Multiple risks and modest benefits suggest moderation in the use of antipsychotics in patients with dementia

Antipsychotics are often prescribed to control behavioral and psychological symptoms of dementia, despite known concerns about their safety. Guidelines indicate that they are only indicated in these cases when non-pharmacological interventions fail, if patients pose risks to themselves or others, as well as if they experience agitation, hallucinations or delusions that cause serious suffering.

Most studies on problems related to the use of psychotics in dementia patients reported only one outcome or type of outcome. In order to provide a more comprehensive estimate of the problems related to this treatment, one study evaluated the risks of stroke, venous thromboembolism, myocardial infarction, heart failure, ventricular arrhythmia, fracture, pneumonia and acute kidney injury in a large cohort of adults with dementia.

Using information from the database Clinical Practice Research Datalink (CPRD) in England, the analysis included 35,339 adults (≥50 years, 63% women) with dementia who had been prescribed antipsychotics for the first time, within a broader population of 173,910 adults with dementia. The authors found significantly higher risks for almost all adverse outcomes assessed in antipsychotic users, with especially marked increases for pneumonia (risk ratio 2.19), acute kidney injury (1.72), and stroke (1.61). and venous thromboembolism (1.62) in the first 90 days after prescription.

The authors concluded that antipsychotic use in adults with dementia was associated with an increased risk of stroke, venous thromboembolism, myocardial infarction, heart failure, fracture, pneumonia, and acute kidney injury, but not ventricular arrhythmia. The range of adverse outcomes was greater than previously recognized, with greater risks occurring soon after starting treatment, particularly pneumonia.

The use of this treatment has been increasing, although evidence indicates only modest benefits. Although there are situations in which prescribing antipsychotics is the least harmful option, it is necessary to consider the risks, the patients’ comorbidities and their vital support. If we decide to prescribe, it should be in minimum doses, for short periods and with frequent reviews of the results.

Anyway, use in moderation!