Antipsychotics in Alzheimer's disease (original) (raw)
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Antipsychotics in Alzheimer's disease: A critical analysis
Dementia & Neuropsychologia, 2011
The estimated worldwide prevalence of dementia among adults older than 60 years of age was 3.9% in 2005. About 90% of demented patients will develop neuropsychiatric symptoms (NS) such as delirium, delusion, aggressiveness and agitation. The treatment of NS involves non-pharmacologic strategies (with varying degrees of success according to the scientific literature) and pharmacologic treatment (PT). The present review of literature examined the current role of AP in the management of NS in dementia. Methods: A thematic review of medical literature was carried out. Results: 313 articles were found, 39 of which were selected for critical analysis. Until 2005, the best evidence for PT had supported the use of selective serotonin re-uptake inhibitors (SSRIs), anticholinesterases, memantine and antipsychotics (AP). In 2005, the U.S. Food and Drug Administration (FDA) disapproved the use of atypical APs to treat neuropsychiatric symptoms in individuals with dementia (the same occurred wit...
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.
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.
The Canadian Journal of Psychiatry, 2016
Antipsychotics are necessary for many older adults to treat major mental illnesses or reduce distressing psychiatric symptoms. Current controversy exists over the role of antipsychotics in the management of neuropsychiatric symptoms (NPS) in persons with dementia. Although some NPS may be appropriately and safely treated with antipsychotics, a fine balance must be achieved between the benefits of these medications, which are often modest, and adverse events, which may have significant consequences. Approximately one-third of all persons with dementia are currently prescribed antipsychotic medications, and there is significant variation in the use of antipsychotics across care settings and providers. Reducing the inappropriate or unnecessary use of antipsychotics among persons with dementia has been the focus of increasing attention owing to better awareness of the potential problems associated with these medications. Several approaches can be used to curb the use of antipsychotics a...
Pharmacological Treatment of Neuropsychiatric Symptoms of Dementia: A Review of the Evidence
Journal of the American Medical Directors Association, 2006
This review concluded that of the drugs used for treating neuropsychiatric symptoms of dementia, risperidone and olanzapine had the best evidence for efficacy although their effect sizes were modest and they increased the risk of stroke. This conclusion appears reasonable. However, there was only a small evidence base for most of the drugs considered in the review. Authors' objectives To evaluate the efficacy of pharmacological agents used in the treatment of neuropsychiatric symptoms of dementia. Searching MEDLINE (from 1966 to July 2004) and the Cochrane Database of Systematic Reviews were searched for English language articles; the search terms were reported. The reference lists of relevant retrieved articles were also checked. Study selection Study designs of evaluations included in the review Double-blind, placebo-controlled, randomised controlled trials (RCTs) and meta-analyses of RCTs were eligible for inclusion. Specific interventions included in the review Any drug therapy for patients with dementia was eligible for inclusion providing it was available for use and used widely in the USA. The studies included in the review involved:
International Psychogeriatrics, 2014
The use of antipsychotics for the management of behavioral and psychiatric symptoms of dementia (BPSD) remains highly controversial. These drugs are well known to be associated with increased mortality from cerebrovascular events, as well as with falls, cognitive impairment, and other serious side effects. In 2009, a UK target was set to reduce their use in dementia patients by two-thirds over a three-year period (Banerjee, 2009).
Antipsychotic Agents in Patients with Dementia
Pharmacotherapy, 2000
We conducted a MEDLINE search to obtain data on various antipsychotics administered to patients with dementia and psychosis or behavioral symptoms. Additional unpublished data from conference proceedings and unpublished clinical trials were provided by Janssen Pharmaceutica, Eli Lilly and Company, and Zeneca Pharmaceuticals. All clinical trials that evaluated traditional typical or atypical antipsychotics in patients with dementia were reviewed for efficacy and safety data. Consensus guidelines published in 1994 or later were considered. After reviewing clinical trials and expert opinions, we devised an algorithm for optimal treatment of these patients. Although data are limited and do not conclusively show superiority of one agent over another, based on clinical experience and side effect profiles, risperidone is considered to be the drug of choice for treating patients with dementia and psychosis. Alternative treatment options in an algorithmic format also are recommended.
Management of Neuropsychiatric Symptoms in People with Dementia
CNS Drugs, 2010
Background. Alzheimer's disease (AD) is by far the most common type of dementia and it is commonly considered as a memory disorder although behavioral and psychological (including psychiatric) symptoms (BPSD) are largely represented in these patients. Psychosis could explain the worsening of the functional prognosis in these patients, therefore antipsychotic drugs are comonly prescribed. The risks associated with antipsychotics use limit their recommendation and antidepresants or NDMA (N-methyl-d-aspartate) antagonists could represent an alternative. Aims. The aim of this study was to evaluate changes in the clinical status of the psychomotor agitated patients with neurocognitive disorder on stable antidementia therapy after the addition of antidepressants or NMDA antagonists. Methods. The primary variables of this study are related to the severity of agitation under the action of pharmacological factors. Agitation as part of the BPSD was evaluated by CMAI (Cohen-Mansfield Agitation Inventory)-short version. A total of 37 subjects (24 female, 14 male) participated in this observational study. They received as add-on antidepressants between weeks 1-8 or NMDA antagonists between weeks 8-16. Inclusion criteria were DSM IV-TR criteria for diagnosing dementia, AD and vascular dementia (VD) and also NINDS-ADRDA clinical criteria. Data analysis was achieved through SPSS software, version 20, using ANOVA-paired t-tests and independent t tests. Results. The efficacy of memantine over general agitation was significantly superior to antidepressants. Regarding the modulation of the CMAI scores evolution by the type of neurocognitive disorder, treatment and duration, it was observed that the statistical difference between groups became significant after 8-16 weeks of memantine treatment. At the endpoint visit the decrease in agitation was superior in the AD versus VD group (p = 0.012). Conclusions. The overall trend was toward a decrease of the agitation severity after each treatment trial for both types of dementia, including cumulative drugs effects. In the literature, the data are controversial in terms of prescribing antidepressants in the neurocognitive disorders even when BPSD is important, the keystone being the general consensus of limiting the use of antipsychotics and polypharmacy.
Rethinking antipsychotic use in dementia: a literature review on efficacy, safety, and alternatives
2024
Background an objectives. Dementia and its associated behavioral and psychological symptoms (BPSD) significantly impact patients' quality of life, healthcare systems, and caregivers. Current treatments often include antipsychotic medications; however, their efficacy and safety profiles require careful evaluation. This review aimed to examine the use of antipsychotics in dementia, focusing on their role, efficacy, adverse effects, and clinical monitoring guidelines. Materials and methods. We conducted a thorough literature review in PubMed and Medline databases, using search terms like "dementia", "BPSD", "antipsychotics", "adverse effects", and "clinical guidelines". Our analysis encompassed a range of research studies, including meta-analyses, randomized controlled trials, observational studies, and clinical practice guidelines. Results. While antipsychotics can be effective in managing severe BPSD symptoms like agitation and psychosis, their use carries an increased risk of mortality, stroke, and other adverse effects. Therefore, strict adherence to clinical guidelines and close monitoring are crucial to minimize these risks. Importantly, nonpharmacological interventions should always be the first-line treatment for BPSD whenever possible. Conclusions. Antipsychotics may be necessary for severe BPSD when nonpharmacological approaches are insufficient. Clinicians must carefully weigh the potential benefits against significant risks, utilizing the lowest effective doses, strict monitoring protocols, and considering alternative pharmacological options when possible. Unveiling safer and more specific BPSD treatments is a critical area for continued research.