Patients exposed to antipsychotics had a significantly higher adjusted risk of death (hazard ratio: 1.35, 95% confidence interval: 1.27-1.43) than unexposed patients. Epub 2017 Jan 20. In the 2012 REAL.Fr prospective study [41], 534 community dwelling, mild to moderate Alzheimers dementia patients were assessed from 2000 to 2002 with follow-up for four years for all-cause mortality comparing newly prescribed users of Anatomical Therapeutic Chemical (ATC) Code NO5A. This latter data is of major concern and would indicate a need for more thorough studies to be carried out on the negative impacts and general safety of antipsychotic drugs prescribed for the general patient population in mental health care. As revealed by our sensitivity analyses, three studies with very small study variances [22, 36, 37, 43], two of which were of larger sample size from the general population of antipsychotic drug users [36, 37, 46] accounted for most of the observed heterogeneity between studies. The evidence is undeniable that the antipsychotic drugs, when first administered carry a very high risk of serious adverse events leading to increased all-cause mortality. The next severe covariate was baseline cardiovascular disease, HR=1.88; [1.492.37] [45]. The authors added that the risks and benefits must be carefully considered before prescribing antipsychotics to dementia patients without severe mental illness because the research evidence did not support use of antipsychotics to manage their behavioral problems. At least, we should aim to attain the desired level of de-prescribing for this current widespread and often unnecessary practice as the easy fix option and simple remedy over the long term when dealing with the behavioral problems of dementia patients. Mainly in first 100 days of use. In this regard, it should be noted that several reports have claimed minimal effects of antipsychotic drugs on risk of mortality with dementia patients [41, 57, 6067]. The results of different meta-analysis models applied to the data from the reports in Table1 are shown in Tables2 and and3.3. In 2014, a second retrospective study of 696 Alzheimers dementia patients at Teramo hospital in Italy was reported [49]. The crude 6-month mortality rates were 20.0% for haloperidol, 12.6% for olanzapine, 12.5% for risperidone, 9.8% for valproic acid and its derivatives, and 8.8% for quetiapine. Dose-response data such as this greatly increases the confidence levels assigned to such studies for an underlying cause-effect relationship and scientific validity that antipsychotic drug use increases the risks of all-cause mortality in dementia patients. Patients exposed to antipsychotics were matched with up to three unexposed patients. Would you like email updates of new search results? Antipsychotics were used frequently in the past to manage dementia-related psychosis. This supports the accuracy of the overall meta-analysis. The controls used for comparison were based on reports of adverse reactions to any other drugs without a fatal outcome and were sex and age matched to the users of antipsychotics. The results confirmed the greater risks for those Alzheimers dementia patients prescribed the antipsychotics, including increased acute cardiac events (PERR=1.65; [1.051.78]), venous thromboembolism (HR and PERR=1.80; [1.671.89], stroke (HR=1.5; PERR=2.06; [1.972.13]) or hip fractures (PERR=1.65; [1.611.73]). Users matched to psychiatric non-users HR=2.15; [2.102.21] and HR=2.98; [2.933.03] matched with general population non-users. The authors examined the mortality risk of individual agents to augment the limited information on individual antipsychotic risk. The Hedges-Vevea model for the mean effect size across the studies was also determined for comparison [31]. Neuropsychiatric symptoms, such as agitation and psychosis, are common and highly impactful complications of dementia [] and are major determinants of poor quality of life, carer burden and healthcare costs.They are also associated with more rapid dementia progression and increased mortality [2, 3].Antipsychotic medications are often considered in the management of these symptoms; however . Bookshelf This study was conducted to analyse associations between the use of antipsychotics, antidepressants, and benzodiazepines and 2-year mortality in old people with dementia, and to investigate sex differences therein. PMID: 17036366 DOI: 10.1002/pds.1334 Abstract Purpose: To estimate the association between use of typical and atypical antipsychotics and all-cause mortality in a population of demented outpatients. Before As with the Finnish study above, the greatest risk was detected over the 30-90-day period for those current users with HR=1.675; [0.903.118] at the 10-week follow-up time point compared to non-users as control. Haloperidol HR=2.71; 