What Are Atypical Antipsychotic Medications
Atypical antipsychotic drugs are so-called to differentiate between these newer antipsychotics and other conventional antipsychotics, such as chlorpromazine and haloperidol . Atypical antipsychotic medications were first introduced in the 1980s. Zyprexa was approved by the Food and Drug Administration in 1996.
Atypical antipsychotic medications have a number of distinct differences and have been marketed as drugs that have fewer major neurological side effects such as extrapyramidal symptoms and low rates of tardive dyskinesia. Atypical antipsychotics are approved for the treatment of schizophrenia but are also prescribed for people with bipolar disorder and in the treatment of agitation and psychosis in dementia.
Different Approaches And New Options
Different pharmacological approaches for the treatment of behavioral symptoms have been evaluated.
Acetylcholinesterase inhibitors demonstrated a mild effect on BPSD, particularly on agitation, delusion, aggression, or hallucination more benefits have been seen in Lewy Body dementia-related hallucinations . A recent meta-analysis demonstrated the efficacy of memantine in controlling positive symptoms such as aggression, agitation, delusions, disinhibition, compared to control it was also effective on hallucinations . The combined use of AChEI+memantine has been evaluated in a meta-analysis by Matsunaga et al the results showed a better outcome of the combined therapy compared to AChEI alone in both behavioral and functional scores, with also a positive trend in cognitive performance . A further meta-analysis confirmed the better outcome in terms of both cognitive and behavioral symptoms of the combined therapy .
An algorithm for the therapeutic approach to agitation and aggression in patients with AD or mixed dementia, revised by a multidisciplinary team, was recently proposed . The algorithm hypothesizes a sequential use of medication, basing on evidences, efficacy, safety and tolerability. Risperidone is the first step of treatment , followed by quetiapine or aripiprazole titration and switching-drug time-point are also suggested. .
Side Effects Of Antipsychotic Drugs For Alzheimers / Dementia
This part is important. The side effects of antipsychotics are powerful, particularly in older people who are far-and-away the majority with Alzheimers and other dementias. One of the side effects, especially after taking the drugs for more than two weeks, is faster cognitive decline, meaning thinking and memory actually worsen.
Any prescription should include a pamphlet that lists the side effects. They vary depending on which specific medicine the doctor recommends, but will probably include most, if not all, of these: shakiness, involuntary movements of the mouth and jaw, lethargy , weight gain, constipation, dry mouth, and blurred vision.
Crucially for people with Alzheimers or related dementia, studies have found an increased likelihood of femur fractures. The combined side effects of sedation and shakiness mean an elderly person on antipsychotics can be prone to falling, and a bad fall can break the bone above the knee.
The potential for blood clots and stroke increases when a person is taking antipsychotics, and mortality rates on these drugs are increased almost double for users over 65.
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Antipsychotic Medications Used In Alzheimers Patients Questioned
More than half of those who have Alzheimer’s disease get symptoms such as delusions, aggression, agitation and hallucinations. There are few options for treating these symptoms, so doctors often prescribe antipsychotic medications even though theyre not FDA-approved for people with Alzheimer’s disease. Second-generation antipsychotic drugs were thought to be at least as effective as older antipsychotic drugs but to cause fewer troubling side effects. According to the first phase of a large-scale clinical trial, however, the advantages arent so clear.
The $16.9 million, five-year trial is known as the Clinical Antipsychotic Trial of Intervention Effectiveness study for Alzheimer’s disease . It involved 421 participants from around the country who had Alzheimer’s-related dementia with delusions, aggression, hallucinations or agitation severe enough to disrupt their lives. An essential component of the trial, which was funded by NIH’s National Institute of Mental Health , was caregiver participation. The caregivers provided input to the study doctors on the patients’progress and reactions to the medications.
The antipsychotic medications may be effective against some symptoms in Alzheimer’s patients compared to placebo, Schneider says, but their tendency to cause intolerable adverse side effects in this vulnerable population offsets their benefits.
