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antipsychotics and Lewy body dementia

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  • antipsychotics increase mortality in elderly patients with dementia
    • should avoid using any antipsychotics (second-generation or conventional) for non-cognitive symptoms or challenging behaviour of dementia unless the patient is severely distressed or there is an immediate risk of harm to them or others (1)
    • any use of antipsychotics should include a full discussion with the patient and/or carers about the possible benefits and risks of treatment
  • DART-AD was a 12-month randomised controlled trial (RCT) in 165 patients with Alzheimer's disease (2)
    • patients were randomised to either continue their antipsychotic medication (mainly risperidone or haloperidol) or to stop treatment and receive placebo instead
    • cumulative probability of survival during the 12-month trial was:
      • 70% ( 95% confidence interval [CI] 58% to 80%) in those who continued treatment
      • 77% (95% CI 64% to 85%) in those who switched to placebo
    • during extended follow-up (up to 54 months), people who took antipsychotics were more likely to die than those taking placebo (hazard ratio for survival 0.58; 95% CI 0.35 to 0.95)
    • difference in mortality was more pronounced after the 12-month randomised phase of the trial
    • however note that fewer patients were analysed at the later time points and so the results should be interpreted with caution
  • evidence suggests that all antipsychotics are associated with an increased risk of serious adverse reactions in elderly patients with dementia

  • NICE guidance on dementia recommends that antipsychotics should be used only in exceptional circumstances in elderly patients with dementia (3):

    • only offer antipsychotics for people living with dementia who are either:
      • at risk of harming themselves or others
      • or experiencing agitation, hallucinations or delusions that are causing them severe distress

    • be aware that for people with dementia with Lewy bodies or Parkinson's disease dementia, antipsychotics can worsen the motor features of the condition, and in some cases cause severe antipsychotic sensitivity reactions

    • before starting antipsychotics, discuss the benefits and harms with the person and their family members or carers (as appropriate)

    • when using antipsychotics:
      • use the lowest effective dose and use them for the shortest possible time
      • reassess the person at least every 6 weeks, to check whether they still need medication

    • stop treatment with antipsychotics:
      • if the person is not getting a clear ongoing benefit from taking them and
      • after discussion with the person taking them and their family members or carers (as appropriate)

    • valproate should not be used to manage agitation or aggression in people living with dementia, unless it is indicated for another condition

  • guidance concerning the management of behavioural and psychiatric symptoms in dementia and the treatment of psychosis in people with a history of stroke/TIA is linked

  • antipsychotic drugs should be avoided in patients suspected of having dementia with Lewy bodies - in these patients, antipsychotics may precipitate irreversible parkinsonism, further disturb consciousness levels and induce an autonomic disturbance similar to neuroleptic malignant syndrome, and increase mortality rates 2-3 fold (5)

  • serious events, as indicated by a hospital admission or death, are frequent following the short-term use of antipsychotic drugs in older adults with dementia. Antipsychotic drugs should be used with caution even when short-term therapy is being prescribed

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