Further Confessions of a GP

The chemical cosh

I hadn’t known Stan before his dementia set in, but by all accounts he was a placid soul. His wife Eileen described him as a devoted husband and father who wouldn’t hurt a fly. The Stan before me now was very different. Most of his time was spent passively in his chair mumbling incoherently to himself. At other times he became agitated and angry and struck out. He rarely recognised his nearest and dearest, and the previous week in his fear, frustration and confusion, he’d hit his wife Eileen with his walking stick. Eileen was devastated. She kept telling me that the real Stan would never hurt her and would be mortified if he could comprehend the consequences of his actions. Eileen’s love and commitment towards her husband never ceased to amaze me – it took a lot for her to ask me for help. This particular morning she was in floods of tears as she requested something to sedate him. Her biggest fear was that unless his aggression was controlled she would end up having to put him in a nursing home, which, in her words, ‘would break both of our hearts’.

I read recently that one in four patients with dementia are being prescribed antipsychotics in order to sedate them and control difficult behaviour. Some have interpreted this as carer laziness, believing that carers don’t want the inconvenience of actually looking after people with dementia. Eileen is often distraught and exhausted but never lazy. She is a devoted wife who wants to try to care for her loving husband who has been transformed beyond all recognition by the dementia caused by his Alzheimer’s disease.

Prescribing an antipsychotic is not something I take lightly and it was not my first course of action. We had tried normal antidepressants and also non-pharmacological techniques such as keeping good lighting and getting more help in. Antipsychotics really are a final resort. They are strong drugs with potential side effects and I spent some time talking through the possible pitfalls with Eileen. We decided to start with a low dose of quetiapine. This antipsychotic is not licensed for dementia care, and may well increase the risk of him having a stroke, but with Stan, I believed it to be the right decision.

Dignity is a word that is now regularly associated with regard to caring appropriately for the elderly and some relatives have complained about antipsychotics robbing their elderly relatives of their dignity through over-sedation. Decisions on whether to prescribe the drugs or not are a delicate balancing act and each case has to be looked at individually. Antipsychotics are not used to treat people whose dementia is at an early stage. They won’t be thrown down the throats of people who have misplaced their door key or forgotten a dental appointment. They are prescribed for agitated, disturbed patients during the last stages of this awful disease.

As always, when I’m making these difficult decisions, I resort to the simple question of ‘What would I want if it was me?’ If I was suffering with advanced dementia and striking out at my family, would I want to be chemically coshed with an antipsychotic? It might sedate me and I might even die sooner as a result, but wouldn’t that be better than the painful indignity of confused aggression directed towards the people I love and who love me?