though it is against federal law, because of serious understaffing in nursing facilities, high turnover of staff, and "aggressive off-label marketing of anti-psychotic drugs," she said.

The pharmaceutical giant Eli Lilly in 2009 paid a nearly 1.5 billion dollar settlement, in which it admitted no wrongdoing, for off-label promotion of its drug Zyprexa as a treatment for dementia. The drug is FDA-approved for bipolar disorder and schizophrenia.

According to Tom Hlavacek, executive director at Alzheimer's Association's southeastern Wisconsin chapter, elderly people with dementia are sometimes prescribed these potent drugs for behaviors that have other causes.

Urinary tract infections, tooth decay, arthritic pain, or simply moving a patient from one place to another can lead to agitated behaviors.

"Our experience indicates that these care transitions can exacerbate behaviors and often lead to escalating drug treatments," he told lawmakers.

Experts said solutions could include creating stronger penalties for inappropriate prescribing, and a renewed focus on trying non-pharmacological approaches to a problem first.

"Most doctors treat unwelcome behavior in all settings as a disease that requires medication. These drugs are used as chemical restraints," said Jonathan Evans, a doctor who specializes in caring for frail elders.

"Behavior is not a disease. Behavior is communication. And in people who have lost the ability to communicate with words, the only way to communicate is through behavior," he added.

"Good care demands we figure out what they are telling us and help them."

Light Box Treatments Recommended for Seasonal Mood Disorder.

For the millions of Americans who suffer from mild to severe winter blues — a condition called seasonal affective disorder, or S.A.D. — bright-light therapy is the treatment of choice, with response rates comparable with those of antidepressants. “Your natural clock is usually longer than 24 hours, and you need light in the morning to set it and keep it on track,” said Dr. Alfred Lewy, a professor of psychiatry at Oregon Health and Science University and an expert on seasonal depression and light therapy.

Yet many experts think light therapy is underused, given its affordability and relative lack of side effects, in large part because there is little profit to be made from it and no commercial incentive to promote the treatment.

Patients generally sit in front of the light box, which can be as small as 9 by 11 inches and 5 inches deep, with the bright light emanating from the square surface, in the morning. “With the natural dawn being later in winter, the body rhythms drift late,” Dr. Lewy said. “If you can fix the drift, you can fix the depression.”

Light therapy may even help with major nonseasonal depression, experts say, and withsleep disorders. And because it has few side effects, researchers are studying whether light therapy can help with depression during pregnancy and be used to treat elderly people with dementia. It is also being investigated for the treatment of bulimia nervosa, severe premenstrual syndrome and even attention deficit hyperactivity disorder and bipolar disorder.

Though randomized controlled clinical trials of bright light are difficult to do properly — one expert is fond of saying that it is difficult to “blind” studies of bright light — the American Psychiatric Association considers bright-light therapy an effective low-risk treatment for both S.A.D. and nonseasonal major depressive disorder.

A 2006 multicenter double-blind randomized controlled trial that compared bright-light therapy head to head with the popular antidepressant Prozac (fluoxetine) in 96 subjects found the two treatments equally effective for alleviating winter depression, though light produced results faster, usually within a week, and with fewer side effects.

Why, then, do so few doctors prescribe bright-light therapy? Some say their patients don’t have the patience to sit in front of a light for 30 to 45 minutes every morning. Moreover, “doctors are just more comfortable prescribing medication, because that’s what they do for everything,” Dr. Lewy said.

Some patients who suffer from chronic depression say they use light therapy in addition to their regular medication in the winter months.

“I’ve always seen a drastic change in my personality from spring and summer to fall and winter, and it got worse as I got older,” said Rick Bach, 54, a painter who owns a hair salon in West Hartford, Conn., and tries to spend every January in Puerto Rico.

But while bright-light treatment is helpful, he said, it is not sufficient for him. “It can help you from falling into a deep depression, but it won’t help you climb out of one,” he said.

No one knows exactly how light treatment works, but most experts seem to agree that the body has a master biological clock that responds to or is “set” by natural light fluctuations.

“Light does more than just enable us to see,” said Dr. Norman Rosenthal, author of the landmark book “Winter Blues,” who was among the first to identify and describe S.A.D. Light also has an effect on hormones, the body’s chemical messengers, affecting the brain’s hypothalamus, which is involved in regulating mood, energy and appetite.

“The hormone melatonin, which is secreted at night, can be suppressed by light,” Dr. Rosenthal said. “Studies have also shown that light influences serotonin and epinephrinepathways in the brain, the same neurotransmitter systems known to be affected in people with general depression.”

But while part of the appeal of light therapy is that it can be self-prescribed, using a light box is not as simple as it may appear. Experts recommend consulting with a knowledgeable health care provider before starting treatment to rule out other medical conditions and to help with monitoring and adjusting bright-light exposure.

Some patients may want to try simply getting more natural light to help with seasonalmood changes — getting out as much as possible during the brightest time of day in the winter, sitting near windows during the day or taking vacations to sunny locales in the winter.

http://www.nytimes.com/2011/11/15/health/policy/light-boxes-may-help-melt-those-winter-blues.html?_r=1&ref=science

Cardiovascular Health in Middle Age Has Link to Brain Health in Later Life.

Studies are mounting that health Cardiovascular Health is paramount in maintaining healthy brain function later in life. 

In a study published online last week in Neurology, scientists at the University of California, Davis, examined 1,352 men and women, ages 45 to 63, and recorded the group’s rates of hypertension, diabetes, smoking, high cholesterol, obesity and other risks.

The researchers also performed brain scans of the participants and administered several widely used tests of mental ability. No subject had symptoms of dementia at the start of the study.

In follow-up examinations 7 to 13 years later, the researchers found that high blood pressure at the start of the study was associated with an increased appearance of white areas on the scan, a sign of brain deterioration.

Midlife diabetes was associated with a greater annual increase in the size of the brain’s temporal horn, a marker of Alzheimer’s disease, in later years. And those with an increased waist-to-hip ratio had a significant decrease in total brain volume over time.

Obese people and those with hypertension eventually performed more poorly on tests of memory and mental skills, even after controlling for baseline cognitive performance, the researchers found.

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