Caring for older patients

Should your patients with dementia be taking antipsychotics?

Off-label prescription of antipsychotics to manage dementia is common, but the risks often outweigh the benefits, JAOA article reports.

Despite national initiatives to reduce the off-label use of antipsychotics for the management of behavioral and psychological symptoms of dementia (BPSD) in all care settings, authors of a new narrative review in The Journal of the American Osteopathic Association (JAOA) argue older adults with dementia who reside in the general community may be at greater risk than those in nursing homes.

Of dementia patients who take antipsychotics, 70-80% do not benefit from taking the drugs, the JAOA reports. Additionally, older adults have a higher risk of experiencing severe or dangerous side effects from antipsychotics—as a result, in 2005, the FDA asked drug manufacturers to add a boxed warning to antipsychotics to alert people of the risks of such off-label use.

With a growing older adult population in the U.S., primary care physicians must consider the risks associated with antipsychotic use in older patients with dementia and be knowledgeable about nonpharmacological alternatives when caring for this population.

“Osteopathic physicians are particularly well-suited to help reduce the off-label prescription of antipsychotics through nonpharmacologic approaches and interventions and collaborative partnerships with patients and caregivers,” says the review’s lead author, Kevin Bain, PharmD, MPH, CPH.

Below is a summary of the authors’ guidance for reducing the use of antipsychotics in older adults with dementia.

Nonpharmacologic management

The authors suggest exploring three different types of nonpharmacologic intervention for managing BPSD in patients with dementia, including:

    • Behavior management
      • Combine training techniques, such as those to help patients learn habits related to day-to-day activities, with positive reinforcement.
    • Cognitive or emotion-oriented therapy
      • One example of this is reminiscence therapy, which involves stimulating memories by using old photos and news articles to help recall past experiences.
    • Sensory stimulation
      • Aromatherapy, music therapy and Snoezelen therapy can be calming techniques for managing BPSD.

“It is imperative for osteopathic physicians to develop a collaborative partnership with patients and the patients’ family or caregiver and provide nonpharmacologic interventions that are both suitable and specifically tailored to their needs,” says Dr. Bain.

He says providing a holistic approach to managing BPSD includes involving the patient in health care decisions to the fullest extent possible.

Pharmacologic management

While substantial evidence for pharmacologic alternatives to antipsychotics in this population is lacking, there is some data to support the use of certain antidepressants, according to the authors.

The authors encourage physicians to consider these pharmacologic alternatives before resorting to antipsychotics:

A summary of alternative pharmacologic strategies for the management of BPSD
Drug or Drug Class Benefits Risks
Antidepressants Similar to antipsychotics in treatment
effectiveness
Mortality rate was relatively lower
Selective serotonin reuptake inhibitors (SSRIs) Significantly better than placebo No difference in trial withdrawals due to adverse drug events (ADEs) compared with placebo
Citalopram No difference between antipsychotic in reducing agitation and psychosis Significantly higher rates of trial withdrawals due to ADEs
Trazodonea As effective as antipsychotic in reducing agitation No difference in ADE rates or trial withdrawals
Antihypertensives
Prazosin Significantly better improvement in behavioral symptoms compared with placebo No difference between prazosin and placebo in ADEs or blood pressure
Combination
Dextromethorphan-quinidineb Significantly better than placebo in reducing Alzheimer disease-related agitation ADEs and serious ADEs occurred at higher rate than placebo

aTrazodone is an antidepressant in the serotonin antagonist and reuptake inhibitor class.

bDextromethorphan is a sigma-1 receptor agonist and quinidine is an antiarrhythmic agent.

Source: Adapted from The Journal of the American Osteopathic Association (JAOA)

Strategies for antipsychotic use

Although antipsychotics should only be used for managing BPSD when nonpharmacologic approaches and interventions fail to improve symptoms or when patients pose a threat to themselves or others, the authors point out that the benefits of using antipsychotics outweigh the risks in some patients.

When physicians have to use antipsychotics as a last resort in managing BPSD, the authors urge caution and encourage physicians to create a care plan for monitoring and eventually reducing the use of the medication.

The study discusses various strategies for reducing antipsychotic use and recommends a gradual dose reduction to alleviate adverse symptoms from the drug.

For more information about nonpharmacologic and pharmacologic management of BPSD in patients with dementia, as well as reduction strategies, visit JAOA.org.

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