Antipsychotics in dementia: Best Practice Guide
Adverse Effects of antipsychotics
Antipsychotics are associated with serious safety concerns and long term adverse effects. In March 2004, the Committee on Safety of Medicines (CSM) in the UK advised that olanzapine and risperidone should not be used for the treatment of BPSD, as there was clear evidence of an increased risk of stroke in elderly patients with dementia. The risk was considered to be sufficiently high to outweigh any likely benefits of treatment.
A subsequent analysis of four placebo-controlled trials in elderly patients with dementia found a three-fold increase in the risk of stroke or transient ischaemic attack (TIA) with risperidone. The CSM then advised that risperidone should be limited to short-term use for acute psychotic symptoms associated with dementia and only under specialist advice. It was recommended that patients already being treated with atypical antipsychotics have their treatment reviewed.16
Atypical antipsychotics have also been associated with an increased death rate compared with placebo.17 A review by the European Pharmacovigilance Working Party concluded that the risk of cerebrovascular events associated with other antipsychotics, was not significantly different from that of olanzapine and risperidone. They advised including a warning about a possible risk of these events in the prescribing information for all typical and atypical antipsychotics.16
The current evidence indicates that both typical and atypical antipsychotics are associated with increased risk of stroke and mortality in people with dementia.
All antipsychotics pose numerous other risks especially in the elderly. Common adverse side effects include sedation, dizziness, postural hypotension and confusion which can all increase the risk of falls. The anticholinergic properties of antipsychotics can worsen cognition or cause delirium. Many of these effects can be worsened by interactions with other medicines and co-morbid conditions.
Dose-related effects (Table 6) are immediately apparent and can be minimised by keeping the dose as low as possible.
Table 6. Common Dose Related Adverse Effects of Antipsychotics.| Adverse antipsychotic side effect | Result | Potential aggravating factors |
| Anticholinergic effects; reduced GI motility | Constipation, urinary retention | Other drugs with anticholinergic effects (e.g. tricyclic antidepressants), opioid analgesics |
| Postural hypotension. | Increased accident and fall risk | Antihypertensives Hyponatraemia (diuretics, SSRIs) |
| CNS depression | Sedation, drowsiness Increased confusion or cognitive impairment |
Hypnotics (e.g. benzodiazepines), opioids, antihistamines, antidepressants Other psychotropics |
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