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Antipsychotics in dementia: Best Practice Guide

 Introduction, Rationale and Key Points 
 Behavioural and Psychological Symptoms of Dementia (BPSD) 
 Assessment of patients with BPSD 
 Non-pharmacological treatment of BPSD 
 Pharmacological treatment of BPSD 
 Adverse effects of antipsychotics 
 Dementia with Lewy Bodies (DLB) 
 Other medicines for BPSD 
 Treatment of comorbid conditions in patients with dementia 
 References 
 Appendix 
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Introduction

This Best Practice Guide focuses on the rational and safe use of antipsychotics in people with dementia. Their place in therapy for symptoms associated with dementia is very limited and use is short-term for most people.

The focus of this guide is on the treatment of behavioural and psychological symptoms of dementia (BPSD). These prescribing principles are common to all indications for the use of antipsychotics.

This guide is intended as a resource for all those involved in the care of patients with dementia. It reflects the important culture of shared care and decision making involving doctors, nurses, pharmacists, caregivers, relatives and the patient.

Rationale for this guide

This guide has been produced in response to increasing concerns about the safety and, at times, inappropriate use of antipsychotics in people in residential care facilities, particularly for symptoms associated with dementia.

Traditionally, the medicines most often used for these indications were the older or conventional (“typical”) antipsychotics such as haloperidol, chlorpromazine and thioridazine. In the 1990s the newer, atypical antipsychotics (e.g. risperidone, olanzapine) were introduced. These became widely prescribed because they were considered less likely to cause adverse reactions resembling symptoms of Parkinson’s disease (extrapyramidal effects). Research reports indicate that atypical antipsychotics are effective for some of the BPSD but that they are also associated with some potentially serious adverse outcomes.

In 2004 the UK Committee on the Safety of Medicines issued a warning that atypical antipsychotics were associated with an increased risk of stroke in people with dementia and advised against their use in that setting. In 2005 the US Food and Drug Administration warned of an increased risk of death in people with dementia treated with atypical antipsychotics. However, subsequent research has indicated that for people with dementia, typical antipsychotics may be at least as strongly associated with these adverse events as atypical antipsychotics.

It is now generally accepted that all antipsychotics, whether typical or atypical, are associated with increased morbidity and mortality in people with dementia. Two recent international communications, an All Party Parliamentary Report from the UK1 and a directive from the Food and Drug Administration in the USA2 have corroborated the need to review prescribing practices for these medicines. Both reports emphasise the limited value of antipsychotics for BPSD and the requirement for a careful benefit:risk analysis before prescribing.

In addition to safety issues there are significant concerns in society, shared by some doctors and organisations such as Alzheimer’s disease associations, that antipsychotics and similar medications are being over-prescribed to people with dementia as an inappropriate first-line means of achieving behavioural control.

Summary
  • Most BPSD are transient and respond to non-pharmacological treatment which should be trialled before drug treatment is considered
  • Antipsychotics are not effective in treating most BPSD and they are reserved for specific indications after careful consideration of the risks and benefits of treatment.
  • Antipsychotics are only indicated as a “last resort” if aggression, agitation or psychotic symptoms cause severe distress or an immediate risk of harm to the patient or others. Even for these indications they are only moderately effective.
  • All antipsychotics are associated with increased morbidity and mortality in people with dementia. During treatment closely monitor all patients for adverse effects.
  • Antipsychotics should only be prescribed for specific problem behaviours and the response to treatment should be closely monitored. If treatment is ineffective the antipsychotic should be withdrawn.

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