Practical Tips On Medications To Manage Difficult Behaviors In Dementia
You may be now wondering just how doctors are supposed to manage medications for difficult dementia behaviors.
Here are the key points that I usually share with families:
- Before resorting to medication: its essential to try to identify what is triggering/worsening the behavior, and its important to try non-drug approaches, including exercise.
- Be sure to consider treating possible pain or constipation, as these are easily overlooked in people with dementia. Geriatricians often try scheduling acetaminophen 2-3 times daily, since people with dementia may not be able to articulate their pain. We also titrate laxatives to aim for a soft bowel movement every 1-2 days.
- No type of medication has been clinically shown to improve behavior for most people with dementia. If you try medication for this purpose, you should be prepared to do some trial-and-error, and its essential to carefully monitor how well the medication is working and what side-effects may be happening.
- Antipsychotics and benzodiazepines work fairly quickly, but most of the time they are working through sedation and chemical restraint. They tend to cloud thinking further. It is important to use the lowest possible dose of these medications.
- Antidepressants take a while to work, but are generally well-tolerated. Geriatricians often try escitalopram or citalopram in people with dementia.
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Antipsychotics And Other Drug Approaches In Dementia Care
Antipsychotic drugs may be prescribed for people with dementia who develop changes such as aggression and psychosis. However this is usually only after other drugs have been tried such as anti-depressant, anti-dementia and anticonvulsant drugs.
Drugs for behavioural and psychological symptoms
Implications For Clinical Practice And Research
What does the study tell us about the risks of antipsychotic use in older people without a dementia diagnosis – in particular those with functional psychoses for whom management with a non-drug treatment or alternative class of psychotropic would not be an option? Gerhard and colleagues acknowledge that dementia may have been underdiagnosed in their sample, but it is just as likely that patients with schizophrenia and bipolar disorder would also have been underdiagnosed and consequently would have been inadvertently included among the two-thirds of participants without a dementia diagnosis. In the absence of an untreated comparison group it is of course impossible to comment on the absolute increase in mortality associated with antipsychotic use in patients with functional psychoses. But the demonstration of a dose-response relationship with mortality risk that was independent of dementia diagnosis is strongly suggestive of similar risks to those seen in people with dementia. It would be important for Gerhard and colleagues to re-examine their data-set, looking specifically at patients who did have a diagnosis of schizophrenia or bipolar disorder to confirm this. It is probably already established practice to use the lowest effective antipsychotic dose and to avoid haloperidol for older patients with functional psychoses, and this study hints at the potential dangers of not following these principles.
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Warning About Zyprexa And People With Dementia
People with dementia who take antipsychotic medications, including Zyprexa, have an increased risk of sudden death. Research has found that most of those deaths were related either to cardiovascular conditions or infections . However, prescribing those medications may still be appropriate for patients who pose a danger to themselves or others and are in profound distress.
Although Zyprexa is not approved to treat older adults with dementia-related psychosis, it sometimes is prescribed “off-label” with the goal of reducing significant behavior problems or psychosis. If antipsychotic medication is used in this situation, it should be after other non-drug approaches are attempted and after confirming that the behaviors pose a danger to the person with dementia or those around them, or their paranoia and delusions are truly distressing for them.
The Challenge Of Treating Bpsd
It has been established through robust placebo-controlled clinical trials that the antipsychotics risperidone, olanzapine and aripiprazole confer modest but significant benefits in the treatment of aggression and psychosis over 6-12 weeks in people with Alzheimers disease.Reference Ballard, Gauthier, Cummings, Brodaty, Grossberg and Robert1,Reference Ballard and Howard3 Trials have also failed to demonstrate treatment benefits for quetiapine.Reference Ballard, Gauthier, Cummings, Brodaty, Grossberg and Robert1,Reference Ballard and Howard3 There is very limited evidence regarding any treatment benefits in people with non-Alzheimers dementia and it is far less clear whether there are any benefits of longer-term treatment,Reference Ballard, Lana, Theodoulou, Douglas, McShane and Jacoby4 although evidence suggests significant continued benefit for at least 6 months in people with a clear initial positive treatment response.Reference Devanand, Mintzer, Schultz, Andrews, Sultzer and de la Pena5
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Who Can Antipsychotic Drugs Help
Some antipsychotics can have a small but significant beneficial effect on agitation, aggression and, to a lesser extent, psychosis in people with Alzheimers disease. Improvements are normally only seen once these drugs have been taken for several weeks.
