Outcomes of Antipsychotic Use in Dementia
It’s well documented that use of antipsychotics in dementia care can lead to an array of adverse medical outcomes. Recent research suggests that antipsychotics may lead to poor behavioral and functional outcomes as well.
Antipsychotics may exacerbate behavioral symptoms
In newly published research appearing in JAMDA, Leme and colleagues conclude that instead of improving behavioral symptoms, antipsychotics used in long-term care may actually “exacerbate behavioral symptoms”.
Their study focused on residents of long-term care facilities in Canada. About 74% of the residents had a dementia diagnosis, and the vast majority were aged 65 or older. The researchers examined scores on the Agitated Behavior Scale (ABS) in follow-up assessments for individuals who were receiving antipsychotic treatment at baseline.
What they found: “The odds of worsening in behavior symptoms at follow-up were greater in participants who used antipsychotics than those who did not use antipsychotics at baseline." In all, the odds of “worsening behavior” increased by 27% in the presence of antipsychotic therapy, they found.
The authors propose possible reasons for this finding. Side effects of antipsychotic regimens could include extrapyramidal symptoms, i.e., movement disorders such as tremor, rigidity, inability to stand and walk, and others that “could exacerbate BPSD,” say the authors. At the same time, anticholinergic effects (sedation, cognitive impairment, and others) could exacerbate existing behavioral and psychotic symptoms—or lead to the emergence of new symptoms, say the authors.
The findings of Leme et al. build on a body of research challenging the efficacy of antipsychotic regimens for BPSD. For example, researching antipsychotic usage in an outpatient memory disorder clinic, Trinkley et al. reported that antipsychotic usage was associated with worsened behavioral/psychological outcomes in 53% of patients. “Antipsychotic treatment improved behavioral/psychological symptoms for less than one-third of patients and increased the potential risk of adverse events for more than half of patients,” Trinkley et al. concluded.
Changes in ADLs
Wang and colleagues examined how use of antipsychotics was associated with functional outcomes among people living with dementia. They looked at how measures of ADLs changed, comparing individuals who were/were not prescribed antipsychotics. The research subjects were receiving home health care services in New York, some in assisted living facilities. Many (43%) of subjects had been referred for home health following a hospitalization.
The subject population included individuals with a range of dementia diagnoses, including Alzheimer’s disease, vascular dementia, frontotemporal dementia, and dementia with Lewy bodies. The subject selection excluded individuals who had a diagnosis of bipolar disorder or a schizophrenia spectrum diagnosis.
The most prevalent antipsychotic medicine was quetiapine, a medication that has been linked to sudden cardiac death. Also commonly used were prochlorperazine and haloperidol. Some individuals were receiving two different antipsychotic medications.
“Worst functional outcomes” with antipsychotics
The researchers measured functional outcomes for ADLs: grooming, dressing upper/lower body, bathing, toilet transferring, transferring, ambulation, and eating. They found that patients receiving antipsychotics during the course of home health care had the most minimal improvements.
In other words, patients living with dementia were more likely “to experience worse functional outcomes when using antipsychotics,” said the authors.
Hindering individuals’ ability to perform ADLs while taking antipsychotics could be several factors, suggest the authors. They cite confusion, memory loss, reduced mobility, and reduced strength, all of which “may make it more challenging for one to improve in ADL function”.
Plan to deprescribe from the start
Antipsychotics are often prescribed “without appropriate indicators or long past the initial indication,” the authors commented, adding, “Antipsychotics are not the first-line therapy for management of BPSD.” They recommend that if antipsychotic treatment is initiated, there should be a “deprescribing plan” from the start.
Resident safety & outcomes
“Despite evidence of small clinical benefits and potential serious adverse effects, some physicians consider antipsychotics to be an efficacious treatment option for BPSD,” observe Leme et al. They underscore the value of monitoring antipsychotic usage and behavioral changes as critical steps in managing quality of care. Non-pharmacological treatment options should receive a first-line priority, they suggest. These steps are critical to ensure resident and staff safety as well, they note. (Learn more about behavioral strategies in the blog, How to Redirect Behaviors in Dementia.)
New paradigm reduces reliance on antipsychotics
The clinical team of GuideStar Eldercare has been reinventing the paradigm of clinical care for dementia and neurocognitive disorders, leading to better outcomes. Antipsychotics are broadly used in treating BPSDs. Yet armed with a growing knowledge base, we can start with neurology instead, GuideStar Founder & CEO Dr. Steven Posar explained in a recent webinar hosted by McKnight’s Long-Term Care News. This allows us to address the symptoms of BPSD without relying on antipsychotics, which are not only dangerous—but likely not even as effective as clinicians have believed.
To learn more about reducing reliance on antipsychotics, visit the blog, How to Achieve CMS Behavioral Health Compliance. If you are aiming to raise the quality of neurobehavioral care for your nursing home patients, feel free to get in touch.