Prescribing antipsychotics in geriatric patients: Focus on dementia

Conclusions

The Table provides a summary of the evidence regarding the use of antipsychotics in patients with dementia. Expert consensus is that among BPSD, aggression and psychosis are the primary indications for using antipsychotics.⁵¹ Based on multiple RCTs and meta-analyses, the evidence for using SGAs to treat these symptoms is moderate at best. However, in real-world practice settings, SGAs are widely used for symptoms, such as wandering, inappropriate behaviors, resistance to care, etc., for which there is no evidence for efficacy other than sedation. Furthermore, even when there is a potential for benefit, this must be balanced against the risk of adverse effects, including somnolence, worsened cognition, extra­pyramidal symptoms, stroke, and mortality.
 

Clinicians who care for older adults with BPSD should strive to increase the use of first-line nonpharmacologic strategies, by using structured approaches such as DICE (Describe, Investigate, Create, Evaluate) described in the Box.⁵¹ Antipsychotics should be reserved for situations in which nonpharmacologic approaches are unsuccessful, or there is concern for serious or imminent risk to the patient or others.

In the future, observational studies using biomarkers, such as neuroimaging markers, of brain health in older patients taking antipsychotics for various durations may give us a better understanding of long-term antipsychotic safety and tolerability and the monitoring required to assess long-term burden of specific antipsychotics in real-world samples.⁵² However, because of various biases, observational data may not provide answers to all questions,⁵³ and a major challenge is that the number of published RCTs specific to geriatric patients is not growing substantially. Pharmacotherapy evidence is not keeping up with demographic trends. Key developments in RCTs will be the inclusion of biomarkers via neuroimaging, drug serum or brain levels, and genetic profiling. Because of the modest findings of benefits of antipsychotics in dementia and safety concerns addressing brain health in preclinical or early stages, identification of effective non-drug interventions and identifying true disease-modifying agents will be the next challenges of dementia research.