Antipsychotic drugs may be prescribed for people with Alzheimers disease, vascular dementia or mixed dementia .
If a person with dementia with Lewy bodies or Parkinsons disease dementia is prescribed an antipsychotic drug, it should be done with the utmost care, under constant supervision and with regular review. This is because people with these types of dementia, who often have visual hallucinations, are at particular risk of severe negative reactions to most antipsychotics.
The doctor is likely to choose a drug with the least side effects, but they will only be able to use very small doses. This is unlikely to have much effect on agitation and psychosis.
These changes are likely to need personalised non-drug approaches.
No Easy Solutions But Improvement Is Usually Possible
As many of you know, behavior problems are difficult in dementia in large part because there is usually no easy way to fix them.
Many probably too many older adults with Alzheimers and other dementias are being medicated for their behavior problems.
If your family is struggling with behavior problems, I know that reading this article will not quickly solve them.
But I hope this information will enable you to make more informed decisions. This way youll help ensure that any medications are used thoughtfully, in the lowest doses necessary, and in combination with non-drug dementia behavior management approaches.
To learn about non-drug management approaches, I recommend this article: 7 Steps to Managing Difficult Dementia Behaviors
And if you are looking for a memory care facility, try to find out how many of their residents are being medicated for behavior. For people with Alzheimers and other dementias, its best to be cared for by people who dont turn first to chemical restraints such as antipsychotics and benzodiazepines.
This article was first published in 2016, and was last updated by Dr. K in May 2022.
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Antipsychotics Use In Assisted Living And Memory Care
Assisted living and memory care residences have been caught using antipsychotics to manage residents behavior. This practice is called chemical constraints, and has resulted in massive penalties for drug manufacturers. The manufacturers of Zyprexa, for instance, had to pay more than $1.4 billion after settling with the government over accusations they marketed the drug to nursing homes as a treatment for dementia. In 2017, Human Rights Watch released a report titled They Want Docile. It began: In an average week, nursing facilities in the United States administer antipsychotic drugs to over 179,000 people who do not have diagnoses for which the drugs are approved. They determined it was the sedative effect, rather than any medical benefit, motivating the use of antipsychotics. Antipsychotic drugs are used sometimes almost by default, for the convenience of the facility, including to control people who are difficult to manage.
Did You Know?
Even worse: Reports have found residents were often given these drugs without their knowledge. Because a company may have marketed itself as effective for dementia when it isnt, and because the sedative effect makes residents easier to care for, and because side effects like the acceleration of cognitive decline are happening internally and thus not apparent by the patients actions, staff may be unaware of the harm theyre committing.
Types Of Medication For Difficult Behaviors In Dementia
Most medications used to treat difficult behaviors fall into one of the following categories:
1.Antipsychotics. These are medications originally developed to treat schizophrenia and other illnesses featuring psychosis symptoms.
Commonly used drugs: Antipsychotics often used in older adults include:
- For a longer list of antipsychotics drugs, see this NIH page.
Usual effects: Most antipsychotics are sedating, and will calm agitation or aggression through these sedating effects. Antipsychotics may also reduce true psychosis symptoms, such as delusions, hallucinations, or paranoid beliefs, but its rare for them to completely correct these in people with dementia.
