"Adverse effects of anti-psychotics are 'tip of the iceberg'"

[LETTER TO THE EDITOR] from Caplan, Louis R. MD
Professor Neurology, Harvard Medical School, Boston, MA

Regarding Increased Risk of Death with Antipsychotics for Demented Elderly (Jan.3, page 18), I believe that the adverse effects of these agents in this group of patients are just the tip of an iceberg. The overuse and abuse of antipsychotics (typical and atypical), especially haloperidol and risperidone, may cause the death and morbidity of patients who have been admitted to a hospital for an acute illness.  These drugs, used to control agitation, are often given in high
doses to very sick patients in intensive care units or on medical and surgical units.

Agitation is not a disease; it is a symptom of complex medical and neurological problems. Unfortunately, the anti-psychotics cause over-sedation that impairs speech and other interactions, making it difficult to take a history or perform the neurological examination.

A neuro-pharmacological colleague called haloperidol and risperidone medical straight-jackets. They make patients feel wooden and grossly diminish activity and communication skills. When patients rebound and become more alert they naturally become agitated and then they are knocked down again, often with high doses of haloperidol. It may take weeks and months for the CNS effects of haloperidol to wear off.

In two different studies, Dennis M. Feeney, PhD, and colleagues found that even single doses of haloperidol in experimental animals and humans with strokes retarded recovery by two weeks (Science 1982; 217:855-857); (Proc West Pharmacol Soc 1985: 28:209-211).  In later studies, Larry B. Goldstein, MD, and the late Jim Davis, MD, showed that these antipsychotic drugs adversely affect recovery (Stroke 1990; 21 (Suppl 3): 139-142); (Neurology 1988; 38:1806-1809); (Arch Neurol 1998; 55: 454-456).

In the 15 years that I chaired the Neurology Department at the New England Medical Center, we forbade the use of haloperidol for neurology patients.  Originally, these anti-psychotics were used for young schizophrenic patients.  Old sick people with abnormal brains do not tolerate these drugs well.

In patients with Lewy-body disease and some Parkinsonian syndromes, their use is a disaster, setting patients back for weeks.

I know that most neurologists are circumspect about the use of haloperidol and risperidone but psychiatrists, non-neurology intensivists, and surgeons are not, and these drugs are grossly over-prescribed and overused.  They cause symptoms and neurological dysfunctions that are a common reason for neurological consultations in the hospital.

Perhaps a collection of cases collaborated on by neurologists and a position paper by the AAN will help to stem this large public health preventable problem.

Louis R. Caplan, MD
Professor Neurology, Harvard Medical School, Boston, MA