Mirtazapine And Olanzapine Use - Peripheral Edema?

Does anyone have personal experience of this problem? A 79-year-old friend with vascular dementia has been prescribed a whole series of atypical antipsychotic drugs over the past eight months, all with varying disastrous results. And yes - I know this is an off-label use of this group but they still get prescribed for dementia sufferers all over the western world.

She's been on mirtazapine 20mg once daily for about five years (with no apparent ill effects) and olanzapine 10 mg once a day for three months. Two months ago she very rapidly - over a few days - developed massive swelling of her left hand, with complete loss of use of the middle, ring and little fingers of that hand. An X-ray was inconclusive, mainly as she couldn't straighten the three affected fingers, and her doctor has been mystified by this ever since. He finally decided it was arthritis but it didn't look much like it to me, given the degree of swelling and deformity, and the speed with which it had come on. Anti-inflammatory drugs have been prescribed, but with minimal effect.

I visit her in her high-security psycho-geriatric unit at least three times a week. Last Tuesday (six days ago) she was still feeding herself perfectly normally with her right hand, once her food had been cut up for her. Three days later, she could no longer hold a spoon, fork or cup. Her right hand isn't swollen but I can clearly see the identical deformity in her last three fingers as in her left hand. All three fingers on both hands are curled up and twisted over each other.

After raising Cain at the home, I've managed to get her an emergency appointment at a rheumatology clinic tomorrow. In preparation for this, I've been doing some research over the weekend (and no, not on Wikipedia) and have discovered peripheral oedema (swelling) is a rare, but known, side-effect of olanzapine. I also found a long paper that had clearly been published in a learned journal on the subject of peripheral oedema with combined mirtazapine and olanzapine use. Unfortunately, it was in Turkish!

Has anyone suffered from this and how quickly did it improve once the olanzapine dosage was reduced? Also, how serious is the rebound psychosis when olanzapine is withdrawn?

She was originally on risperidone, but when that had to be tailed off because it left her with severe Parkinson-like symptoms, it left her way more psychotic than she'd been at the outset, with the result she stabbed another resident in the lovely retirement home she was living in. She's stayed that way ever since, hence the transfer to a grim high-security psychiatric unit, where she'll end her days. She was subsequently put on clozapine for a couple of months, which caused terrible athetotic movements - constant bobbing, weaving movements of head, jaw, tongue, arms and upper trunk - which made her life unbearable. I have to say, however, that when that was gradually withdrawn, I didn't notice any rebound psychosis.

I'm furious with myself for not researching this sooner, as I'm a former nurse, though neuro was my speciality. I'm even more furious with her idiot doctor for prescribing a med that isn't authorised for dementia, then failing to notice she was suffering from a known side-effect. Ditto the nursing staff at the home. When I mentioned this to the head nurse today, she blithely said she'd known all along it was a side-effect of olanzapine - though I suspect she was just covering up her ignorance.

My friend is beside herself, and it breaks my heart to see her like this. She knows there's something wrong, but doesn't understand what it is. She can't feed herself at all now. I tried her with a biscuit this afternoon and she couldn't even hold that. She's already dangerously underweight (BMI 17) and now she's refusing to let the staff feed her, as she's not used to that. I'm the only one who's allowed to feed her, albeit only a few mouthfuls, but I'm 71 myself and can't continue going in twice a day. In the meantime she's screaming and shouting all day and all night in anguish and sheer terror, and attacking everyone who goes near her. She tried to bite my face today.

Sometimes patients who've been on this class of drugs for long periods know much more about them than the professionals, which is why I'm posting here. Is this terrible condition likely to be a result of olanzapine (and possibly mirtazapine)? And can we expect severe rebound psychosis if her doctor tails it off? (Always assuming he even agrees to do that.) Also, does anyone have any experience of other recently-developed anti-psychotics that don't cause appalling side-effects of one kind or another? Though I have to say, from my own nursing experience, that I suspect there's no such animal.