New Practice Guidelines on Antipsychotic Use in Dementia

Megan Brooks

May 03, 2016

Judicious use of antipsychotics to treat agitation or psychosis in patients with dementia is the focus of a new practice guideline from the American Psychiatric Association (APA).

The evidence-based recommendations call for assessing psychological and behavioral symptoms of dementia, developing a comprehensive treatment plan, performing a risk/benefit analysis before prescribing an antipsychotic, and using these medications judiciously and not indefinitely.

"The topic of this guideline is timely and important, for several reasons," guideline author Laura Fochtmann, MD, MBI, told Medscape Medical News.

"With the aging of the population, there is a corresponding increase in numbers of individuals who have a diagnosis of dementia. And many of these individuals will experience agitation or psychosis at some point in the course of their illness," explained Dr Fochtmann, professor of psychiatry, pharmacological sciences, and biomedical informatics at Stony Brook University School of Medicine, New York, and medical editor for APA practice guidelines.

"Antipsychotic medications have been one of the approaches used to try to address agitation and psychosis when they occur in the context of dementia. However, they are not always effective.

"There is also a growing amount of research that suggests that antipsychotic treatment can be associated with physical risks when these medications are used in individuals with dementia. Thus, we felt it was important to undertake a rigorous review of the literature and then develop guidelines for clinical practice," added Dr Fochtmann.

The executive summary of the guideline was published online May 1 in the American Journal of Psychiatry. The full guideline is available on the APA's website, Psychiatry Online.

Recommendations

Each guideline statement is rated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. A "recommendation" (denoted by the number 1 after the guideline statement) indicates confidence that the benefits of intervention clearly outweigh the harms. A "suggestion" (denoted by the number 2 after the statement) indicates uncertainty regarding the balance of benefits and harms. Each recommendation also has an associated letter rating for the strength of supporting research evidence, indicated as high (A), moderate (B), or low (C).

The guideline includes 15 specific recommendations regarding antipsychotic use to treat agitation or psychosis in patients with dementia:

  1. Assess patients for the type, frequency, severity, pattern, and timing of symptoms. (1C)

  2. Assess patients for pain and other potentially modifiable contributors to symptoms as well as for factors such as dementia subtype that may influence choices of treatment. (1C)

  3. In patients with dementia with agitation or psychosis, assess response to treatment using a quantitative measure. (1C)

  4. Develop a comprehensive treatment plan that includes appropriate person-centered nonpharmacologic and pharmacologic interventions, as indicated. (1C)

  5. Only use nonemergency antipsychotic medication when agitation and psychosis symptoms are severe, are dangerous, and/or cause significant distress to the patient. (1B)

  6. Review the clinical response to nonpharmacologic interventions prior to nonemergency use of an antipsychotic medication to treat agitation or psychosis in patients with dementia. (1C)

  7. Before starting nonemergency treatment with an antipsychotic, assess and discuss with the patient/family/decision maker the potential risks and benefits. (1C)

  8. If a risk/benefit assessment favors the use of an antipsychotic for behavioral/psychological symptoms in patients with dementia, start treatment at a low dose and titrate up to the minimum effective dose as tolerated. (1B)

  9. If a clinically significant side effect of antipsychotic treatment emerges, review the potential risks and benefits of antipsychotic medication to determine whether tapering and discontinuance of the medication are indicated. (1C)

  10. If there is no clinically significant response after a 4-week trial of an adequate dose of an antipsychotic drug, the medication should be tapered and withdrawn. (1B)

  11. In a patient who has shown a positive response to an antipsychotic, decisions about possible tapering of the medication should be made with input from the patient (if feasible) or surrogate decision maker, family, or other caregiver, with the aim of eliciting their preferences and concerns and reviewing the initial goals, observed benefit, and side effects of antipsychotic treatment and potential risks of continued use, as well as past experience with antipsychotic medication trials and tapering attempts. (1C)

  12. For a patient who has an adequate response of behavioral/psychological symptoms to antipsychotic treatment, an attempt to taper and withdraw the drug should be made within 4 months of initiation unless the patient experienced a recurrence of symptoms with prior attempts at tapering of antipsychotic medication. (1C)

  13. For a patient whose antipsychotic medication is being tapered, assess symptoms at least monthly during the taper and for at least 4 months after medication discontinuance to identify signs of recurrence and trigger a reassessment of the benefits and risks of antipsychotic treatment. (1C)

  14. In the absence of delirium, if nonemergency antipsychotic medication treatment is indicated, haloperidol should not be used as a first-line agent. (1B)

  15. A long-acting injectable antipsychotic medication should not be utilized unless it is otherwise indicated for a co-occurring chronic psychotic disorder. (1B)

Some Surprises

"Many of the recommendations in this guideline will be correctly seen as reinforcing general principles of good clinical care," said Dr Fochtmann. "For example, it's always appropriate to assess the characteristics of a patient's symptoms and look for underlying causes of symptoms that may need to be addressed."

