Choosing Wisely:

Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.

Rationale and Comments: Behavioral and psychological symptoms of dementia are defined as the noncognitive symptoms and behaviors, including agitation or aggression, anxiety, irritability, depression, apathy, and psychosis. Evidence shows that risks (e.g., cerebrovascular effects, mortality, parkinsonism or extrapyramidal signs, sedation, confusion and other cognitive disturbances, and increased body weight) tend to outweigh the potential benefits of antipsychotic medications in this population. Clinicians should limit the use of antipsychotic medications to cases where nonpharmacologic measures have failed and the patients’ symptoms may create a threat to themselves or others. This item is also included in the American Geriatric Society’s list of recommendations for “Choosing Wisely.”
Sponsoring Organizations:
  • American Psychiatric Association
  • Sources:
  • Cochrane Database of Systematic Reviews
  • Agency for Healthcare Research and Quality
  • Disciplines:
  • Geriatric Medicine
  • Psychiatric and Psychologic
  • References: • American Psychiatric Association: Practice guideline for the treatment of patients with Alzheimer’s disease and other dementias, second edition. Am J Psychiatry. 2007 Dec;164(Dec suppl):5-56. Available from: http://psychiatryonline.org/content.aspx?bookid=28§ionid=1679489.
    • Ballard CG, Waite J, Birks J. Atypical antipsychotics for aggression and psychosis in Alzheimer’s disease. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD003476.
    • Gitlin LN, Kales HC, Lyketsos CG. Nonpharmacologic management of behavioral symptoms in dementia. JAMA. 2012 Nov 21;308(19):2020-9.
    • Maglione M, Ruelaz Maher A, Hu J, Wang Z, Shanman R, Shekelle PG, Roth B, Hilton L, Suttorp MJ, Ewing BA, Motala A, Perry T; Southern California Evidence-Based Practice Center. Off-label use of atypical antipsychotics: an update. Rockville, Md.: Agency for Healthcare Research and Quality; 2011 Sep 437 p. Report No.: HHSA290-2007-10062-1.
    • Nasrallah HA. Atypical antipsychotic-induced metabolic side effects: insights from receptor-binding profiles. Mol Psychiatry. 2008 Jan;13(1):27-35.
    • Richter T, Meyer G, Möhler R, Köpke S. Psychosocial interventions for reducing antipsychotic medication in care home residents. Cochrane Database Syst Rev. 2012 Dec 12;12:CD008634.
    • Schneider LS, Tariot PN, Dagerman KS, Davis SM, Hsiao JK, Ismail MS, Lebowitz BD, Lyketsos CG, Ryan JM, Stroup TS, Sultzer DL, Weintraub D, Lieberman JA; CATIE-AD Study Group. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med. 2006;355(15):1525-38.

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