The Ongoing Dilemma on the Use of Antipsychotics to Manage the Behavioral Symptoms of Dementia

Abstract

For over a decade now, the ongoing dilemma on whether to use antipsychotics to manage the behavioral symptoms of dementia is still being discussed because we have yet to come to a consensus of what is best for these patients. The article by Greenblatt and Greenblatt1 exemplifies this dilemma. After nonpharmacological treatments are tried and either failed or provided suboptimal results, what is a nursing home practitioner to do for those numerous patients with behavioral symptoms associated with dementia? The FDA boxed warnings about the increased risk of sudden death associated with the use of antipsychotics in this population is used as “evidence” by attorneys to show how patients are being chemically restrained in nursing homes or are being treated inappropriately.2 As a result, there is substantial information available for clinicians to use on how to mitigate risk when prescribing antipsychotics to dementia patients through the use of consent forms and thorough appropriate documentation. Greenblatt and Greenblatt make a worthy notation in their review. The American Society of Consultant Pharmacists has made an effort to bring a perspective in regard to the FDA boxed warnings because the reality is that most of the nursing home residents will need management beyond nonpharmacological interventions. Many medications, not just antipsychotics, are used off-label every day.3 The review also comments on a sad reality: most nursing homes are not well staffed, and an adequate trial of nonpharmacological treatments requires the intervention of well-trained staff members. Some institutions, specifically adult day care centers, have tried—in many cases successfully—to decrease the burden on the caregiver by structuring their services when they are needed the most: they are open from 7 pm to 7 am, when dementia patients may experience worsening of their behavioral symptoms. Perhaps, that is a schedule that nursing homes should consider because traditionally staffing is decreased during the evening and overnight shifts when dementia symptoms are worse for patients. The efficacy of antipsychotics in managing the agitation, anxiety, aggression, and paranoia of dementia patients is inconclusive, with many remaining questions, as noted by Greenblatt and Greenblatt. Which antipsychotic works best? Neurologists and psychiatrists rely on their own experience in choosing the antipsychotics, based on the patient's comorbidities, the drug's side effect profile, or simply which is the preferred agent based on the institution's drug formulary. The review of the possible mechanisms of increased risk of cardiovascular events by antipsychotics is described in the review. We simply do not know the exact mechanism(s) of toxicity, nor do we know which antipsychotic(s) are most likely to contribute to these toxic events. Almost 11 years have passed since the first FDA warning was issued about the use of antipsychotics in dementia patients and the increased risk of sudden death. We still have inconclusive answers for most of the original questions. However, progress has been made to provide some guidance to practitioners in which a step approach can be used to manage dementia patients, as described in the “Clinical Considerations” section of the review, which is based on the recommendations set forth by the Centers for Medicare and Medicaid Services (1). The “Dementia Care Principles” described in Table 2 in Greenblatt and Greenblatt,1 are a good starting point for nursing homes on what they should be striving to achieve for their dementia patients. The successful management of behavioral symptoms in dementia patients is a great challenge that nursing homes as well as home caregivers continue to face. Even though current literature is inconclusive in regard to the risk of prescribing antipsychotics in this patient population, once nonpharmacological treatments fail, pharmacotherapy is the next best option.