The term “behavioural and psychological symptoms of dementia” (BPSD) has been proposed to describe the spectrum of non-cognitive manifestations of dementia that include verbal and physical aggression, agitation, psychotic symptoms (hallucinations and delusions), sleep disturbances, and wandering.1
BPSD can decrease quality of life for patients and caregivers and increase the likelihood of admission to an institution.2
Management of BPSD has not been standardised and currently entails various non-pharmacological and pharmacological approaches. For many years, typical antipsychotic (neuroleptic) drugs were the most common treatment. Although there has been extensive experience with their use, typical anti-psychotics are only modestly effective and have potentially serious adverse effects that limit their usefulness in older adults.3
In the United States, concerns about overuse of antipsychotics led to the introduction of legislation (Omnibus Reconciliation Act 1987) that attempted to restrict prescribing of antipsychotics to residents of nursing homes.4
Before the introduction of the act, up to 55% of nursing home residents were treated with antipsychotic drugs.5
This legislation had a considerable impact on the use of such drugs in nursing homes.4,6
Several trials have shown that antipsychotics can often be safely discontinued in people in long term care.7,8
The experience in the United States has led some authors to examine how similar policies could be adopted in the United Kingdom.9
More recently, atypical antipsychotics have become available. These drugs have been widely adopted to treat psychotic disorders because they are perceived to have superior efficacy and safety compared with typical agents. Like typical antipsychotics, atypical antipsychotics block D2 receptors but they also antagonise serotonergic receptors such as 5-HT2. Depending on the specific drug, there may be effects on muscarinic, α adrenergic, or histaminic receptors. The results of blocking these receptors include anticholinergic effects, orthostatic hypotension, and sedation.
Compared with typical antipsychotic agents, atypical antipsychotics are thought to be less likely to cause extrapyramidal symptoms such as parkinsonism and tardive dyskinesia.10-12
Data supporting the efficacy and safety of atypical antipsychotics need to be examined, especially in light of their high costs and newly identified adverse events. These drugs may be associated with serious adverse events, especially among patients with risk factors such as metabolic disease.13
While the use of atypical antipsychotic drugs has been well studied in younger adults with psychotic symptoms, less information is available regarding their use in older adults. In practice, however, atypical antipsychotics are increasingly used to treat older patients with BPSD, and there have been striking increases in expenditures for antipsychotic drugs with their introduction. A Canadian study using data from 1998-2000 found that 24% of nursing home residents with no previous exposure to antipsychotics were newly started on an antipsychotic drug during their first year after admission, and atypical antipsychotics accounted for 40% of these prescriptions.14
Despite their frequent use in Canada, only risperidone has been indicated for the treatment of behavioural disturbance in patients with severe dementia.15
In the United Kingdom and United States, the treatment of BPSD is not listed as an indication for the use of any atypical antipsychotic drug.16,17
To assess the benefits and risks of atypical antipsychotic drugs for BPSD, we performed a systematic review of the randomised trials in this field.