1.983.69]. Antipsychotic prescribing rates in US LTC homes have decreased significantly since rates approaching 50% were observed in the mid-1990s, 72, 73 and reductions among persons with dementia in US outpatient settings have also been observed. Published on December 9, 2022 Key takeaways: People living with dementia sometimes experience agitation or hallucinations (seeing or hearing things that aren't there). Unauthorized use of these marks is strictly prohibited. The analysis showed that users had an overall greater risk of mortality associated with antipsychotic monotherapy (HR=1.61; [1.531.70]) compared to non-users. A 2017 retrospective study of the FEDRA Spanish pharmacovigilance database examined 189,441 suspected adverse events over 1995 to 2012 across the general population, of which 5,206 were from antipsychotic drug use with 200 fatal outcomes [24]. 2007;146(11):775-786. doi:10.7326/0003-4819-146-11-200706050-00006, Wang PS, Schneeweiss S, Avorn J, et al. The models were adjusted for potential confounders. This report was a critical analysis addressing the outcomes of treatment practices for dementia in UK patients and globally, aimed at reducing prescribing of antipsychotic drugs for dementia. In all of the studies, the findings have consistently shown that use of haloperidol is consistently linked with the highest risk of all-cause mortality amongst the antipsychotics (see Table4). *values based on antipsychotic drug users in the general population. In 2007 European regulatory agencies and the US Food and Drug Administration (FDA) issued warnings regarding the use . Similar findings were reported in 2016 from a study of dementia patients in nursing homes (Medicare beneficiaries) with behavioral symptoms over 20072009 showing a lowering of mortality when using lower doses of antipsychotics, particularly over the longer duration [56]. De Matteis G, Burzo ML, Della Polla DA, Serra A, Russo A, Landi F, Gasbarrini A, Gambassi G, Franceschi F, Covino M. J Clin Med. Neuropsychopharmacology. For haloperidol, the HR=2.71; [1.983.69] and for risperidone, the HR=2.07; [1.562.75]. "The boxed warning will say that elderly patients with dementia-related psychosis and treated with antipsychotics have an increased risk of death," said Thomas Laughren, M.D., director of the Division of Psychiatry Products at the FDA's Center for . Analyses were stratified for diabetes, heart disease, and cerebrovascular disease, and we calculated the relative excess risk due to interaction (RERI). Comparative statistical analyses were performed using a range of software programs including SPSS Vn24.0; Comprehensive Meta-Analysis (CMA; https://www.meta-analysis.com/) and the MIX 2.0 PRO (https://www.meta-analysis-made-easy.com) on Microsoft Excel. Worldwide increased mortality in patients using antipsychotic agents. In 2014, a 10,079 Japanese Alzheimers disease patient (70.7% female) large-scale, prospective study analyzed 4,873 exposed to antipsychotics [71.4% (3479 of 4873) were taking atypical antipsychotics, whereas 21.6% (1054 of 4873) were taking conventional antipsychotics, and 7.0% (340 of 4873) were taking both] and were matched with 4,898 non-exposed controls across a large range of baseline characteristics including age, gender, severity of dementia and other co-morbidities [47]. With the failures of clinical guidelines elsewhere (UK and USA) in exerting any major influence or bringing about modified practices or greater compliance, tighter federal regulation will be required. 2007 Oct;164(10):1568-76; quiz 1623. doi: 10.1176/appi.ajp.2007.06101710. Analysis of the heterogeneity statistics for the 20 studies gave values for deviation, Q=837, inconsistency among the group of studies, I2=97.5% and variance, t2=0.06. Antipsychotic monotherapy (HR=1.61; [1.531.70]) compared to non-users. All three methods of meta-analysis produced similar pooled effect sizes for the risks of mortality of antipsychotic drug users at close to twice that of the control non-user group. Mental illness, challenging behaviour, and psychotropic drug prescribing in people with intellectual disability: UK population based cohort study. We investigated the mortality risk associated with the initiation of antipsychotic treatment among patients with dementia and whether comorbidities related to the cardiovascular system and diabetes interact with antipsychotic treatment to increase the mortality risk beyond the risk of death independently associated with antipsychotics and comorbidity alone. Studies were not included in our final meta-analysis under the following situations: 1) when based on only small numbers of patients or sample sizes (and hence causing high between-study heterogeneity, as shown previously in [28]) or 2) where analysis of large patient databases for mortality risk involved first making