Antipsychotic use and risk of death in older adults with cognitive impairment: The role of frailty

Introduction: The use of antipsychotics has been associated with serious adverse events including death among older adults with cognitive impairment. Geriatric syndromes, such as frailty, are also associated with death in this population. The purpose of this study was to evaluate the impact of frailty on the risk of death among nursing home (NH) residents with cognitive impairment treated with antipsychotic medications. Method(s): Retrospective cohort study based on data from 57 NHs of 7 European countries and Israel participating to the Services and Health for Elderly in Long TERm care (SHELTER) project. Frailty was defined according to the Frail-NH scale. Risk of death associated with frailty was the main outcome. The inter-Resident Assessment Instrument for Long Term Care Facilities (interRAI LTCF) was used to assess participants. Follow-up time was 12 months. Result(s): Overall, 604 residents aged 65 years or older on antipsychotics were included in the study. The prevalence of frailty in the study sample was 42.8% (n = 299). Among antipsychotic users, frailty was associated with higher mortality (incidence rate (IR) 0.27 per person-year in the frail residents compared with 0.17 per personyear in the robust individuals). After adjusting for potential confounders, frail residents were over 70% more likely to die than robust individuals (hazard ratio = 1.74; 95% confidence interval 1.18-2.56). Key conclusions: Part of the observed excess risk of death associated with the use of antipsychotic medications in older adults with cognitive impairment may be attributable to frailty. Caution is needed when prescribing antipsychotic medications to frail older adults.