Antipsychotics in dementia: Best Practice Guide
Pharmacological treatment of BPSD
Indications for antipsychotics | Drug selection | Start low and go slow | Maintenance | Monitoring | Withdrawal
Summary Points
- Antipsychotics have limited clinical effectiveness for most features of BPSD.
- Before an antipsychotic is prescribed the benefits and risks of treatment should be assessed. People must have the opportunity to make informed decisions about their care and treatment
- An antipsychotic is only indicated if aggression, agitation or psychotic symptoms cause severe distress or an immediate risk of harm to the patient or others.
- Pharmacological treatment should be aimed at the modification of clearly identified and documented target behaviours.
- If a trial of one antipsychotic is ineffective another agent can be tried. Risperidone is often the first choice due to the lower risk of extrapyramidal effects especially with longer term treatment. Haloperidol may be useful for short-term treatment of delirium or psychoses associated with BPSD.
- Any medication that is given as required (PRN) needs to have a specific indication with a maximum dose. Treatment should be monitored and stopped as soon as possible.
- There is little evidence to support the use of drugs other than antipsychotics in the treatment of BPSD. Cholinesterase inhibitors (not funded) may be considered if antipsychotics are inappropriate or ineffective.
- Avoid haloperidol and other typical antipsychotics in people with dementia with Lewy bodies and similar conditions. Quetiapine or risperidone may be tried cautiously.
- Concurrent non-pharmacological measures should be employed along with drug treatment.
- Start with the lowest possible dose, and if a dose increase is necessary titrate slowly to effect.
- Regularly review the patient for clinical response and adverse effects.
- Review the need for ongoing treatment with an antipsychotic after three months and regularly afterwards. Consider withdrawing the antipsychotic as symptoms may not recur.
- Review the continued requirement for an antipsychotic if a person arrives in residential care already taking maintenance treatment.
Indications for antipsychotics
As described previously, BPSD refers to a spectrum of quite diverse symptoms which cannot be placed under the same treatment umbrella. The important message is that antipsychotics are not effective for all BPSD.
There is some evidence that typical (e.g. haloperidol) and atypical (e.g. risperidone, quetiapine) antipsychotics are effective for psychotic symptoms (e.g. delusions or hallucinations) associated with dementia, or for people who are aggressive or agitated without psychoses.
An antipsychotic is only indicated if aggression, agitation or psychotic symptoms cause severe distress or an immediate risk of harm to the patient or others. Unless immediate drug treatment is required, standard non-pharmacological measures should be tried first. A trial of drug treatment should be viewed as a short term strategy and reviewed at least every three months.
At best, the effectiveness of antipsychotics for BPSD is modest. For example, data from placebo-controlled trials involving risperidone and olanzapine suggest that 5 - 14 people need to be treated for 12 weeks for one additional person to show significant improvement in aggressive symptoms associated with dementia.11 |
Symptoms that do not usually respond to an antipsychotic include wandering, social withdrawal, shouting, pacing, touching, cognitive defects and incontinence.12 These symptoms may respond to interventions such as subtle changes to the environment.
It is important to realise that psychotic symptoms may be present without causing concern to the person or other people, and in this setting close observation and non-pharmacological management are appropriate.
Drug selection
Most experience is with haloperidol and risperidone and they do not differ significantly in clinical effectiveness. At low doses, and in short term use, there are no appreciable differences in extrapyramidal effects, but haloperidol is associated with greater risk of tardive dyskinesia.
Haloperidol is often suitable for the acute and short term treatment of delirium and the appropriate symptoms of BPSD, but for longer term treatment an atypical agent such as risperidone is preferred. However, it should be recognised that risperidone behaves like a typical antipsychotic at higher doses, with the associated increased risk of extrapyramidal effects. This emphasises the need to keep the dose as low as possible.
Olanzapine offers no clinical advantage over the other antipsychotics used for BPSD and has anticholinergic properties that can be particularly problematic in this population. It is often associated with rapid and significant weight gain.
Quetiapine appears to be increasingly widely used in elderly people but there is little evidence to support its effectiveness in BPSD and it can cause significant postural hypotension and sedation. It does not have an indication in New Zealand for the treatment of symptoms associated with dementia.
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Consent to treatment |
Start low and go slow
If a trial of antipsychotic treatment is considered necessary the starting dose should be as low as possible. This is particularly important for those people who are older, frail, cognitively impaired, or who carry a specific significant risk that the antipsychotic may increase, such as falling. The starting dose can be divided or timed according to the behaviour, for example a lunchtime dose for those patients exhibiting increased agitation towards the end of the day (“sundowning”).
Dose increments should be modest and occur at no less than weekly intervals depending on response. Prior to starting a treatment trial, it is advisable to estimate what will constitute a worthwhile clinical response, the duration of treatment and the maximum dose. Avoid high doses or prolonged use of antipsychotics that have not significantly improved the target behaviour.
Recommended starting and maintenance doses are given in Table 5. Information on a complete range of potentially useful treatments is available from the RANZCP clinical recommendations.
Table 5. Recommended starting and maintenance doses for antipsychotics in the treatment of BPSD| Drug | Initial Daily Dose | Maximum Daily Maintenance Dose | Comments |
| Haloperidol | 0.25mg | Up to 2 mg twice daily. | Initial dose of 0.5 mg can be given at night |
| Risperidone | 0.25- 0.5 mg | 2 mg | In 1 or 2 divided doses |
| *Olanzapine | 2.5 mg | 10 mg | In 1 or 2 divided doses |
| *Quetiapine | 12.5 mg | 100 mg | Needs divided dosing |
Maintenance
Treatment with an antipsychotic should be considered a trial to establish whether there is a reduction in the intensity and/or frequency of target behaviours. Carers must know what key side effects to monitor during treatment initiation and maintenance. Changing to an alternative strategy is preferable to ongoing dose increases which will only tend to worsen adverse effects.
Maintenance treatment may be appropriate for those who have demonstrated a clear benefit from antipsychotic treatment without undue adverse effects, and where a trial dose reduction has resulted in reappearance of the target problem. A formal monitoring plan to assess changes in response and the significance of adverse effects should be in place. The prescriber should review the target behaviour, changes in function and significance of adverse effects at least every three months.13
Monitoring
There should be routine monitoring for adverse effects such as constipation, sedation, postural hypotension and extrapyramidal side effects. Additional monitoring may be appropriate, e.g. blood glucose with olanzapine.
Withdrawal
BPSD are often temporary, so if symptoms are stable, gradual dose reduction and eventual withdrawal can be tried every three months. Studies have reported that most patients who are taken off an antipsychotic for treatment of BPSD showed no worsening of behavioural symptoms.14,15
Withdrawal of antipsychotics should be done gradually, e.g. by reducing the dose by 50% every two weeks then stopping after two weeks on the minimum dose, with monitoring for recurrence of target symptoms or behaviours or emergence of new ones.
The longer a medication has been prescribed, the slower the withdrawal, this will lessen the possibility of symptoms emerging related to drug withdrawal.
Challenging behaviours or symptoms may persist over time and not everyone on antipsychotics should have their medication changed or stopped. Reasons for continuing antipsychotics include:
- An assessment of high risk of adverse consequences if they are withdrawn, especially if treatment has only been partially effective or prior relapses have occurred.
- When the consequences of symptom relapse are deemed to be unacceptably severe.
- When no alternative treatment approaches have been possible or effective in the past.
Decisions to continue antipsychotics should be documented including the risks and benefits.
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