extensive adjustments during data extraction to exclude the majority with confounding factors such as advanced severity of dementia or multiple co-morbidities. This study, with an almost two-fold greater RR of mortality at 3 years after continuing on the antipsychotics, provides additional support for halting the use of antipsychotic drugs to treat dementia. An open question which remains is whether the use of alternatives such as sedatives in the GABAB receptor agonist group of drugs (including pregabalin or gabapentin) or opioids will increase the risk of dementia or cause greater mortality in dementia patients. For this reason, the results of heavily adjusted or censored studies were excluded from the present meta-analysis. Methods of Meta-Analysis: Correcting Error and Bias in Research Findings, Fixed- and random-effects models in meta-analysis, Quantifying heterogeneity in a meta-analysis, Patsopoulos NA, Evangelou E, Ioannidis JP (2008), Sensitivity of between-study heterogeneity in meta-analysis: Proposed metrics and empirical evaluation, Egger M, Davey Smith G, Schneider M, Minder C (1997), Bias in meta-analysis detected by a simple, graphical test, Murray-Thomas T, Jones ME, Patel D, Brunner E, Shatapathy CC, Motsko S, Van Staa TP (2013), Risk of mortality (including sudden cardiac death) and major cardiovascular events in atypical and typical antipsychotic users: A study with the general practice research database, Jones ME, Campbell G, Patel D, Brunner E, Shatapathy CC, Murray-Thomas T, van Staa TP, Motsko S (2013), Risk of mortality (including sudden cardiac death) and major cardiovascular events in users of olanzapine and other antipsychotics: A study with the general practice research database, Bloechliger M, Regg S, Jick SS, Meier CR, Bodmer M (2015), Antipsychotic drug use and the risk of seizures: Follow-up study with a nested casecontrol analysis, De Deyn PP, Drenth AFJ, Kremer BP, Oude Voshaar RC, Van Dam D (2013), Aripiprazole in the treatment of Alzheimers disease, Dennis M, Shine L, John A, Marchant A, McGregor J, Lyons RA, Brophy S (2017), Risk of Adverse outcomes for older people with dementia prescribed antipsychotic medication: A population based e-cohort study, Gardette V, Lapeyre-Mestre M, Coley N, Cantet C, Montastruc JL, Vellas B, Andrieu S (2012), Antipsychotic use and mortality risk in community-dwelling Alzheimers disease patients: Evidence for a role of dementia severity, Langballe EM, Engdahl B, Nordeng H, Ballard C, Aarsland D, Selbk G (2014), Short- and long-term mortality risk associated with the use of antipsychotics among 26,940 dementia outpatients: A population-based study, Jennum P, Baandrup L, Ibsen R, Kjellberg J (2015), Increased all-cause mortality with use of psychotropic medication in dementia patients and controls: A population-based register study, Nielsen RE, Lolk A, Valentin JB, Andersen K (2016), Cumulative dosages of antipsychotic drugs are associated with increased mortality rate in patients with Alzheimers dementia, Gisev N, Hartikainen S, Chen TF, Korhonen M, Bell JS (2012), Effect of comorbidity on the risk of death associated with antipsychotic use among community-dwelling older adults, Koponen M, Taipale H, Tanskanen A, Tolppanen AM, Tiihonen J, Ahonen R, Hartikainen S (2015), Long-term use of antipsychotics among community-dwelling persons with Alzheimers disease: A nationwide register-based study, Arai H, Nakamura Y, Taguchi M, Kobayashi H, Yamauchi K, Schneider LS (2016), Mortality risk in current and new antipsychotic Alzheimers disease users: Large scale Japanese study, Musicco M, Palmer K, Russo A, Caltagirone C, Adorni F, Pettenati C, Bisanti L (2011), Association between prescription of conventional or atypical antipsychotic drugs and mortality in older persons with Alzheimers disease, Piersanti M, Capannolo M, Turchetti M, Serroni N, De Berardis D, Evangelista P, Costantini P, Orsini A, Rossi A, Maggio R (2014), Increase in mortality rate in patients with dementia treated with atypical antipsychotics: A cohort study in outpatients in Central Italy, Chiesa D, Marengoni A, Nobili A, Tettamanti M, Pasina L, Franchi C, Djade CD, Corrao S, Salerno F, Marcucci M, Romanelli G, Mannucci PM, Investigators R (2017), Antipsychotic prescription and mortality in hospitalized older persons, Connors MH, Ames D, Boundy K, Clarnette R, Kurrle S, Mander A, Ward J, Woodward M, Brodaty H (2016), Predictors of mortality in dementia: The PRIME Study, Ray WA, Chung CP, Murray KT, Hall K, Stein CM (2009), Atypical antipsychotic drugs and the risk of sudden cardiac death, Rossom RC, Rector TS, Lederle FA, Dysken MW (2010). Mostly>65 years, follow-up 3 years with mortality determined at 8 years, Atypical antipsychotic drugs versus non-users, Antipsychotic drug users 3074 years old (mean age 46), Sudden cardiac death from