Download Therapeutic Update - South West Yorkshire Partnership NHS

Dementia and Antipsychotic Drugs
What are the issues with the use of Antipsychotics in Dementia?1,2,3,4,8

Elderly people with dementia are at risk of serious life-threatening side-effects when treated with antipsychotics.
o increased risk of stroke
o small increased risk of death

In 2004 former UK CSM advised:o increased risk of stroke (approx. 3-fold) when risperidone or olanzapine used in elderly people with
dementia

In 2008 European Medicines agency and MHRA issued advice following assessment of observational data
o typical antipsychotics are also associated with increased mortality when used in elderly people with
dementia

Unless more evidence becomes available assume all antipsychotics (typical and atypical) carry risk

Also need to consider risk of other side-effects such as extra-pyramidal symptoms, hypotension, weight gain,
dysregulation of blood glucose levels
If an antipsychotic is to be initiated the risks (increased risk of stroke,
transient ischaemic attack and changes in cognition) and benefits (small
reduction in psychosis, aggression and agitation) of treatment should be
discussed (and documented) with the patient and/or carers.
If a person with dementia develops distressing non-cognitive symptoms or behaviour
that challenges, do an early assessment to identify factors that may influence
behaviour. Include:-
Assessment of
Patient3,5,8
Individual Care
Plans5,8

Physical health

Infections (especially UTI)

Dehydration

Depression

Possible undetected pain or discomfort

Side effects of medication - (including acetylcholinesterase inhibitors) Psychosis
in Parkinson’s Disease

Individual biography

Psychosocial factors – against who is the aggression directed? Reason?

Physical environment

Behavioural and functional analysis in conjunction with carers and care workers

Is the behaviour primarily a problem for the person with dementia, or for their
carers?

Develop individual care plans, record in the notes and review regularly at a
frequency agreed with carers and staff

Involve carers in creating treatment plans

Consider interventions tailored to person’s preferences, skills and abilities
Monitor response and adapt care plan as needed
Can Antipsychotics
ever be
considered?3,5,8,9
Before starting
Antipsychotic
treatment5,8,9

Antipsychotic drugs should not be used for mild-to-moderate non-cognitive
symptoms in:
o
Dementia with Lewy Bodies (DLB), because of
adverse reactions
o
Alzheimer’s disease, vascular dementia or mixed dementia, because
of the increased risk of cerebrovascular adverse events and death
the risk of severe

Medication for non-cognitive symptoms or behaviour that challenges should only
be considered as a first-line option if there is severe distress or an immediate
risk of harm to the person with dementia or others

People with DLB are at particular risk of severe ADRs with antipsychotics.

Seek specialist advice either through the free medicines information helpline on
01924 327619 or by emailing [email protected] before starting
antipsychotic therapy in patients with DLB.

Discuss risks and benefits of treatment (with the patient and /or carers and
document in the notes)
o
Assess cerebrovascular risk factors and discuss possible increased
risk of stroke/transient ischaemic attack and
o
Possible adverse effects on cognition.

Document clearly that non-pharmacological measures have failed.

Identify, quantify and record target symptoms, so that changes can be regularly
assessed and recorded.

Changes in cognition should be regularly assessed and recorded; consider
alternative medication if necessary.

Consider co-morbid conditions, such as depression.

NICE recommends that the antipsychotic is chosen after an individual
risk-benefit analysis.
Both typical and atypical antipsychotics have been associated with increased
morbidity and mortality.
Risperidone▼ is the only antipsychotic licensed for:
o Short-term (up to 6 weeks’) treatment of persistent aggression in
Alzheimer’s dementia unresponsive to non-pharmacological
approaches and where there is a risk of harm to the patient or others


