Use and Safety of Antipsychotics in Behavioral Disorders in Elderly People With Dementia

Abstract

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. Conventional antipsychotics have been widely used for BPSD; some studies showed they have an efficacy superior to placebo only at high doses, but they are associated with several and severe adverse effects. Atypical antipsychotics showed an efficacy superior to placebo in randomized studies in BPSD treatment, with a better tolerability profile versus conventional drugs. However, in 2002, trials with risperidone and olanzapine in elderly patients affected with dementia-related psychoses suggested the possible increase in cerebrovascular adverse events. Drug regulatory agencies issued specific recommendations for underlining that treatment of BPSD with atypical antipsychotics is "off-label." Conventional antipsychotics showed the same likelihood to increase the risk of death in the elderly as atypical agents, and they should not replace the atypical agents discontinued by Food and Drug Administration warnings. Before prescribing an antipsychotic drug, the following are factors to be seriously considered: the presence of cardiovascular diseases, QTc interval on electrocardiogram, electrolytic imbalances, familiar history for torsades des pointes, concomitant treatments, and use of drugs able to lengthen QTc. Use of antipsychotics in dementia needs a careful case-by-case assessment, together with the possible drug-drug, drug-disease, and drug-food interactions.

Quantifying the Role of Adverse Events in the Mortality Difference between First and Second-Generation Antipsychotics in Older Adults: Systematic Review and Meta-Synthesis

“…On the one hand, the large degree of unexplained mortality in either situation might demand investigation of other unsuspected adverse events. For instance, drug-drug interactions with antipsychotics may occur in the elderly whose age-related changes in drug metabolism and clearance may be exacerbated by complex medication regimens for comorbid conditions [70]. On the other hand, our inability to explain the mortality difference despite considering many known risks is also consistent with hypotheses of residual and unmeasured differences between patients who receive FGAs versus SGAs.…”

Effects of Aripiprazole on the QTc: A Case Report

“…The only other known risk factors for QTc prolongation were being elderly and female and, potentially, receiving fluoxetine, which had not shown that effect in this patient previously. 2 Ms A's serum potassium and magnesium levels were both within normal limits. Manual QTc measurements were done with lead V5 using the tangential method with heart rate correction using the Bazett formula.…”

“…Concurrently, risk for iatrogenic corrected QT (QTc) prolongation on electrocardiogram (ECG) remains a concern with the use of many antipsychotic agents because of its associated potential for fatal arrhythmias. 2 Many elderly patients require antipsychotic pharmacotherapy yet incur risks from inherent cardiac disease, begging the question: How does one treat a psychotic or delirious patient with a prolonged QTc? The following case illustrates experience at our institution with safe reinitiation of aripiprazole after myocardial infarctionrelated QTC prolongation in an older adult with chronic psychosis.…”

Delirium: actualización en manejo no farmacológico

“…En psicogeriatría, estos fármacos se usan siempre en la dosis más baja posible, evaluan-do diariamente su real necesidad, ya que su uso prolongado puede incrementar el riesgo de muerte y de eventos cardiovasculares en pacientes con demencia 17 . Por este motivo, previo al uso de antipsicóticos se recomienda evaluar la presencia de enfermedades cardiovasculares, intervalo QT en el ECG, alteraciones hidroelectrolíticas, antecedente familiar de torsades de pointes y uso concomitante de fármacos que podrían prolongar el QT 18 .…”