Case Study in poly-pharmacy: Dementia (Part 2)

Last week, as part of this case study I described dementia and the medications prescribed for the cognitive effects of demetia like memory loss. This week I discuss the medications prescribed for the psychological effects that can occur with dementia like agitation, anxiety and depression. I specifically deal with why they should be regularly reviewed.

Anti-psychotic drugs

Antipsychotic drugs are frequently prescribed with the aim of reducing behavioural and psychological symptoms of dementia (BPSD) in older people. In the UK, studies indicate up to 20% of patients diagnosed with dementia are prescribed anti-psychotics for PBSD. The first line treatment for psychotic symptoms in dementia is atypical antipsychotic (olanzapine, risperidone). These are associated with fewer extrapyramidal effects (tremors, movement disorders) than conventional or older antipsychotics such as haloperidol. Extrapyramidal effects can include Parkinson symptoms (Tremor), dystonia (abnormal face and body movements), akathisia (restlessness) and tardive dyskinesia (rhythmic, involuntary movements of tongue, face and jaw)

Despite this high rate of use, antipsychotics have only limited benefit in treating BPSD in older people with dementia and carry risks. In 2009, antipsychotics were estimated to cause approximately 1800 deaths and 1620 cerebrovascular events in people with dementia in the UK annually for treatment of PBSD. However, clinical trial evidence in nursing home patients with dementia indicates that chronically prescribed antipsychotic drugs can be safely discontinued in many patients, with longer term follow-up suggesting a significant reduction in mortality. However, this needs to be balanced against the fact that antipsychotics can greatly improve quality of life in some dementia patients suffering with the likes of severe agitation with dementia.

Why should anti-psychotics be prioritised for review?

Patients who have dementia and who have been on antipsychotics for more than 3 months and have stable symptoms should be reviewed with a view to reducing or stopping antipsychotic medication. Antipsychotics are associated with an increased risk of falls, disorientation, cerebrovascular events (e.g. Strokes) and death.

Depression

Depression is a common with dementia. Exercise may help reduce the symptoms of depression, and clinical trials support the use of antidepressants. Newer selective serotonin reuptake inhibitors (Prozac type anti-depressants) are the preferred class, rather than the older tricyclic agents, which have troublesome side effects. Small studies have demonstrated beneficial effects with trazodone and citalopram.

Conclusion

Frequent review of the person’s medication is essential to prevent unnecessary prescriptions and the harm this can cause. The pharmacist has an important role in reducing risks in reducing over-prescribing, especially in older patients who can be more susceptible to adverse effects.

References available upon request

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