A study found that antipsychotic medication in dementia patients is associated with a higher risk of serious health problems, such as stroke and pneumonia, especially in the short term. after starting treatment. This highlights the need for careful assessment and management of antipsychotic use in this vulnerable population.
Experts emphasize that it is necessary to be more careful in the first stage of treatment, because the risk is greatest after starting the medicine.
A recent study published by Price of BMJ finds that antipsychotic use in people with dementia is associated with a higher risk of several side effects, including stroke, heart attack, and stroke , heart failure, fractures, pneumonia and kidney injury, compared to non-use.
These findings show a greater range of harms associated with antipsychotic use in people with dementia than previously recognized in regulatory notices, with the highest risk shortly after the beginning of the drug, highlighting the need for more attention in the first stages of treatment. Despite safety concerns, antipsychotics are still prescribed for behavioral and psychological symptoms such as apathy, depression, aggression, anxiety, irritability, delirium and psychosis.
Previous regulatory warnings when prescribing antipsychotics for these symptoms were based on evidence of an increased risk of stroke and death, but evidence of other adverse effects was less clear in people with dementia.
To address this uncertainty, researchers have investigated the risk of adverse effects of antipsychotic use in people with dementia. Outcomes of interest include stroke, venous thromboembolism, myocardial infarction, heart failure, ventricular arrhythmia, fractures, pneumonia and kidney injury.
Study design and methods
Using data relating to primary care, hospitalization and death in England, they identified 173,910 people (63% women) with dementia aged 82 years between January 1998 and May 2018 who were not prescribed antipsychotics in the year before diagnosis. . Each of the 35,339 patients prescribed an antipsychotic on or after the date of dementia diagnosis was matched with 15 randomly selected patients.
Patients with a history of the specific outcome under investigation prior to their visit were excluded from the investigation of that outcome. The most common antipsychotics are risperidone, quetiapine, haloperidol, and olanzapine, which account for nearly 80% of all prescriptions.
Potential influencing factors such as patient characteristics, lifestyle, pre-existing medical conditions, and prescribed medications were also taken into account. Compared to non-use, antipsychotic use was associated with an increased risk of all outcomes, except ventricular arrhythmia. For example, in the first three months of treatment, the rate of pneumonia among antipsychotic users was 4.48% vs 1.49% for non-users. At one year, this rose to 10.41% for antipsychotic users vs 5.63% for non-users.
The risk is also higher among antipsychotic users for kidney injury (1.7 times increased risk), as well as stroke and venous thromboembolism (1.6 times increased risk) compared to non-users. For all outcomes, the risk was highest during the first week of antipsychotic treatment, especially for pneumonia.
Researchers estimate that during the first six months of treatment, antipsychotic use may be associated with one additional case of pneumonia for 9 treated patients, and an additional heart attack for 167 patients treated. Over two years, there would be one additional case of pneumonia for every 15 patients treated, and one additional heart attack for every 254 patients treated.
The results of the study
This was an observational study so no firm conclusions can be drawn about cause and effect, and the researchers cautioned that there may be bias in the use of some antipsychotics. And although they adjusted for many factors, they cannot rule out the possibility of other unmeasured variables affecting the results.
However, this is a large-scale analysis based on reliable clinical data that investigated a variety of adverse events and reported relative and absolute risks over several time periods.
Thus, the researchers said that antipsychotics are associated with more serious side effects than previously highlighted in legal notices, with the highest risk after the start of treatment, and because it is directly related to guideline developers, regulators, physicians, patients, and their caregivers.
The benefits of antipsychotic treatment need to be weighed against the serious risks and the treatment plan should be reviewed regularly, they said.
The results of this study will equip medical professionals with more data to help guide specific treatment decisions, American researchers said in a related editorial.
They explained that international guidelines recommend limiting use to adults with behavioral and psychological symptoms of dementia, but the rate of prescribing has increased in recent years. in recent years, in part due to the lack of effective non-prescription drugs and the resources needed to implement them. .
"Increasing the priority of more patient-centered care, customized care planning, regular evaluation of management options, and avoidance of overprescription of antipsychotics is over ", they concluded.
Reference: "Multiple adverse effects associated with antipsychotic use in people with dementia: a population-based cohort study" by Pearl LH Mok, Matthew J Carr, Bruce Guthrie, Daniel R Morales, Aziz Sheikh, Rachel A Elliott, Elizabeth M Camacho, Tjeerd van Staa, Anthony J Avery and Darren M Ashcroft, 17 April 2024, BMJ.
DOI: 10.1136/bmj-2023-076268
The study was funded by the National Institute of Health and Care Research (NIHR).
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