Journals Club - Antipsychotic prescribing for patients with dementia

Curriculum statement 9: Care of older adults

Key trials

• Adverse effects for atypical antipsychotics in dementia patients have emerged in recent years. There is a threefold increase in risk of stroke with atypical drugs and mortality risk is raised for both typical and atypical antipsychotics (Lancet Neurol 2009; 8: 125).
• One study found that among elderly patients, the risk of death associated with conventional antipsychotic medications is comparable with, and possibly greater than, the risk of death associated with atypical antipsychotic medications (CMAJ 2007; 176: 627-32).
• The DART-AD trial was the first long-term follow-up study to show that patients with Alzheimer's disease on antipsychotic drugs are at increased risk of mortality. Patients who received antipsychotic treatment for 12 months were more likely to have died by the 24-month and 36-month follow-up than patients who received placebo (Lancet Neurol 2009; 8: 151-7).

Evidence base

• In view of the cerebrovascular adverse events and death associated with antipsychotic use in dementia patients, one article has highlighted the studies examining the risks and benefits of antipsychotic drugs. The authors conclude that weighing small but significant risks compared with benefits is a complex decision (J Psychosoc Nurs Ment Health Serv 2008; 46 : 19-23).

Guidelines

• NICE guidance advises that clinicians should avoid using any antipsychotics for non-cognitive symptoms or challenging behaviour of dementia unless the patient is distressed or there is an immediate risk of harm to them or others. Any use of antipsychotics should include a full discussion with the patient and/or carers (NICE. Dementia. CG42. London, NICE 2006).

• The Royal College of Psychiatrists (RCP) has produced a prescribing update entitled Atypical antipsychotics and behavioural and psychiatric symptoms of dementia.
• The RCP states that when prescribing antipsychotics for behavioural and psychiatric symptoms of dementia, clinicians should take both NICE and the RCP guidelines into account and use their clinical judgment. (The Psychiatrist 2009: 33; 57-60).
• A revised implementation plan for the National Dementia Strategy (NDS) was published in 2010. One of the objectives is to reduce the overprescribing of antipsychotic drugs to people with dementia by two-thirds by November 2011 (DoH. Quality outcomes for people with dementia: building on the work of the NDS. 2010)
• The European Medicines Agency has completed a review of the evidence available on the safety of conventional antipsychotic medicines in elderly patients with dementia. It states that the evidence of the increased risk of mortality does not provide a basis for switching between atypical and conventional antipsychotics in patients with dementia.

Contributed by Dr Louise Newson, a GP in the West Midlands.