Dosage and duration of antipsychotic treatment in demented outpatients with agitation or psychosis (original) (raw)
Related papers
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.
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 Additional unpublished data from conference proceedings and unpublished clinical trials were provided by Janssen Pharmaceutica, Eli Lilly and Company, and Zeneca Pharmaceuticals.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.
Use and safety of antipsychotics in behavioral disorders in elderly people with dementia
Journal of Clinical Psychopharmacology, 2014
In recent years, the use of antipsychotics has been widely debated for reasons concerning their safety in elderly patients affected with dementia. To update the use of antipsychotics in elderly demented people, a MEDLINE search was conducted using the following terms: elderly, conventional and atypical antipsychotics, adverse events, dementia, and behavioral and psychotic symptoms in dementia (BPSD). Owing to the large amounts of studies on antipsychotics, we mostly restricted the field of research to the last 10 years.
Pharmacological Treatment of Psychosis and Agitation in Elderly Patients with Dementia
Drugs & Aging, 2002
A number of studies, using different research designs and assessment instruments, have been conducted to elucidate the differential effects of drug treatments for psychosis, agitation and aggression in elderly patients with dementia. We have reviewed literature published from 1960 to 2000 on this topic; 48 studies that met our selection criteria were identified from Medline and Science Citation Index. Antipsychotic medication was generally effective for the treatment of psychosis and agitation in elderly patients with dementia. In double-blind, placebocontrolled trials in this population, mean improvement rates were 61% with antipsychotics and 35% with placebo. Atypical antipsychotics appeared promising, but the number of well-designed studies has been small so far. Methodological limitations of the studies reviewed are discussed; future trials should ensure adequate sample size and duration and involve direct comparisons of individual medications.
BULLETIN OF INTEGRATIVE PSYCHIATRY, 2020
Antipsychotic treatment is widely used for treating aggression/agitation and psychosis in the elderly population. The doses used are lower, administering medication is done over a prolonged time period, tests done and clinical observation is more frequent compared to the non-geriatric population. The objective of this case-series was to present a particularity encountered in the use of antipsychotics. Three patients suffered from increased aggression and agitation during treatment with antipsychotics. After medication administration was ceased the symptomatology remitted. Tests used for this study included Mini-Mental State Exam (MMSE), Neuropsychiatric Inventory Nursing Home Version (NPI-NH). We found that the elevation of the NPI-NH score was significant with increased dosage, thus after reaching the maximum allowed doses for patients with dementia, the decision was made to stop the antipsychotic and change to another agent (antipsychotic or anticonvulsant). These results suggest that more studies should focus on fast management of the antipsychotics' side effects, and the dynamics between symptom development and treatment decisions. The delay between the start of medication and the decision to switch could have a negative impact for the patients. Future treatment algorithms should take into consideration the possibility of worsening the symptoms and more in-depth studies should be conducted to widen the picture of antipsychotic treatment in the geriatric population, especially for patients with severe dementia. 120/Bulletin of Integrative Psychiatry New Series June 2020 Year XXVI No. 2 (85)
Risk of Mortality Among Individual Antipsychotics in Patients With Dementia
American Journal of Psychiatry, 2012
Objective: The use of anti psychotics to treat the behavioral symptoms of de mentia is associated with greater mortal ity. The authors examined the mortality risk of individual agents to augment the limited information on individual antipsy chotic risk. Method: The authors conducted a ret rospective cohort study using national data from the U.S. Department of Veter ans Affairs (fiscal years 1999-200S) for dementia patients age 65 and older who began outpatient treatment with an an tipsychotic (risperidone, olanzapine, que tiapine, or haloperidol) or valproic acid and its derivatives (as a nonantipsychotic comparison). The total sample included 33,604 patients, and individual drug groups were compared for 1S0-day mor tality rates. The authors analyzed the data using multivariate models and propensity adjustments. This article is featured in this month's AJP Audio, is discussed in an Editorial by Drs. Corbett and Ballard (p. 7), and is an article that provides Clinical Guidance (p. 79)
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.
Antipsychotics and Mortality in Dementia
American Journal of Psychiatry, 2012
A n tip sy c h o tic s a n d M o rta lity in D e m e n tia Dement ia represents a significant clinical challenge, with an estimated 35.6 million people with dementia in the world, of whom 4.38 million reside in the United States (1, 2). Ninety percent of people with dementia experience behavioral and psychological symptoms of dementia at some point during their illness. Behavioral and psychological symptoms of dementia commonly manifest as agitation, aggression, depression, or psychosis (hallucinations and delusions), which can cause significant distress to the person and their caregiver as well as have a direct effect on the person's quality of life and likelihood of institutionalization. Although the majority of best practice guidelines emphasize the importance of nonpharmacological treatments and judicious shortterm use of pharmacological treatment for behavioral and psychological symptoms of dementia, antipsychotic drugs are commonly used as a first-line approach for managing these symptoms. It is therefore a critical issue to understand the clinical efficacy and safety profile of individual antipsychotics to inform guidance on prescribing practice and choice of antipsychotic medication in situations where a prescription is deemed necessary. In this issue of the Journal, the cohort study conducted by Kales et al. (3) provides extremely valuable new knowledge pertinent to these key treatment decisions. A substantial number of trials have focused on the effectiveness of atypical antipsychotics for the treatment of behavioral and psychological symptoms of dementia. In total, 18 placebo-controlled randomized controlled trials conducted over a 6-to 12-week period have been undertaken in people with Alzheimer's disease. The best evidence of efficacy for the treatment of agitation, aggression, and psychosis relates to risperidone. Five trials have indicated a modest but significant improvement in aggression and psychosis, equating to a small treatment effect size (Cohen's d=0.2 at the optimal dose) (4, 5). However, this must be considered in the context of the widely reported side effects of atypical antipsychotics, which include extrapyramidal symptoms, sedation, gait disturbances, and falls. Many agents also lead to anticholinergic side effects, including delirium (4). Tardive dyskinesia with atypical antipsychotics appears to occur less frequently than with typical antipsychotics, but QTc prolongation has been reported as a significant problem associated with several atypical antipsychotics. A meta-analysis also identified a significant increase in respiratory and urinary tract infections as well as peripheral edema in people treated with risperidone, compared with placebo (4). These are likely to be class effects of atypical antipsychotics. It has also become clear that other, more serious adverse outcomes, such as stroke and related cerebrovascular events, accelerated cognitive decline, and death, are significantly increased in people with dementia who are prescribed antipsychotics, compared with people with dementia not treated with these agents. Deaths related to bronchopneumonia, thrombo-embolic events (including stroke and pulmonary embolism), and sudden cardiac arrhythmias are all significantly increased in people with dementia receiving antipsychotic treatment (6). The most significant clinical issue has been the increased mortality associated with antipsychotic use among people with dementia. An initial meta-analysis completed Key questions for clinical practice include whether there are differences in mortality risk between different antipsychotics.