Geriatric Psychiatrists See Limited Role for Antipsychotics for Dementia

One could get the impression from recent reports in the popular press that antipsychotic medications should not be used in demented patients.

Some scientific reports also suggest that the use of antipsychotics in demented patients may be harmful, according to a statement released in June by APA's Council on Aging. For example, the use of high-potency antipsychotics in demented individuals has been linked with restlessness and parkinsonian symptoms; the use of low-potency ones with sedation, confusion, and delirium. A large government-sponsored trial linked antipsychotic use in Alzheimer's patients with weight gain and harmful metabolic effects (Psychiatric News, May 25).

In addition, second-generation antipsychotics carry a black-box warning for increased risk of death in demented individuals; recent data suggest that first-generation antipsychotics carry at least a similar risk.

Nonetheless, there is also scientific evidence that antipsychotics can benefit demented patients, the Council on Aging statement reports. For example, a study that was published online June 2, 2008, in the American Journal of Psychiatry found that atypical antipsychotics improved some clinical symptoms in Alzheimer's patients. While the evidence is derived mostly from shorter trials in nursing-home residents and outpatients, considerable clinical experience bolsters it.

Thus, taking both the negative and positive effects into consideration,“ antipsychotics currently have a place in the treatment of carefully selected patients with dementia complicated by psychosis and agitation,” the Council on Aging statement concludes. “Their use should be preceded by a discussion of risks and benefits with the patient and/or other decision-makers. Clinicians should monitor patients closely, prescribe the lowest effective dosages, and discontinue the drugs as soon as possible.”

The reason that the council issued this statement, Robert Roca, M.D., chair of the Council on Aging and vice president of medical affairs at Sheppard Pratt Health System in Baltimore, told Psychiatric News, is to provide guidance to general psychiatrists to help them navigate these tricky waters. ▪