The use of low-dose antipsychotic medication

Abstract

Alois Alzheimer observed behavioural disturbances in dementia over a century ago with a description of his first patient. Behavioural disturbances are prominent characteristics of dementia and can be very distressing to the individual, their family and caregivers. These symptoms include agitation, aggression, disinhibition and sleep disturbances. Up to 90% of patients with dementia suffer from such behavioural disorders (Muller-Spahn, 2003). This high prevalence may be partly due to a complex interaction of cognitive deficits, psychological symptoms and behavioural abnormalities. In particular, it is purported that neurodegenerative processes in various brain areas, like fronto-temporal cortex and limbic regions lead to a dysfunction of key neurotransmitters like acetylcholine, serotonin and noradrenalin, leading to a cocktail of behavioural symptoms with personality traits playing a modifying role. A large number of pharmacological treatment strategies have been used to manage behavioural disturbances in people with dementia (Zaudig, 1996). These have included antipsychotics, benzodiazepines or anticonvulsants. Though these drugs may substantially reduce undesirable behaviour, they may cause adverse side effect that may impact on the patient’s ability to perform activities of daily living. Historically, antipsychotic drugs have often been used to treat these behavioural abnormalities, but the extant literature is sceptical about their longterm use for this indication (Declercq et al, 2013). Ostensibly, their long-term effectiveness is limited and there is concern about their propensity to induce adverse effects, including higher mortality with long-term use. The National Institute for Clinical Excellence (NICE) guideline on dementia cautions against the use of any antipsychotics for non-cognitive symptoms or challenging behaviour of dementia unless the person is severely distressed or there is an immediate risk of harm to themselves or others (NICE, 2015). However, other recent meta-analytic studies have challenged previous findings of the unfavourable safety profile of antipsychotics in people with dementia (Hulshof et al, 2015). Overall, current consensus favours the judicious treatment of aggression and psychosis with antipsychotics for no more than 12 weeks under carefully defined conditions (Zuidema et al, 2015). Where the treatment with antipsychotics is indicated, a distinction ought to be made between antipsychotic treatment of severe behavioural symptoms Stanley Mutsatsa Senior Lecturer, City University London, Northampton Square, London Stanley.Mutsatsa@city.ac.uk The use of lowdose antipsychotic medication