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expert reaction to antipsychotics for dementia and associated harms

A study published in The BMJ looks at antipsychotic use in people with dementia.

Dr Richard Oakley, Associate Director of Research and Innovation at Alzheimer’s Society, said: 

“900,000 people are living with dementia in the UK. Despite safety concerns, antipsychotics continue to be prescribed for the management of behavioural and psychological symptoms of dementia. 

“Alzheimer’s Society research has shown that using person centred care can help manage symptoms like severe agitation and reduce the need for these antipsychotic drugs. 

“Dementia is the UK’s biggest killer, and this new evidence reinforces the risks of antipsychotic drugs and our previous calls to reduce their dangerous overprescribing. They should only ever be considered as a last resort for treatment.”

Dr Sheona Scales, Director of Research at Alzheimer’s Research UK, said:

“This study reinforces existing evidence about the risks of prescribing antipsychotics to help people with dementia manage their symptoms. These concerns have been known for some time. Alzheimer’s Research UK-funded researchers revealed dangers of antipsychotics in 2008, which raised concerns about their use and prompted government intervention to reduce their prescription.

“The distressing symptoms of dementia, such as confusion and agitation, pose significant challenges for people living with dementia, their families, and caregivers. Treatments that can help manage these symptoms are essential for a better quality of life, but options are currently limited, and in certain circumstances antipsychotics can be used to treat severe symptoms.

“However, these new findings suggest that these risks may be more severe than previously understood, which is particularly concerning given the rise in their use during the pandemic.

“With nearly one million people affected by dementia in the UK, there is an urgent need for research to develop safer and more effective treatments. This means medicines that can alleviate these symptoms, and also address the underlying disease processes that cause dementia. There’s been welcome progress recently, but so much work remains to be done. Alzheimer’s Research UK is committed to delivering effective new treatments for people affected by dementia and eventually, a cure.”

Prof Masud Husain, Professor of Neurology, University of Oxford, said:

“These findings add to existing evidence about the need to be cautious in prescribing antipsychotics to people with dementia. But we need to be clear that they don’t show antipsychotics cause all the adverse outcomes reported. Although the study tried extremely hard to have a matched ‘control’ set of dementia patients who were not prescribed antipsychotics, the people who were prescribed the drugs may simply have been more vulnerable to some of the conditions that occurred more frequently in them, such as pneumonia and cardiovascular disorders.”

Dr Tom Russ, Reader in Old Age Psychiatry and honorary Consultant Psychiatrist, University of Edinburgh, said:

“We have known that there are risks associated with the use of antipsychotic medications in people with dementia and best practice is that the potential risks should always be weighed against the severity of the symptoms the person is experiencing and the possible benefits of using the medication. As with any medication, the prescription should be considered in partnership with the person themselves and their family who should all be provided with enough information to make a decision. This helpful study provides very high quality information about the risks of these medications to inform these discussions. As someone who works with people with dementia in an acute admission ward in a psychiatric hospital, this study does not suggest to me that these medications should never be used, but they should be used sparingly in situations where other avenues (attention to pain, general health, psychosocial interventions including the Newcastle model and arts therapies, as well as other medications) have been explored.”

Prof Robert Howard, Professor of Old Age Psychiatry, UCL Division of Psychiatry, UCL, said:

“Antipsychotic drugs are used to treat severely agitated behaviour and distressing delusions and hallucinations in people with dementia when non-drug treatments have been tried and found to be unhelpful. We aim to use the drugs in as few people with dementia as possible and, when we do use them, this should be at the lowest doses and for the shortest times. Although we have been aware of the potential dangers of treatment for many years, this study highlights that risks of pneumonia, bone fractures and stroke are particularly raised when people with dementia are treated with an antipsychotic drug.

“The study couldn’t exclude reverse causality – where the presence of a physical illness like pneumonia might lead to delirium which could then be treated with an antipsychotic drug – but all of us who prescribe in this situation should be mindful of the risks of treatment. Initiation of these drugs in people with dementia should only ever be under specialist supervision, with involvement of patients and family members in informed discussion and review.”

Prof Charles Marshall, Professor of Clinical Neurology, Centre for Preventive Neurology, Wolfson Institute of Population Health, QMUL, said:

“This evidence should prompt renewed efforts to reduce the prescribing of antipsychotics to people living with dementia. There are rare circumstances where antipsychotics are genuinely required, and the benefits outweigh these risks, but for the majority of patients with behavioural symptoms that might lead to them being prescribed antipsychotics, we should be focussing on much safer behavioural management approaches. The problem is that this type of intervention is quite expensive and resource-intensive. There is a risk therefore that patients might be prescribed harmful antipsychotics simply because trained staff who can safely manage their behaviour are not sufficiently available.”

‘Multiple adverse outcomes associated with antipsychotic use in people with dementia: population based matched cohort study’ by Pearl L H Mok et al. was published in The BMJ at 23:30 UK time on Wednesday 17th April.

DOI: 10.1136/bmj-2023-076268

Declared interests

Prof Masud Husain: I don’t have any conflicts of interest.

Tom Russ: I have no relevant conflicts of interest.

Prof Robert Howard: I don’t have any relevant conflicts.

Prof Charles Marshall: I have no relevant conflicts to declare

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