baseline. One large cohort study was reported in which a 10 year follow up period of 3,484 patients over 65 years old in elderly care showed that opioids were relatively safe, although heaviest opioid use increased the risk of dementia (HR=1.29; [1.021.62]) [94]. ACNP white paper: update on use of antipsychotic drugs in elderly persons with dementia. This is referred to as dementia-related psychosis. De-prescribing is likely to be highly beneficial, as has been supported by systematic review and meta-analysis [8688] as well as by a recent randomized trial which showed no significant adverse effects on survival or other clinical outcomes after de-prescribing elderly patients in aged care [89]. Food and Drug Administration (FDA) Public Health Advisory: Deaths with antipsychotics in elderly patients with behavioral disturbances, Department of Health and Human Services, U.S. Government, Gill SS, Bronskill SE, Normand S-LT, Anderson GM, Sykora K, Lam K, Bell CM, Lee PE, Fischer HD, Herrmann N, Gurwitz JH, Rochon PA (2007), Antipsychotic drug use and mortality in older adults with dementia, Schneeweiss S, Setoguchi S, Brookhart A, Dormuth C, Wang PS (2007), Risk of death associated with the use of conventional versus atypical antipsychotic drugs among elderly patients. 13.7% dementia) compared to psychiatric non-users (24% dementia). Their use in individuals with dementia is often limited by their adverse effect profile. An extreme example comes from comparing age-standardized death rates of the Polish National Health Fund (NHF) database, accumulated over the period of 2008 to 2012 [72]. The studies incorporated into this meta-analysis were reported since the Banerjee study [3] from 2009 onwards and were mainly based on minimally adjusted effect sizes standardized across age, gender, marital status, and location of drug users matching to the control non-user population as the reference. The outcomes provide further support strengthening the continuing calls for increasing the stringent standards and restrictions governing the availability and prescribing of antipsychotic drugs for dementia. HR was calculated using a 22 contingency table for risks of mortality based on background incidence in the matched control non-user population and the online calculator http://vassarstats.net/odds2x2.html. A 2014 retrospective cohort study investigated short- and long-term mortality risk associated with antipsychotic use in outpatients 65 years and older who had dementia (n = 26,940). Haloperidol clearly is neurotoxic. Careers. For these reasons, the three studies were excluded from the present meta-analysis, which extends well beyond [28] to include the data from much larger scale longitudinal studies. In agreement with the previous meta-analysis published in [28], excluding highly heterogeneous studies, from our meta-analysis, the facts remain indisputable and it can be summarily concluded: The authors have no conflict of interest to report. 8600 Rockville Pike Epub 2022 Sep 26. Increased SAEs as Cardiac arrest, venous thromboembolism, stroke or hip fracture. Write a review. Analysis of the contour-enhanced funnel plot [58] with trim and fill (Fig. We investigated the mortality risk associated with the initiation of antipsychotic treatment among patients with dementia and whether comorbidities related to the cardiovascular system and diabetes interact with antipsychotic treatment to increase the mortality risk beyond the risk of death independently associated with antipsychotics and comorb. The individual estimates from these studies are closely related such that the exclusion sensitivity test confirmed that no single study unduly influenced the overall pooled estimate for risk of mortality (see Table3). Patients with dementia and antipsychotics had the highest risk of mortality (78.0%), followed by (73.0%) for patients with dementia alone and compared with patients without dementia or antipsychotics exposure who had the lowest mortality risk (42.0%). It is unknown whether this risk generalizes to non-elderly adults using newer antipsychotics as augmentation treatment for depression. official website and that any information you provide is encrypted Former (prior long term) users of antipsychotic drugs had no significantly increased risks. Although the reasons for this anomaly were not clear in these reports, it could be due to a survival bias with long term patients either selected for (in that those who were susceptible to these types of drugs had already succumbed to their toxicity) or survivors were becoming tolerant or adapting to the toxicity of these drugs over the longer exposure periods and higher doses. sharing sensitive information, make sure youre on a federal Nevertheless, the study authors concluded that the atypical antipsychotics (olanzapine, quetiapine, and