A variety of behavioural disturbances such as physical aggression, agitation, hallucinations, and wandering commonly accompany dementia. The term behavioural and psychological symptoms of dementia—BPSD—describes this spectrum of non-cognitive manifestations of dementia.1
The presence of BPSD can decrease quality of life for patients and caregivers, and increases the likelihood of the patient being placed in an institution.2
Treatment of BPSD is challenging. A variety of non-pharmacological and pharmacological approaches have been assessed.3,4
Atypical antipsychotics are often prescribed to manage BPSD. Although such prescriptions represent off-label prescribing, this practise is widely endorsed because atypical antipsychotics are among the best studied treatments for BPSD and there is a perception that they have fewer adverse effects than typical antipsychotics.5,6
Recently, however, concerns have been raised that atypical antipsychotics may increase the risk of cerebrovascular adverse events, including stroke, among older adults with BPSD.
In October 2002, Health Canada and Janssen-Ortho (a manufacturer of atypical antipsychotics) issued a warning to Canadian clinicians of a possible link between risperidone use and cerebrovascular adverse events.7
This concern emerged from a clinical trial evaluating risperidone in the management of BPSD,8
and a subsequent meta-analysis of the risperidone trials for this indication also showed more cerebrovascular adverse events among participants receiving risperidone (4%) than among participants receiving placebo (2%).9
The US Food and Drug Administration issued a similar warning in April 2003.10
More recently, pooled data from clinical trials evaluating olanzapine for BPSD have shown that it may also be associated with an increased risk of cerebrovascular adverse events.11,12
These data suggest around a threefold increase in the relative risk of cerebrovascular events among people taking risperidone or olanzapine. Based on these data, the UK Committee on Safety of Medicines issued a warning in March 2004 advising that risperidone and olanzapine should no longer be used to manage BPSD, and that patients already receiving these drugs for BPSD should be switched to other treatments.12
These warnings have led to controversy among clinicians.13,14
To date, the warnings only extend to older adults receiving atypical antipsychotics for BPSD and not to patients receiving these drugs for schizophrenia or other indications. No warnings have been issued on the use of other atypical agents, such as quetiapine or aripiprazole, as few studies have been published on their use to manage BPSD. Recent data from a clinical trial of quetiapine to treat BPSD show no increased risk of cerebrovascular adverse events compared with placebo.15
The potential link between atypical antipsychotics and cerebrovascular adverse events in patients with BPSD is important, given the common use of these drugs in this patient population. If atypical antipsychotics are thought unsafe, clinicians may consider using typical antipsychotics to treat BPSD. We compared the incidence of admissions to hospitals for stroke among older adults with dementia who received atypical or typical antipsychotics.