Use of Antipsychotics for the Treatment of Behavioral Symptoms of Dementia

Abstract

Antipsychotic medications are widely used in the management of behavioral and psychological symptoms of dementia. While nonpharmacological interventions should be the first-line treatment for behavioral symptoms of dementia, these are often unfeasible and/or ineffective. Conventional and atypical antipsychotic agents appear to have modest to moderate clinical efficacy in the treatment of these symptoms, though it is unclear which individual agents are most effective. No conclusive evidence exists that any available alternative medications are safer and more effective than antipsychotics. A number of studies have shown an increased risk of mortality associated with antipsychotics in patients with behavioral symptoms of dementia, though the observed risk increase may be partially confounded by illness severity and/or preexisting health determinants. The mechanisms of increased mortality risk are not fully established, but are likely to involve cardiovascular events. It is probable, though not certain, that conventional antipsychotics are associated with a greater number of poor outcomes than atypical antipsychotics. In certain patients with refractory behavioral symptoms, antipsychotics are a viable treatment option. Key considerations for antipsychotic prescribing for this population are published in regulatory guidelines, and include minimization of dosage and duration of treatment, continuous reevaluation of symptoms, and involvement of caregivers.

Safety, tolerability, and risks associated with first- and second-generation antipsychotics: a state-of-the-art clinical review

“…More recently, the use of atypical or second-generation antipsychotics (SGAs) has been extended to cover a wide range of psychiatric conditions besides schizophrenia and schizoaffective disorders. They have become especially popular as add-on treatment for patients with MDD who fail to adequately respond to antidepressants,15 for BD,16–18 and for behavioral symptoms associated with dementia 19,20. In addition, systematic evidence and meta-analysis indicate that SGAs are frequently used for several off-label indications;21,22 they have been advocated as “multidimensional” agents 23…”

Amisulpride in Refractory Behavioral and Psychological Symptoms of Dementia

“…Agitated Behavior Scale (ABS) [18], was used for categorization of BPSD as per ABS scores and patients were classified as mild (22)(23)(24)(25)(26)(27)(28), moderate (29)(30)(31)(32)(33)(34)(35)) and severe (>36). Agitated behavior scale (ABS) score > 22 meant absence of clinically significant agitation.…”

“…One important reason of their widespread use is their better efficacy compared to nonpharmacological methods [26]. No conclusive evidence exists to show that antipsychotics have an alternative in terms of their safety for BPSD [26].…”

“…Though antipsychotics are effective for large number of patients with BPSD; still a large number does not respond to the available drugs [26], (refractory BPSD) and hence there is a need of an antipsychotic drug for these patients. Amisulpride was chosen for this study due to its efficacy, safety and the ease of administration.…”

The Ongoing Dilemma on the Use of Antipsychotics to Manage the Behavioral Symptoms of Dementia

“…We still have inconclusive answers for most of the original questions. However, progress has been made to provide some guidance to practitioners in which a step approach can be used to manage dementia patients, as described in the "Clinical Considerations" section of the review, which is based on the recommendations set forth by the Centers for Medicare and Medicaid Services (1). The "Dementia Care Principles" described in Table 2 in Greenblatt and Greenblatt, 1 are a good starting point for nursing homes on what they should be striving to achieve for their dementia patients.…”