Background Antipsychotics (APs) are commonly used to manage neuropsychiatric symptoms (NPS) in the elderly with dementia (approximately 48% of the elderly with dementia are treated with APs), even though several large studies have demonstrated an association between AP treatment and increased morbidity and mortality in people with dementia.
Purpose The aim of this study was to review the scientific literature of the use of AP in the elderly with dementia and to propose an algorithm to assist in decision-making regarding the withdrawal of APs.
Material and methods A computerised literature search (MEDLINE: 1966 to July 2017, EMBASE: 1982 to July 2017) was used to locate relevant literature. The following terms were used in the MESH database and EMTREE thesaurus: aged, antipsychotic agents, behavioural symptoms and dementia. The information and recommendations of full references were extracted to perform an algorithm represented on paper in a flow-chart form. In the algorithm we define non-pharmacological interventions, NPS and signs and symptoms of AP withdrawal. We use the Neuropsychiatric Inventory Questionnaire (NPI-Q) to score the severity of the NPS.
Results Earlier studies of APs used in the elderly with dementia suggest that, in most elderly demented patients, APs can be withdrawn with no effect on behaviour. These patients are likely to benefit from the algorithm we propose to assist clinicians with in the withdrawal of APs (Algorithm 1). Although prolonged treatment in specific circumstances may be advisable in clinical practice, the general advice is to discontinue APs after 12 weeks in cases of agitation or psychosis associated with dementia based on weak and conflicting evidence regarding long-term efficacy. A gradual tapering strategy is to reduce dosage by 25% to 50% every 2 weeks and to end treatment 2 weeks after administering the lowest dose.
Conclusion Information gathered in this review raises the need to establish safe and effective pharmacological approaches to AP prescription for the demented elderly with NPS. We have described an algorithm consisting of three main steps presented in the form of a flowchart that draws on AP withdrawal approaches recommended in both dementia and care guidelines, and which can assist clinicians in the withdrawal of APs.
No conflict of interest
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