Antipsychotic overuse in dementia — is there a problem?

Published in Health News and Evidence

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Practice points | Dealing with dementia: behavioural and psychological issues | Antipsychotics: useful or overused? | Managing behaviourial problems effectively | Information for carers | References

Summary

  • Behaviourial and psychological symptoms of dementia (BPSD) are a common and distressing characteristic of dementia. People with dementia often exhibit aggressive, violent or socially inappropriate behaviour that places themselves, other patients and their carers at risk of psychological and physical harm.
  • Antipsychotics have a long history of being used to reduce the impact of BPSD on patients and carers, but the evidence for their efficacy is modest and they are associated with serious side effects. There is also growing concern that antipsychotics may be used inappropriately to sedate patients as a means of behaviour control.
  • Antipsychotics should only be used in severe cases of BPSD when non-pharmacological interventions have failed, and then only for short periods with regular review.

Practice points

  • BPSD are common
    Almost all patients with dementia exhibit BPSD during the course of their illness. Many patients will exhibit multiple types of BPSD.
  • BPSD can have a serious negative effect on the quality of life of patients and carers
    Consider and investigate any reports of BPSD and treat accordingly.1
  • Management of BPSD can be challenging
    Strategies, both pharmacological and non-pharmacological may only partially reduce the behaviour frequency or impact.1
  • Use non-pharmacological interventions first line
    There are various psychosocial strategies that may help reduce the frequency and severity of behaviourial symptoms.1
  • Antipsychotics may be useful in some patients
    Follow guideline recommendations when prescribing:2
    • use only in severe cases of BPSD1
    • determine other causes of behaviour before prescribing and treat accordingly
    • start at a low dose, review regularly and stop as soon as possible.

Dealing with dementia: behavioural and psychological issues

Almost all people with dementia experience behaviourial and psychological disturbances during the course of their illness.3

BPSD can manifest as apathy, depression, agitation and anxiety and more rarely as euphoria, hallucinations and disinhibition.3 Around half of people with dementia have at least four of these symptoms simultaneously.3,4

As well as the obvious effects on the quality of life of carers and the patients themselves, BPSD are also associated with an increased risk of institutionalisation and increased costs to the healthcare system.3,4

Dealing with these issues can be extremely challenging for carers, as patients can exhibit severe behaviours that place themselves and others at risk of harm.1 Patients can become physically aggressive, resist personal care, have problems with eating and exhibit socially inappropriate behaviour.1

Antipsychotics: useful or overused?

There is a long history of using antipsychotics in patients displaying BPSD.4 However, there is a growing concern that antipsychotics and similar medicines are being overprescribed to people with dementia first line as a means of behaviour control.5-7

Modest efficacy and significant safety concerns

Antipsychotics are regularly used to treat BPSD despite trial evidence demonstrating modest efficacy and safety.8-11

While some studies have shown that antipsychotics may reduce some of the symptoms of BPSD, they have also shown that use is associated with serious adverse effects, in particular, adverse cerebrovascular events.9,11

There is also evidence that the risk of harm increases with increasing length of treatment. Continuing antipsychotic therapy for up to 2 years results in a significant increase in mortality.4,12,13

The FDA also determined that use of atypical antipsychotics, in particular, olanzapine, risperidone, aripiprazole and quetiapine,* were associated with an increased risk of mortality.14


* Only risperidone is PBS listed for the treatment of BPSD in Australia.

An analysis of the use of atypical antipsychotics suggested that treating 1000 people with BPSD with an atypical antipsychotic for around 12 weeks would result in:4

  • an additional 91–200 people showing clinically significant improvement in BPSD
  • 10 additional deaths
  • 18 additional cerebrovascular events
  • an additional 58–94 people with disturbed gait
  • no additional falls or fractures.

The high number of scripts for the 25 mg strength of quetiapine, which is not a therapeutic dose for schizophrenia or biopolar disorder, suggests it is being used for sedation.

High level of inappropriate prescribing

Analysis of PBS prescription data suggests a high level of inappropriate prescribing of antipsychotics in older people.7 This analysis also identified that the high number of scripts for the 25 mg strength of quetiapine in people aged 20–59 years, which is not a therapeutic dose for schizophrenia or biopolar disorder, suggests it is being used for sedation in this age group.7 This may also account for some of the overuse in older people.

Australian data suggest that up to one-third of dementia patients in residential care homes are regular users of antipsychotic medicines.15,16 The reported prescription rates in Australia are comparable to those of other countries.

Studies in the UK found antipsychotic use ranged from 30% to 48%.4 A Swedish study found that around 38% of dementia patients in specialised care units were prescribed antipsychotics.17 This study also reported a high incidence of people on long-term antipsychotics without dose adjustment or review.17 Reasons for prescription included indications for which antipsychotics would not be recommended, such as sedation and restless behaviour.17 In fact, only 39% of patients were prescribed antipsychotics according to national guidelines.17

Managing behaviourial problems effectively

Keep these principles in mind when managing dementia-related behaviour:18

  • the rights of the person with dementia must be recognised and protected
  • the goal of treatment or management is to maximise quality of life and safety within the least restrictive environment
  • behaviour of people with dementia is recognised as a form of communication
  • recognise the impact of BPSD on carers and families
  • collaborate with all affected people.