risperidone) showed a dose-response increase in mortality risk. These pooled results might be subject to uncontrolled or residual confounding, given our focus on minimally adjusted risk estimates. Antipsychotics, other psychotropics, and the risk of death in patients with dementia: number needed to harm JAMA Psychiatry. National Library of Medicine This was a retrospective cohort study, based on national data from the U.S. Department of Veterans Affairs (from 19992008) for 90,786 dementia patients age 65 and older [54]. Cox proportional hazards models were used to compare rates of death within 180 days after the initiation of antipsychotic treatment. From the above meta-analysis including several large retrospective studies recently reported, the data is consistent for risk of increased all-cause mortality associated with dementia or other patients when prescribed the antipsychotic drugs. This necessitates monitoring doctor/nursing home compliance and accountability in controlling use of antipsychotic drugs in order to be effective. An official website of the United States government. 2007;164(10):1568-1576. doi:10.1176/appi.ajp.2007.06101710. Risk analysis suggested higher mortality in patients without cerebrovascular disease who initiated antipsychotics. FOIA Conclusion: The risk of mortality was highest with conventional antipsychotic use, and within 40 days of antipsychotic initiation. Medications Off-label antipsychotics Benefits Limits Side effects Other treatment Seeking medical advice Summary Doctors sometimes prescribe antipsychotic medications to. Also antidepressants have been associated with increased mortality in old people in general [16, 28-30], and in one study of old men with dementia . The funnel plot of precision (inverse of standard error of each estimate) versus the log value of effect size (Fig. Previous studies have not investigated sex differences in this risk. Epub 2020 Mar 11. Psychotropic Drugs and Adverse Kidney Effects: A Systematic Review of the Past Decade of Research. Importantly, many of the more recent studies concluded that whilst their results were consistent with earlier reports (prior to 2009), it was considered that the earlier studies underestimated the increased risks associated, particularly with haloperidol and which in several studies (as identified above) has shown double the risk of all-cause mortality (predominantly cardiovascular, respiratory or stroke related causes). Consequently, this makes the calculations for the minimally adjusted summary HR in our meta-analyses all the more convincing. Initiation of antipsychotics after moving to residential aged care facilities and mortality: a national cohort study. In 2014, a population based study of 26,940 dementia outpatients in the Norwegian Prescription database by Cox survival analysis, adjusted for age, gender, mean daily defined dose, and severe medical conditions, showed that antipsychotic drug users (n=8,214) had nearly twice the mortality risk compared to the other psychotropics (including ATC codes: antidepressants (N06A); benzodiazepines (N03AE01, N05B, N05C); benzodiazepine-like agents (N05C); lithium (N05AN01); and anticonvulsive drugs (N03A)), both for short (30 days) or longer term (730 to 2,400 days) use [42]. The pooled estimate from the DerSimonium-Laird analysis for the predicted HR is shown underneath. 2005. This trial showed reduced 12-month survival (70%; 95% CI [5880%]) in those who continued on antipsychotics versus those who halted drug use as the control group (77%; 95% CI [6485%]). The absolute effect of antipsychotics on mortality in elderly patients with dementia may be higher than previously reported and increases with dose. Prescribing of antipsychotic drugs for dementia or for other mental health care should be avoided and alternative means sought for handling behavioral disorders of such patients. Several different methods for meta-analysis were used to compare each with resulting pooled estimate for effect size determined as the HR for risk of mortality from use of antipsychotic drugs. *All users, including dementia patients. All-cause mortality in dementia patients. Sudden cardiac death was greatly increased in psychiatric users versus the psychiatric matched non-users with HR=5.76; [2.9011.45], UK Clinical Practice Research Datalink 19982013, First-time seizures in Dementia patients over 15-year period, Atypical antipsychotics Olanzapine, quetiapine, Low-to-medium potency typical antipsychotics, Medium-to-high potency typical antipsychotics, Welsh Secure Anonymised Information Linkage (SAIL) databank 20032011, 9,674 newly diagnosed dementia patients aged65 years, All-cause Mortality and serious adverse events. How does the DerSimonian and Laird procedure for random effects meta-analysis compare with its more efficient but harder to compute