Pharmacological treatments for alleviating agitation in dementia: a systematic review and network meta‐analysis

Kongpakwattana, Khachen; Sawangjit, Ratree; Tawankanjanachot, Itthipol; Bell, John; Hilmer, Sarah N.; Chaiyakunapruk, Nathorn

doi:10.1111/bcp.13604

Cited by 47 publications

(45 citation statements)

References 91 publications

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“…For instance, concurrent use of anticholinergic medicines is not recommended with cholinesterase inhibitors; however, the primary pharmacological management for behavioural and psychological disturbances in dementia are antipsychotics such as risperidone. 15,18,[28][29][30][31][32] In our study, the antipsychotic risperidone was the most commonly dispensed medicine with anticholinergic effects both before and after initiating dementia medicines. Under PBS restrictions, risperidone formulations are only eligible for government subsidy for managing behavioural and psychological symptoms of dementia; thus accounting for the substantial number of dispensings captured in our data.…”

Section: Discussionmentioning

confidence: 70%

“…This leads to increased challenges for clinicians with ever‐extensive clinical responsibilities and makes it difficult to determine what approach to take. For instance, concurrent use of anticholinergic medicines is not recommended with cholinesterase inhibitors; however, the primary pharmacological management for behavioural and psychological disturbances in dementia are antipsychotics such as risperidone …”

Section: Discussionmentioning

confidence: 99%

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Anticholinergic medicines use among older adults before and after initiating dementia medicines

Narayan

Pearson

Litchfield

et al. 2019

Brit J Clinical Pharma

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Aims We investigated anticholinergic medicines use among older adults initiating dementia medicines. Methods We used Pharmaceutical Benefits Scheme dispensing claims to identify patients who initiated donepezil, rivastigmine, galantamine or memantine between 1 January 2013 and 30 June 2017 (after a period of ≥180 days with no dispensing of these medicines) and remained on therapy for ≥180 days ( n = 4393), and dispensed anticholinergic medicines in the 180 days before and after initiating dementia medicines. We further examined anticholinergic medicines prescribed by a prescriber other than the one initiating dementia medicines. Results One‐third of the study cohort (1439/4393) was exposed to anticholinergic medicines up to 180 days before or after initiating dementia medicines. Among patients exposed to anticholinergic medicines, 46% (659/1439) had the same medicine dispensed before and after initiating dementia medicines. The proportion of patients dispensed anticholinergic medicines increased by 2.5% (95% confidence interval [CI]: 1.3–3.7) after initiating dementia medicines. Antipsychotics use increased by 10.1% (95% CI: 7.6–12.7) after initiating dementia medicines; driven by increased risperidone use (7.3%, 95% CI: 5.3–9.3). Nearly half of patients dispensed anticholinergic medicines in the 180 days after (537/1133), were prescribed anticholinergic medicines by a prescriber other than the one initiating dementia medicines. Conclusion Use of anticholinergic medicines is common among patients initiating dementia medicines and this occurs against a backdrop of widespread campaigns to reduce irrational medicine combinations in this vulnerable population. Decisions about deprescribing medicines with questionable benefit among patients with dementia may be complicated by conflicting recommendations in prescribing guidelines.

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Section: Discussionmentioning

confidence: 70%

Section: Discussionmentioning

confidence: 99%

Anticholinergic medicines use among older adults before and after initiating dementia medicines

Narayan

Pearson

Litchfield

et al. 2019

Brit J Clinical Pharma

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“…Atypical antipsychotics is superior compared to placebo in reducing behavioral symptoms in patients with dementia, whereas haloperidol is not [73] and in elderly patients with various conditions, risperidone has been found to be as efficacious as haloperidol [74]. Moreover, several very large observational studies have demonstrated that haloperidol is associated with higher mortality, risk of pneumonia and cardiovascular disease compared to atypical antipsychotics (including risperidone) [53,54].…”

Section: Justification For Recommendationsmentioning

confidence: 99%

A European Academy of Neurology guideline on medical management issues in dementia

Frederiksen

Cooper

Frisoni

et al. 2020

Euro J of Neurology

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Background and purpose Dementia is one of the most common disorders and is associated with increased morbidity, mortality and decreased quality of life. The present guideline addresses important medical management issues including systematic medical follow‐up, vascular risk factors in dementia, pain in dementia, use of antipsychotics in dementia and epilepsy in dementia. Methods A systematic review of the literature was carried out. Based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework, we developed a guideline. Where recommendations based on GRADE were not possible, a good practice statement was formulated. Results Systematic management of vascular risk factors should be performed in patients with mild to moderate dementia as prevention of cerebrovascular pathology may impact on the progression of dementia (Good Practice statement). Individuals with dementia (without previous stroke) and atrial fibrillation should be treated with anticoagulants (weak recommendation). Discontinuation of opioids should be considered in certain individuals with dementia (e.g. for whom there are no signs or symptoms of pain or no clear indication, or suspicion of side effects; Good Practice statement). Behavioral symptoms in persons with dementia should not be treated with mild analgesics (weak recommendation). In all patients with dementia treated with opioids, assessment of the individual risk–benefit ratio should be performed at regular intervals. Regular, preplanned medical follow‐up should be offered to all patients with dementia. The setting will depend on the organization of local health services and should, as a minimum, include general practitioners with easy access to dementia specialists (Good Practice statement). Individuals with dementia and agitation and/or aggression should be treated with atypical antipsychotics only after all non‐pharmacological measures have been proven to be without benefit or in the case of severe self‐harm or harm to others (weak recommendation). Antipsychotics should be discontinued after cessation of behavioral disturbances and in patients in whom there are side effects (Good Practice statement). For treatment of epilepsy in individuals with dementia, newer anticonvulsants should be considered as first‐line therapy (Good Practice statement). Conclusion This GRADE‐based guideline offers recommendations on several important medical issues in patients with dementia, and thus adds important guidance for clinicians. For some issues, very little or no evidence was identified, highlighting the importance of further studies within these areas.

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“…15 A recent network meta-analysis reported that SSRIs as a class had efficacy for alleviating agitation, but when analysed separately, citalopram was not significantly efficacious. 28 Evaluation of efficacy and the potential for deprescribing should take place after two months. 15 The time to onset of action, importance of adherence, and 15 There is uncertainty about the use of antidepressants in the treatment of depression in Alzheimer's disease.…”

Section: Management Of Bpsdmentioning

confidence: 99%

“…32 For treating agitation/ aggression, risperidone and olanzapine have the strongest evidence, while weaker evidence exists for aripiprazole. 28 Olanzapine and quetiapine have been reported to have the best tolerability. 15 The only antipsychotic currently listed on the PBS for BPSD, including psychotic symptoms and agitation, is risperidone.…”

Section: Management Of Bpsdmentioning

confidence: 99%

Current approaches to the pharmacological treatment of Alzheimer’s disease

Tan¹,

Hilmer²,

García-Ptacek³

et al. 2018

Aust J Gen Pract

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Pharmacological treatments for alleviating agitation in dementia: a systematic review and network meta‐analysis

Cited by 47 publications

References 91 publications

Anticholinergic medicines use among older adults before and after initiating dementia medicines

Anticholinergic medicines use among older adults before and after initiating dementia medicines

A European Academy of Neurology guideline on medical management issues in dementia

Current approaches to the pharmacological treatment of Alzheimer’s disease

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