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Antipsychotic Use in Dementia: More Adverse Outcomes

medication box being loaded by elderly person

Newly published research indicates that pneumonia and a range of adverse outcomes is associated with antipsychotic use among patients who have dementia. “Antipsychotics are commonly prescribed for the management of behavioral and psychological symptoms of dementia, despite longstanding concerns about their safety,” commented the researchers, Mok and colleagues.

They investigated outcomes using health records of 173,910 individuals in the UK who had been diagnosed with dementia, using a matched cohort design. The mean age of patients was 82.1. The study analysis included the antipsychotic medications haloperidol, risperidone, quetiapine, and other antipsychotics. The researchers blocked usage into timeframes to analyze discrete risks over time.

Most prescribed antipsychotics

More than 24,000 records examined included prescriptions for antipsychotics. Most prescribed were:

  • Risperidone: (29.8% of all antipsychotic prescriptions)
  • Quetiapine (28.7%)
  • Haloperidol (10.5%)
  • Olanzapine (8.8%)

As noted in a previous blog, quetiapine has been linked to sudden cardiac death.

Pneumonia, adverse outcomes

The association between antipsychotics and pneumonia was most striking in these results. The authors explain their findings, “Over the 180 days after drug initiation, use of antipsychotics might be associated with one additional case of pneumonia for every nine patients treated.” They also saw a heightened risk of myocardial infarction—one additional case for every 167 patients treated.

The pneumonia risk was highest in the first seven days of treatment, they add, and this initial period was high-risk for other adverse outcomes as well.

Other adverse outcomes noted were the risk of stroke, venous thromboembolism, fracture, and acute kidney injury. These risks “remained increased among continuous antipsychotic users up to two years after initiation of treatment,” they reported.

Zeroing in on specific medications, they noted that haloperidol (compared with risperidone) posed higher risks for fracture, pneumonia, and acute kidney injury. However, risks for stroke, venous thromboembolism, myocardial infarction, and heart failure were about equal for the two medications.

For quetiapine versus risperidone, both medications carried about equal risks for myocardial infarction, heart failure, and fracture. The pneumonia risk was lower with quetiapine than risperidone.

As compared with women, men had the highest risk of most adverse outcomes, they added.

A wide “range of harms”

The authors conclude that antipsychotic use among individuals with dementia is associated with a wide “range of harms”.  They underscore that the most acute risks occur in the first week of treatment, yet risks persist with ongoing use. They urge long-term care clinicians to “actively consider the risks” along with a patient’s comorbidities when making prescribing decisions. When antipsychotics are used, they advocate for close clinical monitoring.

The authors also acknowledge that in the face of risks, there has been a trend towards replacing antipsychotics with alternate psychotropic drugs, such as anticonvulsants, benzodiazepines, and others—but these drugs pose risks as well.

In addressing behavioral and psychological symptoms of dementia (BPSD), their stand is that we need to work harder to develop safer and more effective treatments, including non-drug options.

The GuideStar Eldercare team helps long-term care professionals navigate the challenges of managing BPSD, while reducing antipsychotic usage through an evidence-based protocol. How can you manage the risks of adverse outcomes for residents in your care? Reach out to learn more.