247 Antipsychotic Medication in the Management of Non-cognitive Symptoms of Dementia: An Updated Evidence Review

Abstract Background Antipsychotic medications are commonly used in the management of non-cognitive symptoms of dementia (also termed behavioural and psychological symptoms of dementia), such as agitation, calling out, hoarding, or aggression. This is despite increased recognition of adverse effects, including mortality, from these medications for people with dementia. The current aim was to review the most recent evidence for the efficacy and safety of antipsychotic medications in the management of non-cognitive symptoms in dementia. Methods Relevant studies published in English from March 2015 through to March 2018 were identified by searches of 5 databases: Medline, EBSCO, PsycINFO, Cochrane DARE, and Cochrane CENTRAL. Systematic reviews, meta-analyses, and controlled trials evaluating the safety of antipsychotic medication, or comparing the effectiveness of antipsychotic medication with placebo, another antipsychotic medication, or non-pharmacological intervention, were included. Independent article review and data extraction was performed by two reviewers. Study quality was appraised using the Joanna Briggs Institute critical appraisal tools. Results Thirteen studies were included. Benefits and harms vary among antipsychotic medications for people with dementia, however overall efficacy of antipsychotics remains modest at best. A significant number of side effects are associated with antipsychotics, not least cerebrovascular events, sedation, gait disturbances, falls, fractures, urinary tract infections, cognitive worsening, and mortality. Atypical antipsychotics have a more favourable safety profile in some respects. People with certain dementias, notably Lewy Body Dementia, may experience more severe side-effects. Conclusion The evidence reinforces caution when prescribing antipsychotic medications for people with dementia; these medications should only be considered when symptoms are severe or non-pharmacological interventions have failed. Clinicians should closely monitor people with dementia who are prescribed an antipsychotic for side effects, limiting use of these medications to short-term treatment if possible. The forthcoming national clinical guideline for appropriate prescribing of psychotropic medications for non-cognitive symptoms will support clinical decision-making in this regard.

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Depot risperidone in elderly patients: the experience of an Australian aged psychiatry service

International Psychogeriatrics ◽

10.1017/s1041610207005686 ◽

2007 ◽

Vol 19 (4) ◽

pp. 789-792 ◽

Cited By ~ 3

Author(s):

DHIREN SINGH ◽

DANIEL W. O'CONNOR

Keyword(s):

Side Effects ◽

Elderly Patients ◽

Lower Incidence ◽

Maintenance Treatment ◽

Atypical Antipsychotics ◽

Cognitive Symptoms ◽

Antipsychotic Medications ◽

Cardiac Side Effects

Antipsychotic medications form the mainstay of both the acute and maintenance treatment of schizophrenia. In recent years, atypical antipsychotics like risperidone, olanzapine and clozapine have come to be preferred because of their lower incidence of extra-pyramidal, anti-cholinergic and cardiac side-effects and a possible greater efficacy in reducing negative and neuro-cognitive symptoms (Ritchie et al., 2006).

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Efficacy of pharmacological treatment of dementia

Brazilian Journal of Psychiatry ◽

10.1590/s1516-44462002000500004 ◽

2002 ◽

Vol 24 (suppl 1) ◽

pp. 11-14

Author(s):

Leon Flicker

Keyword(s):

Side Effects ◽

High Risk ◽

Cholinesterase Inhibitor ◽

Cholinesterase Inhibitors ◽

Therapeutic Agents ◽

Therapeutic Trial ◽

Cognitive Symptoms ◽

Considerable Evidence ◽

People With Dementia ◽

Functional Symptoms

Over the last 25 years an increasing number of studies have been performed to evaluate therapeutic agents for people with dementia. Although numerous agents have been trialed at this stage there little evidence that therapeutic agents can prevent dementia or ameliorate the progression of dementia of any type. There is some evidence that specific medical management in high risk individuals can prevent strokes, and thus probably prevent vascular dementia, although this is extrapolating from the available evidence. There is considerable evidence that cholinesterase inhibitor are effective for cognitive symptoms in people with mild to moderate AD, and there is some evidence that they are also effective for other behavioural and functional symptoms. The currently available cholinesterase inhibitors seem to have approximately the same sized effect and thus the choice of agent may be largely determined by the incidence of side-effects. These agents have modest effects and a cautious therapeutic trial is indicated for those subjects with mild to moderate AD.

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Antipsychotic Medication Use in the Elderly Patient

Journal of Pharmacy Practice ◽

10.1177/0897190007304982 ◽

2007 ◽

Vol 20 (4) ◽

pp. 318-326 ◽

Cited By ~ 5

Author(s):

Matthew Malone ◽

Ryan M. Carnahan ◽

Eric C. Kutscher

Keyword(s):

Elderly Patient ◽

Side Effects ◽

Elderly Patients ◽

Antipsychotic Medication ◽

Medication Use ◽

The Elderly ◽

Adverse Outcomes ◽

Antipsychotic Medications ◽

Functional Changes ◽

Effects Of Aging

The use of antipsychotic medications in the elderly can be very complex and is ever changing. Consideration must be given to not only the physiologic and functional changes normally associated with age but also to the latest data on safety and adverse outcomes associated with using these agents. Because of new and changing information, this article will review the effects of aging, side effects of antipsychotic medications, and the current issues surrounding their use in elderly patients for those clinicians who are not specialists in this area of practice.

