What does the American Psychiatric Association recommend regarding the use of antipsychotics in patients with dementia?
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Many patients with dementia suffer symptoms beyond cognitive impairment. Neuropsychiatric symptoms such as agitation, aggression, delusions, depression, and hallucinations are common. A recent survey determined that agitation or aggression occurred in over one-third of outpatients with dementia.1 Alarmingly, nearly three-quarters of patients with dementia suffer psychiatric symptoms during hospital admission.2 Despite the prevalence of neuropsychiatric symptoms in patients with dementia, appropriate management remains controversial. Antipsychotic medications are frequently prescribed, but there are numerous concerns with their use. This concern is not new; the Food and Drug Administration (FDA) called attention to this issue over a decade ago. A 2005 FDA statement warned of an increased risk of mortality with atypical antipsychotics in elderly patients with dementia-related psychosis.3 The majority of the deaths were cardiovascular or infection related. In 2008, the FDA expanded this warning to conventional antipsychotics. Unfortunately, there are few effective alternative treatments for agitation or psychosis, and providers often have to weigh the risk versus benefit of these agents for neuropsychiatric symptoms in patients with dementia.
In an attempt to improve the care of patients with dementia who have agitation or psychosis, the American Psychiatric Association (APA) recently provided guidance on the use of antipsychotic medications in these patients.4,5 The guidelines consist of 15 statements in 5 categories rated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system (Table). All guideline statements are depicted with a strength of evidence ranking – high (A), moderate (B), or low (C). Many of the recommendations in the APA guidelines simply support what is being done in good clinical practice; however, some of the parameters may require adaptation to current practice.
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| Table. APA recommendations regarding the use of antipsychotics for agitation or psychosis in patients with dementia.4,5 | |
|---|---|
| Evidence grade | |
| Assessment of psychological or behavioral symptoms of dementia | |
| Assess the type, frequency, severity, pattern, and timing of symptoms | C |
| Assess for pain or other symptom contributors as well as the subtype of dementia that may influence treatment | C |
| Assess response to treatment with a quantitative measure | C |
| Development of a comprehensive treatment plan | |
| Develop a patient-specific treatment plan that includes pharmacologic and nonpharmacologic interventions | C |
| Assessment of benefits and risks of antipsychotic treatment for the patient | |
| Antipsychotics should only be used for agitation or psychosis in nonemergency situations in patients with dementia when symptoms are severe, dangerous, or cause significant distress to the patient | B |
| Response to nonpharmacologic measures should be assessed prior to treating patients with antipsychotics in nonemergency situations | C |
| The potential risks and benefits of antipsychotic medications should be assessed by the clinician and discussed with the patient (if possible), the patient’s surrogate decision maker, family, or others involved in care of the patient in nonemergency situations | C |
| Dosing, duration, and monitoring of antipsychotic treatment | |
| Initiate treatment at a low dose and titrate to the minimum effective dose as tolerated | B |
| When a patient experiences a side effect, the risks and benefits of the medication should be reviewed to determine if tapering and discontinuing the medication is appropriate | C |
| Taper and withdraw antipsychotics in patients who do not have a clinically significant response after 4 weeks of treatment | B |
| In patients who respond to antipsychotic treatment, discuss possible tapering of antipsychotics with the patient (if possible), the patient’s surrogate decision maker, family, or others involved in the care of the patient to determine their preferences | C |
| Taper and discontinue the antipsychotic within 4 months of initiation in patients with an adequate response unless the patient had recurrent symptoms with prior tapering attempts | C |
| Assess patients at least monthly for 4 months while discontinuing antipsychotics | C |
| Use of specific antipsychotic medications, depending on clinical context | |
| In the absence of delirium, haloperidol should not be used first-line in nonemergency situations | B |
| Long-acting injectable antipsychotics are not recommended for agitation or psychosis in patients with dementia unless they are needed for a comorbid disease state | B |
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Initial assessment
The guidelines recommend use of a quantitative measure for treatment response.5 There are a number of scales available for agitation and/or psychosis, and the guidelines recommend using the same scale for a particular patient but do not recommend a particular scale overall. Examples of appropriate scales include the Neuropsychiatric Inventory Questionnaire (NPI-Q) and the Brief Psychiatric Rating Scale (BPRS) as well as the Cohen-Mansfield Agitation Inventory (CMAI) or Modified Overt Aggression Scale in patients who are agitated without other psychosis. In some patients an abbreviated approach such as rating specific symptoms on a Likert scale may be indicated. The patient must also be assessed for factors contributing to his or her symptoms. Pain is a frequent cause of agitation, but communication of pain may be impaired, and use of scales such as the Pain Assessment in Advanced Dementia (PAINAD) scale may be useful.5,6 Other factors such as new medical conditions (e.g., infection) or medication changes should be ruled out as causative factors prior to initiating treatment.5
The treatment plan
The treatment plan should consist of nonpharmacologic and pharmacologic interventions.5 Importantly, the guidelines remind providers that an effective intervention for one patient may be distressing to another. They also point out that while a behavior may be distressing to a caregiver, it may not distress the patient, and the treatment plan should appropriately include the needs of the caregiver. Regular reassessment of the treatment plan is also recommended.
