How to prescribe antispychotics in dementia? American Journal Psychiatry, Sep, 2012


Neuropsychiatric symptoms  (agitation , delusions, aggression  etc) are common  in elderly patients with dementia and often cause much distress. Atypical antipsychotics, though effective ,increase physical morbidity and mortality . 1.5-fold to 1.7-fold greater risk of mortality with the use of atypical antipsychotics in dementia is noted. No atypical antipsychotic has been approved by the FDA for the treatment of any neuropsychiatric symptoms in dementia.Safety of typical antipsychotics is also not established.Evidence for the benefits of psychosocial and behavioral interventions as alternatives is inconclusive

Problems associated with atypical antipsychotics in this group: 1.two- to threefold higher risk of cerebrovascular events 2.adverse cardiovascular effects 3. metabolic effects 4.  extrapyramidal symptoms 5. cognitive worsening, 6. infections 7.  falls.

Authors suggest a very careful evaluation of the symptoms and the need for medications given the risks attached to the treatment.
General outline of recommendations:

1. Avoid antipsychotics unless nonpharmacological options have failed and  patient is a threat to self or others.

2. Nonpharmacological strategies (e.g., reassurance, redirection, increased structure, and activities) should be attempted first.  (see review  Teri and Logsdon 2000,  and by Cohen-Mansfield 2001)

3. Look for contributing environmental or caregiver factors and address them.

4. Medical comorbidity: Pain and infection  are common causes. Delirium due to polypharmacy, especially psychotropic polypharmacy, is a common hazard in the elderly presenting as behavioural problems.

5. If considering antipsychotics,  risks, benefits, and alternatives should be discussed with caregivers.

6. prescribe only  if  you spot identifiable risk of harm to the patient or others , or when  symptoms are causing significant distress, and  the  nonpharmacological interventions have been unsuccessful

7. Dosages should be the lowest necessary.Common target daily dose ranges in dementia are 0.25–1 mg of risperidone, 2.5–7.5 mg of olanzapine, 12.5–150 mg of quetiapine, and 5–10 mg of aripiprazole.

8. Monitoring of all metabolic parameters is advisable.

9. if  patient achieves remission for 3–6 months, a discontinuation trial should be considered

10. Always review the medication need closely. In the Dementia Antipsychotic Withdrawal Trial–Alzheimer’s Disease study  (Ballard et al 2008), among participants with Alzheimer’s disease who were treated with an antipsychotic for at least 3 months, no significant difference in neuropsychiatric symptoms at 6 months was found between those who continued treatment and the placebo group. This finding, coupled with the evidence of reduced survival in Alzheimer’s patients treated with antipsychotics for 12 months ( Kales et al 2007), highlights the need for frequent evaluation of continued need for treatment

Atypical antipsychotic use in patients with dementia: managing safety concerns.

Steinberg M, Lyketsos CG. Am J Psychiatry. 2012 Sep 1;169(9):900-6.

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