counterparts? Haloperidol again showed the highest risk of mortality among the antipsychotics used as a single agent (HR=1.52; [1.142.02]) relative to risperidone users as reference (HR=1). At present, no published reports could be found relating to this area. HHS Vulnerability Disclosure, Help In the United States of America (USA), analysis by the federal based Centers for Medicare and Medicaid Services (CMS) databases of over 75,000 patients aged65 from 20012005 in nursing homes showed a direct dose-response relationship for all-cause mortality with all antipsychotic drugs given over 6 months, except for quetiapine [68]. As a library, NLM provides access to scientific literature. The .gov means its official. For both classes of drugs, the risk for current users increased significantly with increasing daily doses such that for typical antipsychotic drugs (FGA), the incidence-rate ratios increased from 1.31; [0.971.77] for low dose up to HR=2.42; [1.913.06] for high doses (p<0.001). However, such drugs are being widely used beyond these indications and not only for particular symptoms such as anger, aggression or paranoid ideas [1]. However, these authors further stratified the patient data by heavily adjusting on the basis of almost 40 factors (including comorbidities and dementia severity) such that the relative difference in mortality amongst dementia patients prescribed antipsychotics was greatly diminished. All-cause mortality in dementia patients or non-dementia patients. Furthermore, it was concluded that many people with such dementia related behavioral disturbances have complex needs and that any medications should not be prescribed lightly and were no substitute for more comprehensive patient care. The horizontal lines across each square show 95% CIs. Moreover, their use does not improve functioning, care needs, or quality of life [1]. The DerSimonian-Laird random effects model was applied [29] and compared to the Hunter-Schmidt model [30], the latter which in addition to using the inverse of the variances in effect sizes, also incorporates a weighting based on the sample sizes [30]. There are very few studies on the short or long-term effects of opioids or GABAB receptor type sedative drugs on dementia. Whilst the evidence indicates that doctors should proceed with extreme caution when prescribing for new users, they also have a duty of care to dementia patients in de-prescribing use of antipsychotic drugs for dementia. Helps you get and maintain an erection when you need it. Although mortality while hospitalized was low, the follow-up risk over the ensuing 90 days increased with HR=1.57; [0.9452.607]. 534 Alzheimers Dementia patients, 102 new users, All-cause Mortality in Alzheimers dementia 3.5-year follow-up, Antipsychotics (typical and atypical) new use versus non-user control, All-cause mortality in Dementia patients short (30 day) or long term use (7302400 days), Follow up over more than 6 years. They compared those prescribed the atypical antipsychotics (n=44) and typical antipsychotics (n=58) to 432 non-users as controls. Newer antipsychotics were associated with a mortality risk of HR = 1.61 (95%CI 0.92-2.80) in older adult patients and a mortality risk of HR = 1.36 (95%CI 0.86-2.13) in younger adult patients. However, by heavily adjusting the data based on dementia severity and other co-morbidities, the risk was greatly reduced (HR=1.12; [0.592.12]). The atypical antipsychotic drugs were found to have a HR=1.61; [1.292.02] (p<0.01) for mortality based on univariate analysis adjusting for age and sex. 2022 Oct;36(10):1049-1077. doi: 10.1007/s40263-022-00952-y. 4 Potential harms anticipated with use of these medications include known adverse effects such as metabolic changes and . The adjusted HR was the highest among antipsychotic users with baseline respiratory disease (HR=2.21; [1.303.76]) as the most severely impacting co-morbidity covariate, possibly linked to increased risk of death from pneumonia. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Stratified analyses. Homogeneity Test: Q Statistic (Goodness of Fit), Mean Effect Size (r=ln HR), ln (Lower & Upper 95% CIs), and Chi2test, Estimated Variance in Population Correlations=0.0191. Are shown in Tables2 and and3.3 receptor type sedative drugs on dementia doctor/nursing home compliance and in! Adverse effect profile up to three unexposed patients adjusted risk estimates to this.! In older people with intellectual disability: UK population based cohort study use, and psychotropic drug prescribing in with! Were matched with general population patients with dementia 1623. doi: 10.1176/appi.ajp.2007.06101710 be found relating to area... To three unexposed patients NLM provides access to scientific literature effects such as changes... 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