Behavioral and Psychological Symptoms in Dementia (BPSD) and the Use of Antipsychotics

Abstract

Dementia affects about 47 million people worldwide, number expected to exponentially increase within 30 years. Alzheimer’s disease (AD) is the most common dementia type, accounting on its own for almost 70% of all dementia cases. Behavioral and psychological symptoms (BPSD) frequently occur during the disease progression; to treat agitation, aggressiveness, delusions and hallucinations, the use of antipsychotic drugs should be limited, due to their safety issues. In this literature review regarding the use of antipsychotics for treating BPSD in dementia, the advantages and limitation of antipsychotic drugs have been evaluated. The available medications for the management of behavioral and psychological symptoms are the antipsychotics, classed into typical and atypical, depending on their action on dopamine and serotonin receptors. First generation, or typical, antipsychotics exhibit lack of tolerability and display a broad range of side effects such as sedation, anticholinergic effects and extrapyramidal symptoms. Atypical, or second generation, antipsychotics bind more selectively to dopamine receptors and simultaneously block serotonin receptors, resulting in higher tolerability. High attention should be paid to the management of therapy interruption or switch between antipsychotics, to limit the possible rebound effect. Several switching strategies may be adopted, and clinicians should “tailor” therapies, accounting for patients’ symptoms, comorbidities, polytherapies and frailty.

Potentially Inappropriate Prescriptions of Antipsychotics for Patients With Dementia

“…Neuropsychiatric symptoms, including agitation, aggressiveness, paranoid delusions, and hallucinations, are widely prevalent among dementias, especially in the moderate and severe disease stages, which require either pharmacological or nonpharmacological intervention (Cerejeira et al, 2012). Very often, nonpharmacological management is sufficient to control symptoms, but sometimes, the severity of the disorder, the involvement in the patient, or the risk to oneself or others makes using drugs, including antipsychotics, necessary to control symptoms (Calsolaro et al, 2021). However, the Beers criteria and the STOPP/START criteria consider antipsychotics as potentially inappropriate prescriptions in this group of patients because they are associated with a greater number of adverse outcomes, such as cerebrovascular events and greater functional decline and mortality, and thus recommend avoiding their use unless there are no alternatives for the management of behavioral disorders or delirium ("American Geriatrics Society 2019 Updated AGS Beers Criteria(R) for Potentially Inappropriate Medication Use in Older Adults," 2019;O'Mahony et al, 2015).…”

“…It has been shown that patients treated with antipsychotics can frequently present with anticholinergic side effects, such as orthostatic hypotension, confusion, drowsiness, cognitive impairment, and an increased risk of severe extrapyramidal effects that can be fatal (Schneider et al, 2006a;Schneider et al, 2006b;Calsolaro et al, 2021;Vina Latin Small Letter et al, 2021). In addition, the DART-AD trial found an increased risk of mortality in patients older than 65 years with dementia treated with any class of antipsychotics, both in the short term (12 weeks) and long term (over 48 months) (Hereu and Vallano, 2011).…”

Pharmacological Treatment for Social Cognition: Current Evidence

“…Furthermore, projections of 5-HT2AR pyramidal neurons in the medial prefrontal cortex act as the modulator of mesocortico-limbic dopaminergic neurons [ 105 ]. In fact, they would follow the functional antagonism in the mesocortical pathway where the excess of dopamine causes positive symptoms, while the action as functional agonist in the mesocortical pathway improves the negative symptoms [ 106 , 107 ].…”

Non-Pharmacological Interventions for Wandering/Aberrant Motor Behaviour in Patients with Dementia

“…Apart from the EPS, the antipsychotics also cause agitation, psychosis, aggression, and inappropriate behaviours [ 18 ]. Furthermore, risperidone and olanzapine demonstrated an increased risk of cardiovascular effects [ 20 ]. According to some previous studies [ 21 , 22 , 23 ], there is increased risk of mortality in PwD who are treated with antipsychotics than in PwD who do not take any antipsychotic drug.…”