Dr. Kalapatapu is a Fellow in Geriatric Psychiatry, Mount Sinai School of Medicine, New York City.
Dr. Schimming is Assistant Professor, Department of Psychiatry, Mount Sinai School of Medicine, New York City.
Disclosure: The authors state that they have nothing to disclose.
ABSTRACT
Antipsychotic medications have a modest effect on the neuropsychiatric symptoms of dementia, but product labels warn of the
excess risk of death and morbidity associated with their use in older patients. As such, these agents should not be the first
choice for the treatment of behavioral and psychotic symptoms of dementia. Nevertheless, a trial of these agents may be indicated
in instances in which the severity of symptoms is extreme, or symptoms do not respond to nonpharmacologic methods or other
medications. Most clinical trials in which the efficacy of these agents was studied for the treatment of neuropsychiatric
symptoms were of short duration, and thus may not be representative of true efficacy over the long term. There is no evidence
to suggest differences in effectiveness between atypical and conventional antipsychotics; therefore, the choice of an antipsychotic
for neuropsychiatric symptoms often relies on side effect profile and individual patient circumstances. Extrapyramidal symptoms
and QTc prolongation are concerns with conventional antipsychotic agents. The incidence of cerebrovascular events with either
atypical or conventional antipsychotics appears increased compared with placebo. A discussion of the risk-benefit ratio of
antipsychotics with the patient's family and/or caregivers should precede the decision to use these agents.
Kalapatapu RK, Schimming C. Update on neuropsychiatric symptoms of dementia: Antipsychotic use. Geriatrics. 2009;64(5):10-18.
Key words: antipsychotic, dementia, evaluation, management, symptom, update
The neuropsychiatric symptoms of dementias are perhaps the most distressing and difficult to treat features of these diseases.
A previous article1 reviewed the process of evaluating neuropsychiatric symptoms, the evidence for and specific examples of nonpharmacologic
interventions, and the various classes of pharmacologic interventions (excluding antipsychotics) that may be helpful in the
treatment of neuropsychiatric symptoms.
In this article, data on the efficacy of atypical and conventional antipsychotics for the treatment of agitation will be reviewed.
Given the issuance of US Food and Drug Administration (FDA) "black box" warnings for atypical antipsychotics in April 2005
and conventional antipsychotics in June 2008, the data on morbidity and mortality associated with antipsychotic use will be
examined, and the nuances of how to articulate the antipsychotic risk-benefit ratio with patients and caregivers are explored.
Finally, case examples illustrating appropriate or inappropriate antipsychotic use and a patient and caregiver discussion
are included.
Efficacy for treatment of neuropsychiatric symptoms of dementia
Table 1: Atypical antipsychotics for neuropsychiatric symptoms of dementia in the elderly
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Atypical antipsychotics As a whole, atypical antipsychotic medications (Table 1,) seem to have moderate efficacy in treating the psychotic symptoms
of Alzheimer's dementia (AD),2,3 but not all studies have found their effects to be significantly better than placebo.4,5 Although common sense suggests that antipsychotics would be more effective for inhibiting aggression, as has been shown
in patients with schizophrenia or mental retardation, most studies have not systematically assessed individual symptoms so
that they can be studied independently.
In a recent meta-analysis of 15 randomized controlled trials of atypical antipsychotics in which psychosis and/or agitation
in dementia were outcomes measures, global assessments of neuropsychiatric symptom status improved in a pooled analysis for
risperidone and aripiprazole only.5 Scores specifically related to psychosis improved only in trials with risperidone.6 Full interpretation of these data is difficult, as these trials were performed in a variety of settings using a variety
of outcomes measures.
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