recently british medical journal Researchers are evaluating the adverse effects associated with the use of antipsychotic drugs in patients with dementia.
study: Multiple adverse outcomes associated with antipsychotic use in patients with dementia: a population-based matched cohort study. Image credit: Fahroni / Shutterstock.com
The role of antipsychotics in dementia management
People diagnosed with dementia experience functional impairment and progressive cognitive decline. Common psychological and behavioral symptoms of dementia include anxiety, depression, apathy, aggression, delirium, irritability, and psychosis.
To manage the psychological and behavioral symptoms of dementia, patients are usually treated with antipsychotic drugs. The UK National Institute for Healthcare Excellence currently recommends the use of antipsychotics only when non-drug interventions are ineffective in reducing the behavioral and psychological symptoms of dementia. However, the use of antipsychotics has increased during the recent coronavirus disease (COVID-19) pandemic, which is believed to be due to lockdown measures and the unavailability of non-drug treatments. .
In the UK, risperidone and haloperidol are the only antipsychotic drugs approved to treat the behavioral or psychological symptoms of dementia. In 2003, the U.S. Food and Drug Administration (FDA) highlighted the risks of stroke, transient ischemic attack, and death associated with the use of risperidone in older adults with dementia.
Based on research reports, regulatory guidelines have been developed in the UK, US and Europe to reduce inappropriate prescribing of antipsychotics in the treatment of behavioral and psychological symptoms of dementia. To date, little evidence has been reported of an association between antipsychotic prescription and the risk of multiple diseases such as myocardial infarction, venous thromboembolism, ventricular arrhythmia, and acute kidney injury in older adults with dementia.
About research
The current study investigated the risk of adverse outcomes associated with antipsychotic medications in a large cohort of adults with dementia. Some adverse outcomes considered in this study were venous thromboembolism, stroke, heart failure, ventricular arrhythmia, bone fractures, myocardial infarction, pneumonia, and acute kidney injury.
More than 98% of the UK population is enrolled in primary care general practice with the National Health Service (NHS). All relevant data were collected from electronic medical records held in the Clinical Practice Research Datalink (CPRD) associated with over 2,000 general practices. The CPRD consists of the Aurum and GOLD databases, which are considered to be broadly representative of the UK population.
The subjects were people aged 50 and over who had been diagnosed with dementia. Importantly, none of the study participants had received antipsychotic intervention in the year prior to diagnosis.
The researchers utilized a matched cohort design, using incidence density sampling to match each patient who used antipsychotic medication after their initial dementia diagnosis. The method involved up to 15 randomly selected patients diagnosed with dementia on the same day but not prescribed antipsychotic medication.
Antipsychotics increase risk of side effects in dementia patients
Across the two cohorts, the average age of participants was 82.1 years. A total of 35,339 participants were prescribed antipsychotic medications during the study period.
The mean number of days from initial diagnosis of dementia to date of first antipsychotic prescription was 693.8 and 576.6 days for Aurum and Gold, respectively. The most commonly prescribed antipsychotics were risperidone, haloperidol, olanzapine, and quetiapine.
Current population-based studies show that adults with dementia who are prescribed antipsychotics have an increased risk of venous thromboembolism, myocardial infarction, stroke, heart failure, pneumonia, bone fractures, and acute kidney injury compared with non-users. It turned out to be high. This observation is based on an analysis of 173,910 adults with dementia selected from both databases.
Increased risk of adverse outcomes was most common among current and recent users of antipsychotics. Using antipsychotics for 90 days was associated with a higher risk of venous thromboembolism, pneumonia, acute kidney injury, and stroke than nonusers. However, antipsychotics had no effect on the risk of ventricular arrhythmias, appendicitis, or cholecystitis.
Compared to risperidone use, haloperidol was significantly associated with increased risk of pneumonia, bone fractures, and acute kidney injury. Although side effects of haloperidol were higher than quetiapine, no significant differences were observed between risperidone and quetiapine in terms of risk of fracture, heart failure, and myocardial infarction. The risks of pneumonia, stroke, acute kidney injury, and venous thromboembolism were lower with quetiapine compared with risperidone.
conclusion
This study sheds light on how antipsychotic drugs affect older people with dementia. Use of these drugs has been associated with a number of serious adverse outcomes, including stroke, acute kidney injury, pneumonia, venous thromboembolism, heart failure, and myocardial infarction.
In the future, these risks, along with cerebrovascular events and mortality, should be considered when making regulatory decisions regarding the use of antipsychotics in the treatment of dementia in older adults.
Reference magazines:
- Mok, L.H.P., Kerr, M.J., Guthrie, B.; and others. (2024) Multiple adverse outcomes associated with antipsychotic use in patients with dementia: a population-based matched cohort study. BMJ. doi:10.1136/bmj.2023.076268
