Treatment of behavioural and psychiatric symptoms in dementia: implications of recent safety warnings

Atypical antipsychotics are commonly used off-label to treat behavioural and psychiatric symptoms in dementia (BPSD), particularly in elderly care homes. Much of this use is inappropriate, and trials have shown an increased likelihood of serious cerebrovascular adverse events (CVAEs) such as stroke and transient ischemic attack (TIA) in elderly patients. The aetiology of this risk is not known, but may be related to metabolic effects and excess weight gain. Based on a review of published trials with risperidone and olanzapine that shows a threefold increase in stroke risk in elderly patients with dementia, regulators in Europe and the USA now recommend against using these agents for behavioural control, particularly in patients with a history of cerebrovascular disease. When making prescribing decisions, physicians should pay careful attention to risk versus benefit with psychotropics. Antipsychotics should be regarded only as rescue medications for acute-onset (over hours or days) or for severe chronic BPSD, or used in patients who are aggressive and/or represent a danger to themselves or others. If atypical antipsychotics are prescribed, physicians should screen for risk factors for both stroke and cardiovascular disease when initiating treatment, and regular monitoring should be undertaken if patients with chronic behavioural problems receive antipsychotic maintenance therapy. International guidelines are now required that direct prescribers in the appropriate use of alternative therapies for BPSD. Cholinesterase inhibitors (ChEIs), particularly rivastigmine, can delay the onset and reduce the severity of neuropsychiatric symptoms in dementia, and decrease the requirement for antipsychotic and other psychotropic medications. Evidence suggests that they may be more appropriate for the control of chronic (over weeks to months) mild-to-mode rate BPSD.