Trazodone, Antipsychotics Tied to Similar Fall Risk in Adults With Dementia

By Marilynn Larkin 

NEW YORK—In adults with dementia, rates of falls and major fractures are similar with the antidepressant trazodone and with atypical antipsychotics, researchers say.

Trazodone is increasingly prescribed as a safer alternative to atypical antipsychotics for behavioral and psychological symptoms of dementia, but little is known about its risk of harm.

For a study reported November 26 online in CMAJ, Dr. Jennifer Watt of St. Michael's Hospital in Toronto and colleagues reviewed data on 6,588 adults with dementia in long-term care facilities in Canada who received trazodone for the first time between 2009 and 2015. They also looked at 2,875 first-time recipients of an atypical antipsychotic (quetiapine, olanzapine or risperidone, mostly at a low dose). The mean age was 85; about 68% were women.

Compared with atypical antipsychotics, trazodone was associated with similar rates overall of falls or major osteoporotic fractures (weighted hazard ratio 0.89). The weighted HR for major osteoporotic fracture was 1.03; for falls, 0.91; and for hip fractures, 0.92.

Trazodone, however, was associated with a lower mortality rate (weighted HR 0.75).

"Patients, caregivers, and health care providers can adopt one of three strategies to treat symptoms: medications, non-medication options, or a combination of both medication and non-medication options," Dr. Watts told Reuters Health by email.

"Non-medication options to alleviate symptoms include modification of patients' environments and daily activities to be more tailored to their needs," she said. "For example, if a patient typically listened to music in the evening prior to moving into a nursing home, caregivers can provide a playlist of songs for the patient to listen to each evening."

"Knowledge of patients' previous vocations allows dementia care partners to develop meaningful activities for them," she noted. "If a patient worked in a restaurant, they might enjoy preparing food for others. Or if a patient was a librarian, they might enjoy organizing books. These activities can relieve symptoms of distress or restlessness."

"Certain symptoms, such as pain, may require a combination of both medication (e.g., acetaminophen) and non-medication options (e.g., resting a broken arm on a pillow)," she added.

"Precipitating and perpetuating factors for symptoms can change," Dr. Watts said. "It is important to re-evaluate treatment strategies in a timely manner. To minimize harm, health care providers should decrease or stop medications prior to discontinuing non-medication treatments."

Dr. Elia Abi-Jaoude of the Hospital for Sick Children (SickKids) and University Health Network in Toronto, coauthor of a related editorial, said the study "adds to the evidence showing that trazodone is not a universally safer alternative to antipsychotics."

"Indeed, there is no generally safe drug option," he said in an email to Reuters Health. "This underscores the importance of prioritizing non-pharmacological approaches for the management of behavioral and psychological symptoms of dementia. Existing evidence suggests that these are more effective than psychotropic drugs."

Dr. Abi-Jaoude suggested the following non-drug options: "attending to patient needs, such as pain, sleep problems, fear, boredom, loss of control or purpose, and acute medical problems; providing caregivers with education about dementia, help with communication, and supports around stress management; environmental interventions such as attending to over- or under-stimulation; providing activity, structure and routines; and addressing safety issues."

"It is also important to consider drugs which may be impairing cognition, especially in the long-term care population with dementia who are often prescribed multiple medications," he said. "There need to be adequate resources to support a change to the culture of care, creating a physical environment designed to reduce stress, and ensuring appropriately trained staff."

"We owe this to our most vulnerable seniors," he concluded.

SOURCE: https://bit.ly/2AqApZt and https://bit.ly/2AuOKUq CMAJ 2018.

(c) Copyright Thomson Reuters 2018. Click For Restrictions - https://agency.reuters.com/en/copyright.html