Antipsychotic treatment
The guidelines reinforce the need to weigh the risks and benefits of antipsychotic treatment prior to initiating therapy.5 The risk of adverse effects in older patients with concomitant disease states and medications may outweigh the benefits of treatment. Consideration should also be given to the type of dementia. Patients with Lewy body or Parkinson’s disease dementia may have greater risks associated with the extrapyramidal or cognitive effects of antipsychotic medications.
There are a number of considerations when selecting an initial antipsychotic therapy including insurance coverage, cost, concomitant medication or disease states, medication pharmacokinetics and adverse effects, as well as available dosage forms.5 The guidelines recommend that second-generation antipsychotics be considered first and haloperidol be avoided in non-emergent situations. In a review of the evidence, the APA found risperidone to be effective for psychosis and risperidone, olanzapine, or aripiprazole effective for agitation. They found insufficient evidence for quetiapine and no evidence for asenapine, brexpiprazole, cariprazine, clozapine, iloperidone, lurasidone, paliperidone, or ziprasidone in patients with dementia. The guidelines do not recommend a particular agent as first-line therapy. Long-acting injectable formulations are not recommended as initial treatment but may be used in select patients who have difficulty with adherence.
Regardless of antipsychotic choice, elderly or frail patients require small doses ‒ the guidelines suggest one-half to one-third of the dose used in younger patients as an appropriate initial dose.5 The dose should be titrated. If there is an inadequate response after 4 weeks of treatment at an appropriate therapeutic dose, the antipsychotic should be tapered and discontinued. Careful monitoring of adverse effects and adherence is recommended. The guidelines recommend that an attempt to taper and discontinue the medication should be made within 4 months of initiation for patients that have been prescribed the antipsychotic solely for dementia-related agitation or psychosis. The APA does not provide rationale for the selection of the 4-month time frame but does recommend that specific patient factors are considered in the timing of a discontinuation attempt. They also recommend close monitoring for at least 4 months after discontinuation to assess symptom recurrence.
Conclusion
The APA released 2016 guidelines to improve the care of patients with agitation or psychosis related to dementia. The recommendations are specific to the use of antipsychotics in these patients, and alternative medications are not discussed. Key recommendations in these guidelines include careful patient selection for antipsychotic initiation, the use of quantitative measures for response to therapy, and an attempt at discontinuation as soon as reasonably possible. The guidelines do not recommend a particular antipsychotic but do recommend haloperidol and long-acting antipsychotic avoidance.
References
- Thyrian JR, Eichler T, Hertel J, et al. Burden of behavioral and psychiatric symptoms in people screened positive for dementia in primary care: results of the DelpHi-Study. J Alzheimers Dis. 2015;46(2):451-459.
- Sampson EL, White N, Lord K, et al. Pain, agitation, and behavioural problem in people with dementia admitted to general hospital wards: a longitudinal cohort study. Pain. 2015;156(4):675-683.
- Information for healthcare professionals: conventional antipyschotics. Food and Drug Administration website. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm124830.htm. Published June 16, 2008. Accessed June 24, 2016.
- Reus VI, Fochtmann LJ, Eyler E, et al. The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173(5):543-546.
- Practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Psychiatry Online website. http://psychiatryonline.org/doi/book/10.1176/appi.books.9780890426807. Accessed June 24, 2016.
- Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4(1):9-15.
August 2016
The information presented is current as of July 1, 2016. This information is intended as an educational piece and should not be used as the sole source for clinical decision-making.