Pharmacologic Treatment of Behavioral and Psychological Symptoms of Dementia in Nursing Homes: Update of the 2008 JAMDA Recommendations (original) (raw)
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Role of antipsychotics for treating behavioral and psychological symptoms of dementia
World Journal of Pharmacology, 2014
Over the past three decades, concerns about the high prevalence of antipsychotic use in the nursing homes (NHs) for the management of behavioral and psychological symptoms of dementia continue to be emphasized and intervened by many. However, despite the numerous side effects and the recent blackbox warning by the United States Food and Drug Administration about the increased risks for stroke and sudden death associated with the use of antipsychotics in dementia, the prevalence of antipsychotic use in NHs remains high. While the use of antipsychotics appeared to have modest efficacy in reducing symptoms of aggression and psychosis in dementia, there is insufficient evidence to routinely recommend the use of alternative psychopharmacological treatments for these symptoms. Hence, clinicians have to balance the safety warnings against the need to treat these symptoms in order to prevent harm to the resident that may result from his/her dangerous behaviors. Although the use of antipsychotics may be warranted in some cases, organizational, resource and training support should be provided to encourage and equip NH staff to participate in interventions so as to minimize inappropriate use of these medicines in NHs. This review will discuss the place in therapy, the trend and appropriateness of antipsychotic use in NHs, as well as the effectiveness of current and future strategies for reducing antipsychotic use in the NHs.
ACNP White Paper: Update on Use of Antipsychotic Drugs in Elderly Persons with Dementia
Neuropsychopharmacology, 2008
In elderly persons, antipsychotic drugs are clinically prescribed off-label for a number of disorders outside of their Food and Drug Administration (FDA)-approved indications (schizophrenia and bipolar disorder). The largest number of antipsychotic prescriptions in older adults is for behavioral disturbances associated with dementia. In April 2005, the FDA, based on a metaanalysis of 17 double-blind randomized placebo-controlled trials among elderly people with dementia, determined that atypical antipsychotics were associated with a significantly (1.6−1.7 times) greater mortality risk compared with placebo, and asked that drug manufacturers add a 'black box' warning to prescribing information for these drugs. Most deaths were due to either cardiac or infectious causes, the two most common immediate causes of death in dementia in general. Clinicians, patients, and caregivers are left with unclear choices of treatment for dementia patients with psychosis and/or severe agitation. Not only are psychosis and agitation common in persons with dementia but they also frequently cause considerable caregiver distress and hasten institutionalization of patients. At the same time, there is a paucity of evidence-based treatment alternatives to antipsychotics for this population. Thus, there is insufficient evidence to suggest that psychotropics other than antipsychotics represent an overall effective and safe, let alone better, treatment choice for psychosis or agitation in dementia; currently no such treatment has been approved by the FDA for these symptoms. Similarly, the data on the efficacy of specific psychosocial treatments in patients with dementia are limited and inconclusive. The goal of this White Paper is to review relevant issues and make clinical and research recommendations regarding the treatment of elderly dementia patients with psychosis and/or agitation. The role of shared decision making and caution in using pharmacotherapy for these patients is stressed.
Pharmacological management of behavioural and psychological disturbance in dementia
Human Psychopharmacology: Clinical and Experimental, 2006
Behavioural and psychological symptoms in patients with dementia are common, distressing and often difficult to manage. This review evaluates a range of drugs commonly used to manage these symptoms including antipsychotics, anticonvulsants, antidementia drugs and antidepressants.
management of the behavioural and psychological symptoms of dementia
More than 50% of people with dementia experience behavioral and psychological symptoms of dementia (BPSD). BPSD are distressing for patients and their caregivers, and are often the reason for placement into residential care. The development of BPSD is associated with a more rapid rate of cognitive decline, greater impairment in activities of daily living, and diminished quality of life (QOL). Evaluation of BPSD includes a thorough diagnostic investigation, consideration of the etiology of the dementia, and the exclusion of other causes, such as drug-induced delirium, pain, or infection. Care of patients with BPSD involves psychosocial treatments for both the patient and family. BPSD may respond to those environmental and psychosocial interventions, however, drug therapy is often required for more severe presentations. There are multiple classes of drugs used for BPSD, including antipsychotics, anticonvulsants, antidepressants, anxiolytics, cholinesterase inhibitors and NMDA modulators, but the evidence base for pharmacological management is poor, there is no clear standard of care, and treatment is often based on local pharmacotherapy customs. Clinicians should discuss the potential risks and benefi ts of treatment with patients and their surrogate decision makers, and must ensure a balance between side effects and tolerability compared with clinical benefi t and QOL.
