Antipsychotic drug guidelines for patients with dementia need to be reviewed

Guidelines for reviewing the use of antipsychotic drugs to control neuropsychiatric symptoms – such as aggression, agitation and psychosis – in patients with dementia need urgent review, say researchers.

The study, published in The American Journal of Psychiatry
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on 20 November 2015, looked at the impact on patients of different approaches to reducing antipsychotic drug use in nursing homes.

Researchers found that a review protocol, based on National Institute for Health and Care Excellence (NICE) guidelines, reduced the use of antipsychotic drugs by dementia patients but led to deterioration of neuropsychiatric symptoms. However, when the protocol was used alongside a programme of social interaction and activities, neuropsychiatric symptoms and mortality rates improved.

“Reducing the use of these drugs without any other interventions could result in worsening of neuropsychiatric symptoms, which are highly distressing to the person, their carers and loved ones,” says Anne Corbett, one of the researchers. The results demonstrate the “critical importance” of ensuring that any reduction in medication is accompanied by non-drug approaches to symptom control, particularly social interaction, she adds.

The trial involved 277 patients with dementia living at 16 nursing homes in London, Oxfordshire and Buckinghamshire. The researchers from the Institute of Psychiatry, Psychology & Neuroscience at King’s College London randomly assigned each nursing home to deliver one or more of a combination of three interventions — antipsychotic review, social interaction and an exercise programme — over nine months.

The review protocol reduced antipsychotic drug use by 50% but there was an increase in neuropsychiatric symptoms when used alone (score difference +7.37, 95% confidence interval [CI] 1.53–13.22).

Patients who received the social interaction intervention in addition to the review experienced reduced neuropsychiatric symptoms of -0.44 (95% CI -4.39–3.52) and significantly reduced mortality (odds ratio 0.26, 95% CI 0.13–0.51) compared with the group receiving neither. The social interaction intervention involved at least three planned social interactions per week, delivered via individual or group sessions, to enhance residents’ interactions with staff, family or volunteers.

The exercise programme, which was personalised and involved a 20% increase in exercise activity for at least one hour per week, reduced neuropsychiatric symptoms (score difference -3.59, 95% CI -7.08 to -0.09) but did not improve depression (score difference -1.21, 95% CI -4.35 to -1.93).

“These findings should prompt an urgent review of guidelines for the use of antipsychotic drugs, to ensure that review of these medicines are in the best interests of people with dementia,” Corbett concludes.

The antipsychotic review intervention, based on the NICE dementia guideline published in 2006 and antipsychotics guidance developed by the Alzheimer’s Society, involved regular scrutiny of prescriptions and targeted education for doctors and nurses.

While antipsychotics can be used to control neuropsychiatric symptoms for short periods, their long-term use needs to be carefully monitored as it may result in an increased risk of cognitive decline, stroke and death.

Doug Brown, director of research at the Alzheimer’s Society, says the research sheds light on the need for care to be based on rigorous scientific evidence. “Although it is important to reduce inappropriate antipsychotic use in care homes, other programmes, for example encouraging social interaction, are needed alongside this in order to reduce some of the behavioural symptoms of dementia,” he says. “Further research is needed to fully understand how to provide the very best care for people affected by dementia and to create guidelines to aid care providers in their roles.”