Behavioral and psychotic symptoms of dementia (BPSD), including delusions, hallucinations, agitation and aggression, can all occur in people with Alzheimer's disease. They appear more often in the moderate to severe stages, and if they are not able to be managed, can be one of the main reasons a person with Alzheimer's disease will need inpatient care.
The Use of Atypical Antipsychotics in Alzheimer's Disease Treatment
Although BPSD can be helped to some degree by behavioral measures and the drugs specifically designed to treat Alzheimer's disease, guidelines produced by the American Psychiatric Association (APA) suggest that some symptoms, especially psychosis and agitation, may also be aided by the use of atypical antipsychotics such as risperidone, olanzapine and aripiprazole. However, it must be noted that antipsychotics are not approved by the U.S. Food and Drug Administration (FDA) specifically for the treatment of Alzheimer's disease.
The Advantages of Atypical Antipsychotics
There have been a number of studies of the use of atypical antipsychotics in people with Alzheimer's disease, many of which are reviewed by Clive Ballard and Robert Howard in the June 2006 edition of "Nature." One large study on this topic, involving 421 patients, was the Clinical Antipsychotic Trials of Intervention Effectiveness--Alzheimer's disease trail, or CATIE-AD, and the results after 12 weeks of treatment were published by David Sultzer and colleagues in the "American Journal of Psychiatry" in July 2008.
Overall, these studies have found moderate benefits for atypical antipsychotics for some patients only, although these gains have mostly been in the short-term of up to 3 months. Olanzapine was found to be beneficial for agitation, aggression and "hostile suspiciousness;" risperidone was advantageous for aggression and psychosis, as well as scoring well on overall ratings of improvement in behavior cognition and function; and aripiprazole scored well for agitation and overall behavioral symptoms.
The Disadvantages of Atypical Antipsychotics
There are a number of disadvantages associated with the use of atypical antipsychotics in people with Alzheimer's disease, the most serious of which is reflected in the November 2005 Federal Drugs Administration warning that states that the "FDA has determined that the treatment of behavioral disorders in elderly patients with dementia with atypical antipsychotic medications is associated with increased mortality." Thus, it has been recommended by the APA that trials of atypical antipsychotics are used only a last resort, and have to be carefully monitored once the pros---controlling worrying and possibly dangerous BPSD, and cons---fatality and other adverse effects, have been weighed.
The second serious adverse event found is detailed in a meta-analysis paper of 15 trials published in the March 2006 edition of the "American Journal of Geriatric Psychiatry" by Lou Schneider and colleagues. They found a 2.13-fold increased risk for a cerebrovascular adverse event, such as a stroke, when combining studies of all atypical antipsychotics, and a 3.43-fold increased risk with risperidone. Other adverse events are sleepiness with aripiprazole, risperidone and olanzapine; peripheral edema with risperidone and olanzapine; movement disorders with risperidone; abnormal gait with olanzapine, and increased weight gain and decreased HDL-cholesterol in women with olanzapine.
References
- "Archives of Gerontology and Geriatrics"; Behavioral and Psychotic Symptoms of Dementia (BPSD) Improvements in a Special Care Unit: a Factor Analysis. Mauro Colombo and colleagues, 2007 Supplement
- "American Journal of Psychiatry"; American Psychiatric Association Practice Guideline for the Treatment of Patients with Alzheimer's Disease and Other Dementias. Second Edition; APA Work Group on Alzheimer's Disease and Other Dementias; December 2007
- "Nature"; Neuroleptic Drugs in Dementia: Benefits and Harm; Clive Ballard and Robert Howard; June 2006
- "American Journal of Psychiatry"; Clinical Symptom Responses to Atypical Antipsychotic Medications in Alzheimer's disease: Phase 1 Outcomes From the CATIE-AD Effectiveness Trial; David Sultzer and colleagues; July 2008
- "American Journal of Geriatric Psychiatry"; Efficacy and Adverse Effects of Atypical antipsychotics for Dementia: Meta-analysis of Randomized, Placebo-Controlled Trails; Lon Schneider, Karen Dagerman and Philip Insel; March 2006