Journal of the American Geriatrics Society, 2014
Non-cognitive neuropsychiatric symptoms (NPS) of dementia include aggression, agitation, depression, anxiety, delusions, hallucinations, apathy, and disinhibition. These affect dementia patients nearly universally across dementia stages and etiologies. NPS are associated with poor patient and caregiver outcomes including excess morbidity and mortality, increased health care utilization, and earlier nursing home placement, as well as caregiver stress, depression and reduced employment. While there is no FDA-approved pharmacotherapy for NPS, psychotropic medications are frequently used to manage these symptoms. However, in the few cases of proven pharmacologic efficacy, benefit may be off set by significant risk of adverse effects. Nonpharmacologic treatments, typically considered first-line, also show evidence for efficacy as well as a limited potential for adverse effects. However, their uptake as preferred treatments remains
The treatment of behavioral disturbances and psychosis associated with dementia
Psychiatria Polska, 2016
Behavioral disturbances and psychosis associated with dementia are becoming an increasingly common cause of morbidity in patients with dementia. Approximately 70% of individuals with dementia will experience agitation, and 75% will experience symptoms of psychosis such as delusions or hallucinations. The goal of this article is to review the pharmacologic treatment options for behavioral disturbances and psychosis associated with dementia. A literature review was conducted on PubMed/Medline using key words of “dementia” and “interventions.” The results were filtered for meta-analysis, clinical trials, and systematic reviews. The results were then reviewed. At this time, the most evidence exists for the use of a second generation antipsychotics (SGAs), but consideration should be given to their collective boxed warning of morbidity/mortality. The evidence for second line treatments are limited. There is limited evidence to support the use of first generation antipsychotics (FGAs), an...
Neuropsychiatric symptoms in dementia: Importance and treatment considerations
International Review of Psychiatry, 2008
Neuropsychiatric symptoms are frequent in people with dementia, result in distress for the people experiencing them and their caregivers, and are a common precipitant of institutional care. The safe and effective treatment of these symptoms is a key clinical priority, but is a long way from being achieved. Psychological interventions are recommended as the first line treatment strategy in most good practice guidelines, and there is emerging evidence of efficacy for agitation and depression. Neuroleptics remain the mainstay of pharmacological treatment, although meta-analyses indicate that they are mainly of benefit for the short-term (up to 12 weeks) treatment of aggression in people with Alzheimer's disease, and there have been increasing concerns about serious adverse effects including mortality. The evidence is limited for other pharmacological approaches for the treatment of agitation, and psychosis in people with Alzheimer's disease is limited, but post-hoc analyses do indicate that memantine may be a promising therapy and aromatherapy may be a useful alternative. Autopsy studies indicate that the adrenergic system may be an important therapeutic target. Clinical experience suggests that antidepressants are effective in people with severe depression in the context of dementia, but the evidence base regarding the broader value of antidepressants is far from clear. There are very few trials specifically focusing upon the treatment of neuropsychiatric symptoms in common non-Alzheimer dementias, which is a major limitation and urgently needs to be addressed to provide an evidence base to enable the safe and effective treatment of these individuals.
Ageing Research Reviews, 2012
Please cite this article in press as: Azermai, M., et al., Systematic appraisal of dementia guidelines for the management of behavioural and psychological symptoms. Ageing Res. Rev. (2011), Available online xxx Keywords: Behavioural and psychological symptoms of dementia Antipsychotics Clinical practice guidelines a b s t r a c t Background: Within the treatment of dementia, management of behavioural and psychological symptoms (BPSD) is a complex component.
Neuropsychiatric symptoms are frequent in people with dementia, result in distress for the people experiencing them and their caregivers, and are a common precipitant of institutional care. The safe and effective treatment of these symptoms is a key clinical priority, but is a long way from being achieved. Psychological interventions are recommended as the first line treatment strategy in most good practice guidelines, and there is emerging evidence of efficacy for agitation and depression. Neuroleptics remain the mainstay of pharmacological treatment, although meta-analyses indicate that they are mainly of benefit for the short-term (up to 12 weeks) treatment of aggression in people with Alzheimer's disease, and there have been increasing concerns about serious adverse effects including mortality. The evidence is limited for other pharmacological approaches for the treatment of agitation, and psychosis in people with Alzheimer's disease is limited, but post-hoc analyses do indicate that memantine may be a promising therapy and aromatherapy may be a useful alternative. Autopsy studies indicate that the adrenergic system may be an important therapeutic target. Clinical experience suggests that antidepressants are effective in people with severe depression in the context of dementia, but the evidence base regarding the broader value of antidepressants is far from clear. There are very few trials specifically focusing upon the treatment of neuropsychiatric symptoms in common non-Alzheimer dementias, which is a major limitation and urgently needs to be addressed to provide an evidence base to enable the safe and effective treatment of these individuals.