Risk-Benefit Analysis: Antipsychotics in Dementia Care
Whether to prescribe antipsychotic medications in dementia care can be a challenging decision. In an assessment of risks vs. benefits for antipsychotics, it’s important to be able to identify individuals who may be at high risk of adverse events.
“Almost 9 of 10 antipsychotic users have at least one measure of high-risk use,” according to new research by Hieu et al., just published in JAMDA. More than 4 of 10 have two or more measures of high-risk antipsychotic use, reported the authors. Their research in Australia was based on 22,710 people living with dementia who were prescribed an antipsychotic.
The research team examined antipsychotic risks along four channels:
- Possible drug-drug interactions
- Possible drug-disease interactions, such as diabetes or stroke
- Concomitant psychotropic medication (psychotropic polypharmacy)
- Prolonged duration of use
Each of the above factors has been associated with a heightened risk of adverse events with antipsychotics. In the study population, the most prevalent risk factor identified was psychotropic polypharmacy, affecting more than 3 out of 4 patients. Next was drug-drug interactions (31%), followed by prolonged duration of use (9%).
Diabetes, stroke history
Hieu et al. found that more than 1 in 5 members of the study cohort had diabetes or a history of stroke. What’s the potential for drug-disease interaction? Antipsychotic medications “may increase the risk of stroke and exacerbate the progression of diabetes,” state the authors. Potential adverse effects include orthostatic hypotension, QTc prolongation, tachycardia, and metabolic alterations. Conditions such as Parkinsonism, epilepsy, and renal or liver disease may also be exacerbated, they note.
Psychotropic polypharmacy
The most common psychotropic drug combination involving antipsychotics Hieu et al. found was an antipsychotic plus antidepressants. Next was an antipsychotic plus an opioid.
How well psychotropic drug combinations work is not well known, observe the authors. Meanwhile, psychotropic polypharmacy can increase the risk of falls, hospitalization, and mortality, they say.
In other research, Atee et al. found that about half of Australian long-term care residents living with dementia were prescribed more than one psychotropic medication. Most common medications were antipsychotics, opioids, anxiolytics, sedatives, and antidepressants (in that order).
Vulnerable to psychotropic polypharmacy
Psychotropic polypharmacy may occur as prescribers strive to manage behavioral and psychological symptoms of dementia (BPSDs). Some scenarios of concern cited by Harris and Iaboni are:
- Prescribing cascade – treating the side effects of one psychotropic drug with another psychotropic drug
- Adding a psychotropic drug rather than replacing a psychotropic drug that isn't proving effective
“Older adults with dementia are particularly vulnerable to polypharmacy given dementia’s heterogeneous clinical profile, lack of a single efficacious treatment, and high rates of multimorbidity,” explain Harris and Iaboni.
Aging and frailty can also contribute to the additive risks of psychotropic polypharmacy, they say. Impaired cognitive function and impaired mobility can make it more difficult to detect the adverse effects of polypharmacy in dementia, as well. For example, a fall could be “misattributed to geriatric syndromes or progression of the underlying dementia,” they suggest.
Risks and benefits
The adverse outcomes of antipsychotic use in dementia can be multifold—including the risk of pneumonia, stroke, venous thromboembolism, fracture, and acute kidney injury. Declines in functional outcomes, with changes in ADLs, have also been reported. Ironically, several researchers have discovered worsened behavioral and psychological outcomes in the presence of antipsychotic medications, as explained in a recent GuideStar blog about outcomes of antipsychotic use in dementia.
On the other side of the equation, what are the benefits—and do they outweigh the risks? Not all psychotropic medications present equal risks and benefits, and the best answer is not the same for every resident’s clinical condition. It is helpful to examine the evidence base and establish adequate indications for use. For antipsychotics, Hieu et al. comment, “Evidence indicates that antipsychotics offer only limited benefits in symptom control; they are associated with increased risks of adverse events and mortality.”
It is possible for “other psychotropic and CNS-acting medications to be used in place of antipsychotics for the treatment of neuropsychiatric symptoms,” suggest Harris and Iaboni. For instance, the evidence-based pairing of an acetylcholinesterase inhibitor and memantine can be useful in managing BPSDs.
Along with accurate diagnosis and clinical findings, the decision of whether to prescribe a psychotropic medication can be influenced by what is known about the risks and benefits of a proposed drug. Clinicians can turn attention to any heightened risks that may be present, such as drug-disease interactions, drug-drug interactions, or psychotropic polypharmacy. When behavioral concerns are present, the first-line approach stipulated by CMS F605 is nonpharmacological interventions, such as those for wandering or aggressive behaviors.
The interdisciplinary GuideStar Eldercare team can help with addressing behavioral symptoms and managing psychotropic medications. Feel free to get in touch.