Neurology Central

What is the future for antipsychotic drugs in dementia treatment?

Antipsychotic drugs are regularly prescribed as first-line treatment of behavioral and psychological symptoms in dementia although guidelines recommend non-pharmacological interventions as first approach. Despite these recommendations, it is unlikely that elderly demented patients with behavioral disorders may be treated by non-pharmacological treatment alone, especially when severe aggression and both diurnal and night psychomotor agitation are present.

A wide variety of conventional (haloperidol, promazine) and atypical antipsychotic drugs (risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone and clozapine) are widely used in the management of neuropsychiatric symptoms that are commonly seen in dementia, but results from randomized controlled trials on the efficacy and safety of these agents are controversial [1-4]. Most importantly, adverse events may offset the efficacy of antipsychotics in dementia, although alternative treatments have also not shown any proof of efficacy (i.e. trazodone, selective serotonin reuptake inhibitors such as citalopram, benzodiazepines, memantine, anticonvulsants such as valproate, carbamazepine and topiramate).

Frequently, antipsychotic drugs are prescribed for inappropriate reasons and for too long without regular review. The use of antipsychotics is associated with adverse events like increased risk of falling, stroke, cardiac and metabolic adverse events and mortality. However, there is an overt conflict between the clinical impression of effectiveness and the scientific evidence of risk. Prescribers of these drugs are usually first-line doctors involved in caring for individuals with dementia. In any case, clinicians who have been using these drugs for several years (even ‘off-label’ like occurs in Italy) do not really seem to perceive such a risk/benefit ratio to contraindicate their use.

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