When is it appropriate to prescribe antipsychotics to treat the behavioural and psychological symptoms of dementia?

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This topic has been well publicised in recent years and for good reason. We know that there is a huge disparity between the number of people with dementia who are prescribed antipsychotics (180,000 in England each year) and the number who may derive some benefit from the treatment (36,000). We also know that dangerous side effects are likely in this group with as many as 1,800 people at risk of death and 1,620 at risk of cerebrovascular events each year.

The Banerjee report (ref 2) was published in Nov 2009 and recognised these limited benefits and the NICE dementia guideline (ref 3) was updated in Mar 2011 to take the new findings into account.

This was followed by a report (ref 4) from the NHS Institute in Oct 2011, which looked at the economic alternatives to antipsychotics. It estimated that using behavioural interventions to treat individuals with dementia, rather than antipsychotic drugs, would cost an extra £27.6 million per year. However, health care savings would be nearly £70.4 million due to reduced incidence of stroke, falls, and drug savings. When these health care savings are combined with quality of life improvements, the net benefit of behavioural interventions was estimated at nearly £54.9 million per year.

Prescribing data does not suggest that the message is getting through to the front line. The overall trend in prescribing second generation antipsychotics has steadily risen over the last 5 years, although there are no figures yet for prescribing antipsychotics to people with dementia. The NHS Information Centre is currently conducting an audit (ref 5) of primary care prescribing that will be published later in 2012, so that should help fill this gap.

So, is there ever a place for prescribing antipsychotics to people with the behavioural and psychological symptoms of dementia?

Pharmacological interventions, including antipsychotics, have only a limited role in the management of non-cognitive symptoms of dementia. The NICE dementia quality standard states:

The goal for the proportion of people with dementia and mild-to-moderate non-cognitive symptoms who are prescribed antipsychotic medication should be 0%

  • The NICE guideline states that people with dementia who develop non-cognitive symptoms or behaviour that challenges should be offered a pharmacological intervention in the first instance only if they are severely distressed or there is an immediate risk of harm to the person or others
  • Choose an antipsychotic after an individual risk–benefit analysis
    • Start on a low dose and then titrate upwards
    • Limit treatment time and review regularly (at least every 3 months or according to clinical need)
  • For less severe distress and/or agitation, initially use a non-drug option
  • Do not use antipsychotic drugs for mild to moderate non-cognitive symptoms in:
    • Alzheimer’s disease, vascular dementia or mixed dementia, because of the risk of cerebrovascular events and death
    • Dementia with Lewy bodies because of the risk of severe adverse reactions

Links

  1. Implementing key therapeutic topics 2: Antipsychotics in dementia; statins and ezetimibe; and hypnotics. MEREC Bulletin 22(4), Feb 2012.
  2. Banerjee S. The use of antipsychotic medication for people with dementia: Time for action. Nov 2009.
  3. NICE/SCIE. Clinical guideline 42. Dementia: Supporting people with dementia and their carers in health and social care. Nov 2006 (amended March 2011)
  4. NHS Institute for Innovation and Improvement. An economic evaluation of alternatives to antipsychotic drugs for individuals living with dementia. Oct 2011
  5. NHS Information Centre. The national dementia and antipsychotic prescribing audit.