Risks of use: The risks of antipsychotics are related to how high the dose is, and include:
- Increased risk of falls
- Increased risk of stroke and of death this has been estimated as an increased absolute risk of 1-4%
- A risk of side-effects known as extrapyramidal symptoms, which include stiffness and tremor similar to Parkinsons disease, as well as a variety of other muscle coordination problems
- People with Lewy-body dementia or a history of Parkinsonism may be especially sensitive to antipsychotic side-effects in such people, quetiapine is considered the safest choice
2. Benzodiazepines. This is a category of medication that relaxes people fairly quickly. So these drugs are used for anxiety, for panic attacks, for sedation, and to treat insomnia. They can easily become habit-forming.
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How Do You Deal With Paranoia In Dementia
The best way to deal with paranoia in dementia is through some behavioral techniques meant to calm dementia patients experiencing paranoia. The first such technique is to rule out non-dementia causes of paranoia. Paranoia can also result from:
- Urinary tract infections
- Systemic infections and
- Anxiety disorders
Dementia patients must be told that the cause of paranoia is none of these and only dementia-related reasons. Hiding the reality from them is unwise.
Using validation techniques to acknowledge what the patient is going through is wise. Working to meet the need they are expressing must be done. Such patients should never be proven wrong and must be dealt with honestly. Nothing extra should be added to their reality and remaining calm while dealing with paranoid patients of dementia is of paramount importance.
Arguing is not really that helpful in such cases and offering reassurance is another good option. This can be done through a physical touch combined with reflecting their reality. Shifting attention by turning on the lights or opening blinds or talking on a favorite topic can also be helpful.
What Are Psychotic Symptoms
People who live with severe mental health problems, such as schizophrenia, experience what are called psychotic symptoms. People with dementia can experience psychotic symptoms too. Hallucinations are an example of a psychotic symptom: they involve seeing, hearing, tasting, smelling or feeling something that isnt actually there. The most common type of hallucination is hearing voices, or what is called an auditory hallucination.
Another type of psychotic symptom is a delusion, which means that a person holds very unusual beliefs about themselves or those around them. A person may believe that they are God or another religious figure for example. More frighteningly, they may believe that someone or something is trying to harm them. This is known as a paranoid delusion.
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Why Antipsychotic Drugs Can Be Risky For Dementia Patients
QUESTION: My mother has dementia and lives in a long-term care home. She was put on an antipsychotic drug because she was hard to control. Im worried about her. She seems zonked out all the time. Is there another option?
ANSWER: Its fairly common maybe too common for dementia patients to be given antipsychotic medications.
The drugs were originally developed for people with schizophrenia and other disorders that produce psychotic symptoms such as visual and auditory hallucinations.
Dementia patients can also have hallucinations. So, years ago, doctors began prescribing them to dementia patients who suffer from psychotic episodes or exhibit other troubling behaviour such as aggression and agitation.
However, a growing body of research now suggests that prolonged use of antipsychotic drugs can pose risks to patients, including slightly increasing the chance of developing electrical abnormalities in the heart or causing rigid movements resembling Parkinsons disease.
Whats more, patients taking these drugs face an elevated chance of death from all causes, compared to those who are not on them, says Dr. Barbara Liu, a geriatrician at Sunnybrook Health Sciences Centre.
The reason for the elevated risk of death isnt entirely clear. But its possible that the effects on the heart or the sedation caused by the medication leads to a host of health problems, ranging from bedsores to catastrophic falls.
How Are Antipsychotic Drugs Reviewed
Antipsychotic drug treatments should be reviewed after six or 12 weeks, or both.
When the prescription of an antipsychotic is reviewed, the doctor may suggest stopping the drug in one go or a more gradual reduction known as tapering. In either case, the effects on the persons behavioural and psychological changes should be closely monitored. If they seem to be getting worse, it may be necessary to restart or increase the dose again.
If the person had a pre-existing mental health condition before they developed dementia and this was managed with antipsychotic drugs, they should continue to take them as prescribed by their psychiatrist.
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