Should Physicians Prescribe Antipsychotics in Dementia?

Abstract

Neuropsychiatric symptoms are nearly universal in patients with major neurocognitive disorder and cause significant distress in patients and caregivers. Nonpharmacologic behavioral management is effective; however, in patients with persistent and severe neuropsychiatric symptoms, those who are unresponsive to nonpharmacologic approaches, and those who pose a danger of harm to themselves or others, pharmacologic agents are required. There are currently no US Food and Drug Administration (FDA)-approved agents. Antipsychotics have modest efficacy with the best evidence for risperidone and olanzapine at low doses. The increased risk of mortality with the use of both typical and atypical antipsychotics in dementia has consistently been reproduced in studies, and reflected in the FDA black box warning. Among the agents studied, haloperidol has the highest relative mortality risk and quetiapine the lowest compared to risperidone. The mortality risk shows a dose-response relationship. Antipsychotics have also been implicated with an increased risk of cerebrovascular events. Antipsychotics should be used cautiously in dementia with a thorough consideration of risks and benefits in discussion with patients and families. The lowest effective dose should be used and discontinuation should be attempted periodically. [ Psychiatr Ann . 2016;46(2):97–102.]