The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia

Reus, Victor I.; Fochtmann, Laura J.; Eyler, A. Evan; Hilty, Donald M.; Horvitz-Lennon, Marcela; Jibson, Michael D.; López, Oscar L.; Mahoney, Jane; Pasic, Jagoda; Tan, Zaldy S.; Wills, Cheryl D.; Rhoads, Richard S.; Yager, Joel

doi:10.1176/appi.focus.15107

Cited by 25 publications

(35 citation statements)

References 10 publications

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“…51,52 However, the American Psychiatric Association, the American Alzheimer's Association, and the British National Institute for Health Care and Excellence guidelines liberalize indications to include refractive patient distress. [53][54][55][56] Despite evidence of only modest benefit and proven severe risk, the context of purposeful efforts from the FDA, CMS, and state legislation, and the censure of geriatric societies and patient advocacy groups, physicians continue to prescribe antipsychotics and other medications for BPSD to hundreds of thousands of patients in US nursing homes and communities. 50 The reasons for this apparent conundrum are not well understood, and investigation in this area has been scant.…”

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confidence: 99%

Primary Care Physician Perspectives about Antipsychotics and Other Medications for Symptoms of Dementia

Kerns

Winter

et al. 2018

J Am Board Fam Med

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Background: Guidelines, policies, and warnings have been applied to reduce the use of medications for behavioral and psychological symptoms of dementia (BPSD). Because of rare dangerous side effects, antipsychotics have been singled out in these efforts. However, antipsychotics are still prescribed "off label" to hundreds of thousands of seniors residing in nursing homes and communities. Our objective was to evaluate how and why primary-care physicians (PCPs) employ nonpharmacologic strategies and drugs for BPSD.Methods: Semi-structured interviews analyzed via template, immersion and crystallization, and thematic development of 26 PCPs (16 family practice, 10 general internal medicine) in full time primarycare practice for at least 3 years in Northwestern Virginia.Results: PCPs described 4 major themes regarding BPSD management: (1) nonpharmacologic methods have substantial barriers; (2) medication use is not constrained by those barriers and is perceived as easy, efficacious, reasonably safe, and appropriate; (3) pharmacologic policies decrease the use of targeted medications, including antipsychotics, but also have unintended consequences such as increased use of alternative risky medications; and (4) PCPs need practical evidence-based guidelines for all aspects of BPSD management.Conclusions: PCPs continue to prescribe medications because they meet patient-oriented goals and because PCPs perceive drugs, including antipsychotics and their alternatives, to be more effective and less dangerous than evidence suggests. To optimally treat BPSD, PCPs need supportive verified prescribing guidelines and access to nonpharmacologic modalities that are as affordable, available, and efficacious as drugs; these require and deserve significant additional research and payer support. Community PCPs should be included in BPSD policy and guideline development. (J Am Board Fam Med 2018;31: 9 -21.)

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confidence: 99%

Primary Care Physician Perspectives about Antipsychotics and Other Medications for Symptoms of Dementia

Kerns

Winter

et al. 2018

J Am Board Fam Med

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“…30 Yet our participants' knowledge of the mechanism of action of quetiapine and safety concerns was limited, despite recent educational campaigns. 14,16 Family physicians mitigated this gap through the use of low dosages and, in keeping with previous literature on guideline use, 31,32 prioritized real-world experience by colleagues -both peers and specialists -over information. Ambivalent attitudes and perceptions have been identified as important determinants of inappropriate prescribing.…”

Section: Discussionmentioning

confidence: 97%

“…Several professional bodies, including the Canadian Psychiatric Association, 13 the American Psychiatric Association, 14 the American Diabetes Association 15 and the American Geriatrics Society, 16 caution physicians to use antipsychotics judiciously. [14][15][16] The Choosing Wisely campaign made 4 recommendations for restricting the use of second-generation antipsychotics, in particular to avoid their use for insomnia (in any age group) and behavioural disturbance, particularly in patients with attention deficit hyperactivity disorder or dementia.…”

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confidence: 99%

“…[14][15][16] The Choosing Wisely campaign made 4 recommendations for restricting the use of second-generation antipsychotics, in particular to avoid their use for insomnia (in any age group) and behavioural disturbance, particularly in patients with attention deficit hyperactivity disorder or dementia. 17 Guidelines on deprescribing of antipsychotics were recently published.…”

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confidence: 99%

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The lesser of two evils: a qualitative study of quetiapine prescribing by family physicians

Kelly

Dornan

Pringsheim

2018

cmajo

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Global antipsychotic sales in 2010 were US$25.4 billion; of these, Seroquel (quetiapine) was the fifth highest selling pharmaceutical worldwide, costing an estimated US$6.8 billion. 4 In Canada, prescriptions for quetiapine rose by 300% between 2005 and 2012. Using the IMS Brogan Canadian CompuScript databases to identify prescribing data, researchers found that 50% of filled antipsychotic prescriptions in Canada were for quetiapine, and most came from family physicians.2 Although quetiapine is licensed for the treatment of schizophrenia and bipolar disorder and as an adjunctive to antidepressants in moderate to severe depression, much prescribing of quetiapine is offlabel.2,5 Off-label prescribing of antipsychotics has been studied extensively, including a meta-analysis of 170 studies. 6Leslie and colleagues 7 examined prescribing data from the US Department of Veteran Affairs and found that 60.2% of the 279 778 patients who received a prescription for an antipsychotic in 2007 had no indication for its licensed use; of these, 43% were prescribed quetiapine. More recently, researchers in the United Kingdom examined prescribing data using The Health Improvement Network, a primary care database of almost 10 million patients. 5 They found that only 36% (n = 4824) of those prescribed quetiapine had a serious mental illness recorded. Insomnia, anxiety and behavioural disturbance in elderly people and children are common reasons for off-label use. 3,6,8 Evidence of benefit for these indications is disputed. 6,9,10 Adverse metabolic, neurologic and cardiovascular effects 9,11 pose a significant risk of harm.11,12 Maglione and colleagues 6 calculated a number needed to harm of 8 (odds ratio 5.16, 95% confidence interval 2.93-9.51) for neurologic adverse effects in patients with dementia and of 16 (odds ratio 2.72, 95% confidence interval 2.07-3.56) for weight gain and increased appetite in other conditions. Background: Quetiapine is an antipsychotic that is widely prescribed off-label by family physicians despite evidence that safer alternatives exist. The aim of this research was to explore, in-depth, family physicians' reasons for this behaviour.

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“…Назначение нейролептиков наиболее опасно пациентам с БА, страдающим сердечно-сосудистыми и легочными заболеваниями. Поэтому использование антипсихотических средств рекомендует-ся только у пациентов с низким риском осложнений и(или) в тех случаях, когда нет эффекта от других методов терапии [18,21].…”

Section: лечение психотических расстройств и депрессииunclassified

Management of Patients With Alzheimer’s Disease

Парфенов¹,

Кабаева²

2018

Med. sov.

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The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia

Cited by 25 publications

References 10 publications

Primary Care Physician Perspectives about Antipsychotics and Other Medications for Symptoms of Dementia

Primary Care Physician Perspectives about Antipsychotics and Other Medications for Symptoms of Dementia

The lesser of two evils: a qualitative study of quetiapine prescribing by family physicians

Management of Patients With Alzheimer’s Disease

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