One recommendation that may represent a change in practice is the advice that clinicians use a quantitative measure to track symptoms and response to treatment, she added.

"A quantitative measure could be a rating scale, an overall assessment of symptom severity on a Likert scale, or a count of episodes of agitation. Such measures are straightforward to do and help give a more objective picture of the effects of treatment, changes in the living environment, or other contributors to symptoms, such as pain.

"It may also come as a surprise that we are recommending an attempt at tapering and stopping an antipsychotic medication within 4 months of initiation. It may seem counterintuitive to do this when an individual is doing well. However, studies showed that a significant fraction of individuals with dementia could have an antipsychotic medication stopped without a return of their agitation or psychosis," said Dr Fochtmann.

"Antipsychotics are widely used in the treatment of behavioral and psychological symptoms of dementia, despite only modest evidence of efficacy [and this only for short-term usage] and in the face of ever increasing evidence of a significant risk of mortality and morbidity associated with their use," first author Victor I. Reus, MD, professor, Department of Psychiatry, University of California, San Francisco, School of Medicine, told Medscape Medical News.

"Once initiated, the agents often continue to be prescribed for months or years, long after the original symptoms have abated. Studies have shown that up to 70% of patients can successfully be withdrawn from these agents without relapse and without incurring the ongoing impairment to cognition and quality of life associated with their continued use," he noted.

Dr Reus agrees that the "greatest surprise is likely to be the recommendation that all patients, even those who have had a positive response, should have an attempted withdrawal of their antipsychotic drugs within 4 months, unless they have a history of previous relapse or unless a comorbid condition is being treated.

"For most patients, it seems clear that the risk of ongoing harm outweighs the benefits of continuing treatment, and these individuals will never be identified if a clear protocol for withdrawal is not routinely used. Certainly close and frequent monitoring during an extended taper is required to also identify those who might benefit from continued usage of the drug."

Potentially Useful

Commenting on the guidelines for Medscape Medical News, Donovan Maust, MD, assistant professor of psychiatry, University of Michigan, and research scientist, Center for Clinical Management Research, VA Ann Arbor Healthcare System, said that although this practice guideline is "potentially useful for psychiatrists," he would "like to think many in the field are already following most of the suggestions."

Dr Maust also believes the advice to review nondrug interventions before opting for an antipsychotic "suggests an unfortunately and inappropriately passive role for psychiatrists in addressing challenging behaviors through nonpharmacological means.

"Among medical specialties, psychiatrists should be the experts at understanding such behaviors and crafting a nondrug treatment plan through something like the DICE approach ― in other words, they should be doing more than just 'reviewing response,' as the guidelines suggest.

"Unfortunately, while these 'nondrug interventions' ― especially those that include caregivers ― need to be the mainstay of treatment, the structure of reimbursement and care delivery make them challenging to deliver," Dr Maust said.

Steven Huege, MD, of the Geriatric Psychiatry Section, University of Pennsylvania Perelman School of Medicine, in Philadelphia, said "it's good that the APA has come out with this guideline and is bringing attention to the issues facing older adults with dementia and behavioral disturbances.

"Geriatric patients with dementia are a particularly vulnerable population, and with any medication, there has to be a risk/benefit analysis. For some patients, where the level of agitation or psychosis is so intense, there are instances where patients are very much helped by these medications. These medications do have risks, but psychosis, agitation, and severe distress also carry risks and dangers as well," said Dr Huege, who is in the process of transitioning to the University of California, San Diego, where he will direct the geriatric psychiatry fellowship program.

On the recommendation to attempt taper and withdrawal of antipsychotic medication after a period, Dr Huege said he is not a fan of "blanket statements" and favors a more individualized approach. "I applaud the goal of reducing unnecessary medications, but for some patients, discontinuing these medications might cause more harm than good," he told Medscape Medical News.

Am J Psychiatry. Published online May 1, 2016. Full text

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