Assess contributing environmental factors

When it comes to assessing the behaviour it can be challenging to determine what is driving the behaviour in a person with dementia.18 Often the behaviour is related to environmental factors and frequently there are a number of causes operating together rather than a single obvious cause.6

Consider the BPSD issue as an expression of unmet need on behalf of the patient; this may help carers deal with the behaviour in a more positive way.6 For example, is the patient wandering because they are bored, sad or anxious?6

Make a differential diagnosis

There is a serious risk of harm to dementia patients if there are underlying untreated physical or medical causes for their BPSD. Conditions such as delirium, constipation and pain may result in behaviours such as aggression, hallucinations and sleep disturbance, and it is essential that these are ruled out before deciding on a treatment strategy.2,18

Identify delirium

Delirium is an acute state that can exacerbate behaviours caused by dementia.1 It is characterised by rapid onset, over hours to days, of 'out of character' behaviour. Aggression, hallucinations and disorganised thinking may be evident.18 The person may be hyperactive, hypoactive or mixed.18

Treating delirium is critical, as it is a significant risk to health.1 Focussing on the behaviourial problems delays treatment for the underlying condition and is associated with poor outcomes.18

Risk factors for the development of delirium include; infection, dehydration, constipation, pain and multiple medicines.1

Assess for chronic pain

Pain is a frequent comorbid condition in people with dementia. An estimated 80% of care-home residents experience pain on a weekly basis.18,19

Some types of BPSD are frequently associated with pain; however, they are often not recognised as pain symptoms, rather as symptoms of the dementia.19

A recent meta-analysis concluded that interventions that target pain as well as behaviour are effective in reducing pain and consequently BPSD.19

Investigate other psychiatric causes

Some of the behaviours that form BPSD can be signs of other psychiatric disorders.6 Disorders such as major depression are common in older people, especially in those in residential care facilities. A trial of an antidepressant may be warranted.6

Review medicines

Inappropriate polypharmacy can increase the risk of adverse events and can lead to confusion and functional decline. Review medicines before deciding on a treatment pathway. For more information about the risks of polypharmacy in older people see MedicineWise News: Older, Wiser, Safer and NPS MedicineWise information on medicines in older people.

NPS and Webstercare have recently collaborated to provide pharmacists a mechanism to report use of antipsychotic medicines in each residential aged-care facility for which they supply medicines. More information about this reporting mechanism.

Behaviours that do not respond to antipsychotics

Targetting therapy to the problem is crucial in achieving a positive outcome.6 Certain behaviours are unlikely to respond to antipsychotic therapy. These include apathy, low mood, inappropriate toileting and calling out.

Antipsychotics will probably be less useful when:6

  • the behaviour is intermittent such as aggression once a week rather than daily
  • the behaviour is situation-specific (e.g. resisting one type of care such as showering or dressing versus resisting all care)
  • the behaviour is goal directed (e.g. attempting to leave to achieve a specific task versus continuous anxious hovering around the door).

Try non-pharmacological therapies first

Non-pharmacological interventions are favoured as the first-line therapy for BPSD.2,8 These can include music, pets, exercise, limiting overstimulation and use of aromatherapy.1,6

Appropriate use of antipsychotics

Limit use of antipsychotics to patients showing severe symptoms that may cause extreme distress and harm to patients and carers.2,8 Discuss the potential for stopping antipsychotics at the start of therapy, as they should only be used for a limited period of time.

The key consideration when using antipsychotics is whether benefits outweigh risks, noting that there is modest evidence of efficacy and significant risk of adverse effects.

When risks outweigh the benefits, stop the antipsychotic. For example, for a severe adverse drug reaction such as neuroleptic malignant syndrome, which has an increased risk in older people,20 the person is at a high risk of stroke,2 as well as less obvious risks such as falls.21

Choose pharmacological treatment according to symptoms.2,22 For example, antipsychotics such as risperidone are best targeted at hallucinations, delusions, persistent angry aggressive states and serious behaviourial problems.2,6 Anti-anxiolytics such as the benzodiazepine oxazepam are best used to treat severe anxiety.2,6 Even in these situations the use of antipsychotics should only be for short periods of time.2,8

Generally the newer atypical antipsychotics are favoured in Australia. The older antipsychotics (e.g. haloperidol) are not recommended, as they can cause negative side effects such as excessive sedation, tardive dyskinesia, falls and postural hypotension.2,22

Use caution when prescribing antipsychotics to patients with poorly controlled vascular risk factors such as atrial fibrillation, hypertension, diabetes or prior history of stroke. Use of antipsychotics in these people may be associated with an increased risk of adverse cerebrovascular events. Only use antipsychotics in these people if they are exhibiting intractable aggression or psychosis that does not respond to psychosocial interventions.2

Several studies have reported that most patients who stop antipsychotic medicines do not show worsening behaviour.23,24 Monitor patients regularly, at least 3-monthly, and when appropriate gradually withdraw medicine.2,6,22

It may be useful to use an instrument to monitor BPSD symptoms, such as the Neuropsychiatric Inventory.2,22

Consent

Consent is an important issue when dealing with people with reduced cognition. Commonly the person with dementia is unable to consent, and informed consent must be obtained from the 'person responsible' or the legal guardian before prescribing any medicine for BPSD.22

Information for carers

Caring for a person with dementia is extremely challenging and can be very distressing. There is support for carers. Each State has a dementia behaviour management advisory service (DBMAS) that provides clinical support for people caring for someone who is demonstrating behaviourial and psychological symptoms of dementia.2

  • Provide carers with the contact details of DBMAS in their State
  • Ensure carers understand that any intervention to reduce the incidence or severity of the BPSD may not be effective.
  • Counselling is available for people with dementia, their families and carers aiming to support and assist through the course of the illness. Information can be obtained from the National Dementia Helpline on 1800 100 500
References
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  2. Therapeutic Guidelines Limited. eTG complete [online]. Melbourne, 2013. http://etg.hcn.com.au/desktop/index.htm (accessed 2 May 2013).
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