And when:
o The risks and benefits have been carefully balanced for every patient
o The increased mortality rate associated with antipsychotics in the
elderly has been taken into account
o The risk of cerebrovascular events have been considered before
treating with risperidone▼:
 any patient who has a previous history of stroke or transient
ischaemic attack
 Other risk factors for cerebrovascular disease have been
considered including hypertension, diabetes, smoking, and
atrial fibrillation
Which
Antipsychotic?5,6,7,8,9

Use of other antipsychotics (including liquid specials) will be outside of
licensed indications (See Grey list)

Costs vary between antipsychotics:
o Haloperidol 500mcg x 60 = £2.36
o Risperidone▼ 500mcg x 60 = £2.85, 1mg x 60 = £1.66
o Quetiapine 25mg x 60 = £33.83 (Not recommended as on Grey List)
o Quetiapine 100, 150, 200mg strengths all flat priced at £113.10
All prices correct August 2011 - Drug Tariff
Reviewing patients
with dementia on
antipsychotics3,5



(Please refer to SWYPFT
intranet site under the
QIPP Antipsychotics in
Dementia link8,9 for further
advice on how to review
patients)


Extreme agitation
or aggression3,8




Principles of
pharmacological
control of violence,
aggression and
extreme agitation5,8





Treatment should be time-limited and regularly reviewed
If treatment continued longer than short-term – should continue to be reviewed
regularly (at least every 3 months)
Review should include:o Assessment of target symptoms
 i.e. is there any improvement?
o Assess for side-effects e.g.
 Extra-pyramidal effects
 Over-sedation
 Effects on cognition
 Anticholinergic effects
o Blood pressure and pulse, blood glucose, weight and central obesity
should also be monitored
o Appropriate blood tests: e.g. U+Es, FBC, LFTs and Prolactin
o ECG if necessary
In DLB, monitor for severe untoward reactions, particularly neuroleptic sensitivity
reactions
If oral drug treatment being considered for immediate management of violence,
aggression, extreme agitation
o should be short term (no more than one week)
o use to calm person not sedate
Options; in order of preference; low dose of:
o Oral lorazepam 0.5mg to 2mg daily or
o Oral haloperidol 0.5mg to 4mg daily
Monitor response daily until patient stable
If oral medication refused/ineffective or extreme agitation
o Obtain specialist advice urgently before making arrangements for
admission
Conduct immediate management in a safe, low stimulation environment, away
from others
Use drugs to calm the person and reduce the risk of violence and harm, rather
than to treat any underlying psychiatric condition
Aim to reduce agitation or aggression without sedation
Use the lowest effective dose for shortest possible time. Avoid high doses and
drug combinations, especially in elderly or frail people
Use drugs for control of behaviour with caution, particularly if the person has
been restrained
Offer people with dementia and their carers the opportunity to discuss their
experiences, and explain the decision to use urgent sedation. Record in the
notes
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
Professor Gordon Duff. Chairman Committee on Safety of Medicines. Atypical antipsychotic drugs and stroke. 9th March
2004.
CHM and MHRA. Drug Safety Update. Volume 2. Issue 5. December 2008.
Clinical Knowledge Summaries. Dementia.www.cks.nhs.uk. <Accessed August 2011>
CHM and MHRA. Drug Safety Update. Volume 2. Issue 8. March 2009.
National Institute for Health and Clinical Excellence. Dementia: Supporting people with dementia and their carers in health
and social care. Clinical Guideline 42. November 2006.
The use of antipsychotic medication for people with dementia: Time for Action. A report for the Minister of State for Care
Services by Professor Sube Banerjee. November 2009
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_108303
Summary of Product Characteristics. Risperdal Tablets, liquid and quicklet. Janssen-Cilag Ltd.
http://www.medicines.org.uk/EMC/medicine/12818/SPC/Risperdal+Tablets,+Liquid+%26+Quicklet/ <Accessed August
2011>
http://nww.swyt.nhs.uk/organisation/drugandtherapeutics/qipp.htm
www.choiceandmedication.org/swyp
Reducing Antipsychotic use in Dementia Flowchart