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The PBAR Protocol: Antipsychotic Medication Reduction in the Nursing Home

OBM Geriatrics ◽

10.21926/obm.geriatr.2102172 ◽

2020 ◽

Vol 05 (02) ◽

pp. 1-1

Author(s):

Melodee Harris ◽

◽

Priya Mendiratta ◽

Gohar Azhar ◽

Ruofei Du ◽

...

Keyword(s):

Bipolar Disorder ◽

Quality Improvement ◽

Nursing Home ◽

Side Effects ◽

Antipsychotic Medication ◽

Communication Tool ◽

Interprofessional Communication ◽

Improvement Project ◽

Antipsychotic Medications ◽

Ict Implementation

Neuropsychiatric symptoms (NPS) occur in almost all persons living with dementia. Antipsychotic medications are often prescribed inappropriately for persons living with dementia who experience NPS. Adverse side effects of antipsychotic medications include falls, sedation, cognitive dysfunction, prolonged QTc interval, extrapyramidal side effects, cerebrovascular events, metabolic changes, infection, and mortality. The purpose of this descriptive quality improvement project was to test the feasibility and preliminary effectiveness of using the Psychiatric Background Assessment Recommendation (PBAR) Interprofessional Communication Tool (ICT). The PBAR-ICT was adapted from the Situation Background Assessment Recommendation (SBAR) Protocol by the Principal Investigator and was used to report critical NPS in the nursing home. After approval from the university institutional review board, an education program on identifying NPS was provided to the nursing staff. The education program focused on using terminology to destigmatize and standardize NPS. Training was also provided on how to use the PBAR-ICT. A six-month retrospective and prospective chart review were completed on all charts documenting an antipsychotic medication prescription. Medication changes were analyzed to determine successful or unsuccessful deprescribing by comparing data on pre and post PBAR-ICT implementation. Chart diagnoses (n=104) included dementia (n=55), schizophrenia/bipolar disorder (n=14), schizophrenia/bipolar disorder plus dementia (n=23) or no documented diagnoses (n=12). Relative to pre PBAR-ICT implementation for all charts (n=104), results on post PBAR-ICT implementation estimated 1.57times higher odds (p=0.003) for decreasing and/or discontinuing antipsychotic medications. Outcomes on post PBAR-ICT implementation were analyzed by diagnoses. When compared with the schizophrenia/bipolar disorderplus the dementia group, successful discontinued/decreased antipsychotic medications were statistically significant (p=0.015) for the dementia only group. Results of this quality improvement project demonstrated the feasibility of implementing the PBAR-ICT in the nursing home. The PBAR-ICT is an interprofessional communication tool that can play a role in communicating NPS to discontinue and decrease antipsychotic medications.

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Systematic review of the efficacy of non-pharmacological interventions in people with Lewy body dementia

International Psychogeriatrics ◽

10.1017/s1041610217002010 ◽

2017 ◽

Vol 30 (3) ◽

pp. 395-407 ◽

Cited By ~ 13

Author(s):

Hamilton Morrin ◽

Ton Fang ◽

Donald Servant ◽

Dag Aarsland ◽

Anto P. Rajkumar

Keyword(s):

Systematic Review ◽

Lewy Body ◽

Assessment Tool ◽

Repetitive Transcranial Magnetic Stimulation ◽

Case Reports ◽

Lewy Body Dementia ◽

Nucleus Basalis ◽

Pharmacological Intervention ◽

Cognitive Symptoms ◽

Pharmacological Interventions

ABSTRACTBackground:Pharmacological interventions for Lewy body dementia (LBD), especially for its non-cognitive symptoms, are limited in their efficacy and tolerability. Clinicians are often uncertain about non-pharmacological interventions and their efficacy in managing cognitive and non-cognitive symptoms of LBD. Therefore, we aimed to systematically review the existing literature on non-pharmacological interventions for people with LBD.Methods:We carried out a systematic search using six databases. All human studies examining impact of any non-pharmacological intervention on LBD were assessed for cognitive, physical, psychiatric, and quality-of-life outcomes. Study quality was assessed by Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies and the CARE criteria checklist.Results:Prevailing evidence supporting the efficacy of non-pharmacological interventions is weak. We screened 1,647 papers. Fifteen studies (n= 61) including 11 case reports were found eligible for this systematic review. Interventions and reported outcomes were heterogeneous. Deep brain stimulation of the nucleus basalis of Meynert reportedly conferred cognitive benefit. Electroconvulsive therapy and repetitive transcranial magnetic stimulation have been reported to ameliorate depressive symptoms. Transcranial direct current stimulation was observed to improve attention. Exercise-based interventions reportedly improve various clinically important outcomes. Spaced retrieval memory training and environmental intervention for “mirror sign” have also been reported.Conclusions:Several non-pharmacological interventions have been studied in LBD. Although evidence supporting their efficacy is not robust, prevailing preliminary evidence and limitations of available pharmacological interventions indicate the need to consider appropriate non-pharmacological interventions, while planning comprehensive care of LBD patients. Larger trials evaluating the efficacy of non-pharmacological interventions for LBD are needed.

