ATYPICAL ANTI-PSYCHOTIC MEDICATION

Atypical Anti-Psychotic Medication In The Management Of Aggression In People With Dementia



Atypical Anti-Psychotic Medication In The Management Of Aggression In People With Dementia

Litreature review

Atypical antipsychotic drugs have been used off-label in clinical practice for treatment of serious dementia-associated agitation and aggression (Teri L, Gibbons LE, McCurry SM, et al. 2003). Following reports of cerebrovascular adverse events associated with the use of atypical antipsychotic in elderly patients with dementia, the FDA issued black box warnings for several atypical antipsychotics, titled “Cerebrovascular Adverse Events, including Stroke, in Elderly Patients with Dementia (Pollock BG; 2005).” Subsequently, the FDA initiated a meta-analysis of safety data from 17 registration trials across six antipsychotic drugs (five atypical antipsychotics and haloperidol). In 2005, the Agency issued a black box warning regarding increased risk of mortality associated with the use of atypical antipsychotic drugs in this patient population (Sloane PD, Hoeffer B, Mitchell CM, McKenzie DA, Barrick AL, Rader J, Stewart BJ, Talerico KA, Rasin JH, Zink RC, Koch GG. 2004). Geriatric mental health experts participating in a 2006 consensus conference reviewed evidence on the safety and efficacy of antipsychotics, as well as nonpharmacologic approaches, in treating dementia-related symptoms of agitation and aggression. Other studies have suggested that risperidone, olanzapine, and quetiapine may be more effective for treating the symptoms of agitation and aggression than for hallucinations and delusions in the psychosis of dementia. Small scale studies of treatment with drugs other than antipsychotics have produced equivocal results. Trazodone (Pollock BG; 2005), anti-convulsant mood stabilizers, SSRIs, benzodiazepines, and cognitive enhancers may reduce symptoms of agitation and aggression in a proportion of patients with dementia, although the overall results are inconsistent. The available data are limited by small numbers of subjects or shortcomings in study design, and a number of these drugs have their own adverse effects. None of these drugs has been approved by the FDA for treatment of behavioral symptoms of dementia (Ostwald SK, Hepburn KW, Caron W, et al. 1999).

Dementia-Related Symptoms of Agitation and Aggression

Katz IR, Jeste DV, Mintzer JE, et al. (1999) overview tha despite extensive clinical experience with off-label prescribing, as well as published clinical trials of conventional (typical) and atypical antipsychotic drug treatment of symptoms of agitation and aggression in dementia, the efficacy of these drugs for psychosis and these behavioral symptoms has not been established in FDA-required registration trials (Katz IR, Jeste DV, Mintzer JE, et al. 1999). In the past decade, in an effort to encourage research and improve clinical practice, geriatric psychiatrists placed the behavioral and psychotic symptoms of Alzheimer disease (AD) into a new diagnostic category of “psychosis of Alzeheimer disease and related dementias”. By 2000, the FDA had accepted this new diagnosis, which made possible the diagnostic differentiation of dementia-associated psychosis from late-life schizophrenia and other late-life psychoses (Kovach CR, Taneli Y, Dohearty P, et al. 2004).

Data from functional imaging studies and neuropathology suggest that among the multiple causes of symptoms of agitation and aggression in AD, patients may have an identifiable pathophysiology (Ostwald ...