Refractory aggressive behavioral and psychological symptoms of dementia
Typical presentation: A nursing home patient with dementia has acute onset of serious aggressive behaviors. She is physically aggressive toward caregivers and has tried to punch them several times. She is at risk of harm to herself and to others. Nonpharmacologic interventions haven’t been effective.
Treatment
First, rule out medical causes. Identify and treat any underlying conditions.
1st-line: Nonpharmacological interventions.
Pharmacologic therapy: Indicated if nonpharmacologic tx is ineffective + medical causes have been ruled out + the patient is at risk of harm to self or others.
-Rx: Aripiprazole (Abilify) — Off-label use, Not FDA approved. D/c if symptoms don’t improve.
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Olanzapine and Ziprasidone aren’t effective.
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Atypical antipsychotics are associated with a higher risk of death due to stroke or sudden cardiac death in patients with dementia.
2nd-generation antipsychotics have an FDA black box warning. In elderly patients with dementia, they are associated with a 1.6- to 1.7-fold increased risk of death due to stroke or sudden cardiac death. 1st-generation antipsychotics also have a black box warning for the same thing.
“In the elderly population, the largest number of prescriptions for atypical antipsychotics is written for the neuropsychiatric symptoms (NPS) of dementia (1). NPS (e.g., delusions, depression, agitation) affect up to 97% of people with dementia over the course of their illness. No atypical antipsychotic is FDA-approved for the treatment of any NPS in dementia.
The decision to initiate an atypical antipsychotic in the elderly with dementia is not one to be taken lightly.
Large-scale meta-analyses of clinical trials have consistently demonstrated a 1.5–1.7 times increased risk of mortality with their use in dementia (3,4). All atypical antipsychotics carry a black box warning from the FDA about this risk, and a similar warning applies to conventional antipsychotics. Atypical antipsychotics are also linked to a 2–3 fold higher risk of cerebrovascular events (CVAE) (absolute risk of approximately 1%). The 2012 American Geriatric Society (AGS) Beers consensus criteria for safe medication use in the elderly recommend avoiding antipsychotics to treat NPS of dementia due to the increased mortality and CVAE risk “unless nonpharmacological options have failed and the patient is a threat to self or others”. Additional adverse effects include cardiovascular and metabolic effects, extrapyramidal symptoms, cognitive worsening, infections, and falls.” Am J Psychiatry. 2012 Sep; 169(9): 900–906.
Further Reading / Reference
Am J Psychiatry. 2012 Sep; 169(9): 900–906. ATYPICAL ANTIPSYCHOTIC USE IN PATIENTS WITH DEMENTIA: MANAGING SAFETY CONCERNS.
Am Fam Physician 2014;90(3):150-158. Delirium in older persons: Evaluation and management.
Am Fam Physician 2016;94(4):276-282. Behavioral disorders in dementia: Appropriate nondrug interventions and antipsychotic use.
JAMA 2005;294(15):1934-1943. Risk of death with atypical antipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials.
BMJ 2005;330(7489):445. Atypical antipsychotic drugs and risk of ischaemic stroke: Population-based retrospective cohort study
CMAJ 2007;176(5):627-632. Risk of death associated with the use of conventional versus atypical antipsychotic drugs among elderly patients.
Am Fam Physician 2010;81(5):617-622. Adverse effects of antipsychotic medications.
Dtsch Arztebl Int. 2017 Jun 30;114(26):447-454. The Diagnosis and Treatment of Behavioral Disorders in Dementia.