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Side-effect monitoring of continuing LAI antipsychotic medication in UK adult mental health services

Therapeutic Advances in Psychopharmacology ◽

10.1177/2045125321991278 ◽

2021 ◽

Vol 11 ◽

pp. 204512532199127

Author(s):

Carol Paton ◽

Tom K. J. Craig ◽

Brittany McConnell ◽

Thomas R. E. Barnes

Keyword(s):

Mental Health ◽

Side Effects ◽

Mental Health Services ◽

Health Services ◽

Adverse Effects ◽

Antipsychotic Medication ◽

Side Effect ◽

Antipsychotic Medications ◽

Adult Mental Health ◽

Effect Monitoring

Background: Long-acting injectable (LAI) antipsychotic medications are used to optimise treatment outcomes in schizophrenia. Guaranteed medication delivery increases the responsibility of prescribers to monitor and manage adverse effects. Methods: In the context of a quality improvement programme conducted by the Prescribing Observatory for Mental Health, a clinical audit addressed documented side-effect monitoring in patients prescribed continuing LAI antipsychotic medication under the care of United Kingdom adult mental health services. Results: A total of 62 mental health services submitted data on 5169 patients prescribed LAI antipsychotic medication for more than a year. An assessment of side effects had been documented in the past year in 2304 (45%) cases. Post hoc analysis showed that extrapyramidal side effects were more likely to have been assessed and found to be present in those patients prescribed LAI haloperidol, flupentixol or zuclopenthixol. There was little other targeting of assessments to the known side effects profiles of individual LAI antipsychotic medications, but when dysphoria had been assessed it was most commonly found with LAI haloperidol treatment and when weight gain, sexual and prolactin-related side effects had been assessed, they were more often identified with LAI paliperidone. Conclusion: The data suggest a relatively low frequency of side-effect assessments, largely untargeted. This is likely to result in many adverse effects going unrecognised and unmanaged, thus failing to tackle their potential to confound mental state assessment and adversely affect physical health and adherence. Patients receiving LAI antipsychotic medication have regular contact with a healthcare professional who administers the medication, which provides an opportunity to potentially remedy this situation.

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Risks of Cardiovascular Disease and Beyond in Prescription of Nonsteroidal Anti-Inflammatory Drugs

Journal of Cardiovascular Pharmacology and Therapeutics ◽

10.1177/1074248419871902 ◽

2019 ◽

Vol 25 (1) ◽

pp. 3-6 ◽

Cited By ~ 4

Author(s):

Manas A. Rane ◽

Alexander Gitin ◽

Benjamin Fiedler ◽

Lawrence Fiedler ◽

Charles H. Hennekens

Keyword(s):

Cardiovascular Disease ◽

Side Effects ◽

Health Care Providers ◽

Clinical Decision Making ◽

Clinical Decision ◽

Care Providers ◽

Relieve Pain ◽

Gastrointestinal Side Effects ◽

Inflammatory Drugs ◽

Anti Inflammatory

Introduction: Nonsteroidal anti-inflammatory drugs (NSAIDs) include aspirin, naproxen, diclofenac, and ibuprofen, as well as selective cyclooxygenase 2 inhibitors such as celecoxib. Their use is common, as well as their side effects which cause 100 000 hospitalizations and 17 000 deaths annually. Recently, the US Food and Drug Administration strengthened its warning about the risks of cardiovascular disease (CVD) attributed to nonaspirin NSAIDs. Methods: When the sample size is large, randomization provides control of confounding not possible to achieve with any observational study. Further, observational studies and, especially, claims data have inherent confounding by indication larger than the small to moderate effects being sought. Results: While trials are necessary, they must be of sufficient size and duration and achieve high compliance and follow-up. Until then, clinicians should remain uncertain about benefits and risks of these drugs. Conclusions: Since the totality of evidence remains incomplete, health-care providers should consider all these aforementioned benefits and risks, both CVD and beyond, in deciding whether and, if so, which, NSAID to prescribe. The factors in the decision of whether and, if so, which NSAID to prescribe for relief of pain from inflammatory arthritis should not be limited to risks of CVD or gastrointestinal side effects but should also include potential benefits including improvements in overall quality of life resulting from decreases in pain or impairment from musculoskeletal pain syndromes. The judicious individual clinical decision-making about the prescription of NSAIDs to relieve pain based on all these considerations has the potential to do much more good than harm.

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