Antipsychotics for patients with dementia: The road less traveled

Alternative psychopharmacologic treatments based on a psychobehavioral metaphor should also be considered (Table 2¹¹). This approach matches the dominant target symptoms to the most relevant medication class.¹¹ For example, in the case of a verbally and physically agitated patient who is also irritable, negative, socially withdrawn, and appears dysphoric, we might first undertake a trial of an antidepressant. Conversely, if the patient shows agitation in the context of increased motor activity, loud and rapid speech, and affective lability, we might consider the use of a mood stabilizer. Pharmacologic treatment should be aimed at the modification of clearly identified and documented target behaviors.

Indications to use antipsychotics for patients with dementia include:

• severe agitation and aggression associated with risk of harm
• delusions and hallucinations
• comorbid preexisting mental health conditions (eg, bipolar disorder, schizophrenia, treatment-resistant depression, etc.).

Symptoms that do not usually respond to an antipsychotic include wandering, social withdrawal, shouting, pacing, touching, cognitive defects, and incontinence.¹² These symptoms may respond to interventions such as changes to the environment.

Continued to: Choosing an antipsychotic

Choosing an antipsychotic

Once you have identified that an antipsychotic is truly indicated, the choice of an agent will focus on patient-related factors. Considerations such as frailty, comorbid medical conditions including diabetes, history of falls, hepatic insufficiency, cardiac arrhythmias, and cerebrovascular risk factors, should all be analyzed prior to initiating an antipsychotic. The presence of these conditions will increase the likelihood that adverse effects may occur. It will also guide the dose trajectory and the target dose for discontinuation. Antipsychotics differ with respect to their efficacy and adverse effect profile. For practical purposes, adverse effects typically guide the selection of these agents when used for patients with dementia.

Continued to: Gradual structural changes occur...