Antipsychotics

If you've Behavioural and Psychological Symptoms of Demetia (BPSD) then how should these be managed?

The National Institute of Health and Clinical Excellence (NICE) have a view on non-drug approaches which they explain in their Clinical Guideline, CG 42, on page 28 :
"Approaches that may be considered, depending on availability, include:
● aromatherapy
● multi-sensory stimulation
● therapeutic use of music and/or dancing
● animal-assisted therapy
● massage"

I'm not opposed to these. NICE continue to say that this is, ". . . because there is some evidence of their clinical effectiveness."
NICE is correct. They can work. Of course, the truth of it is in divining what works. Is it that essential oils in aromatherapy works, or is it that having a staff member spend half an hour to an hour giving one to one time, reassauring physical contact, continuous dialogue and eye contact, all is useful? I would imagine so. I am not sold on lavender as a panacea for all ills, helping sleep and relaxing one and all. Yet the evidence is sound, for many folks it can help. We do it in our service and, for some folk, it really is useful.

What perturbs me is the vogue to move wholly away from medication.

If you've dementia and your memory is poor, your concentration is poor, your language and organisation of words is poor, your sequencing is poor, your information processing is poor, how do you think the flow of your thoughts fairs? Unsurprisingly, focussing on thoughts, generating notions and words and structuring these, following a train of thought, communicating it all is harder as the dementia progresses.

Misperceptions, misinterpretations, flawed cognitions all mean that someones thoughts aren't as clear and lucid and flowing as once they were.

Can't find your glasses? Can't find your wallet? No idea where your bank book is? Ak, someone must have broken in to your home and nicked off with them, why else aren't they where (you believe) you left them? Paranoid thoughts increase. Sometimes they become delusional and distressing. You live in a world where you're uncertain, unable to recall details of what's been happening, it's bewildering, and now it seems you've someone nicking or moving stuff in your own home. Much badness.

Can this be improved upon? Why, yes it can. You've abberant ideation through thoughts being more jumbled up than they should be. But, huzzah, we've medication that can help improve the flow of thoughts, we've antipsychotics. They can help damp down paranoid and delusional beliefs too. Splendid, a patient has unpleasant symptoms but we've medication to help so all's good. But, sadly not.

Although the benefit of antipsychotics in dementia care for some patients is widely accepted, they have risks. They increase the risk of disability and death. If you have dementia and you're on olanzapine or risperidone for a year your chance of a stroke is about 3% (compared to folk off the drugs, where the chance is about 1%). That's the problem. They're not placebo, they're proper drugs, they have real effects, so can cause serious adverse events as they change how your body ticks. As clinicians we know this and discuss it with our patients (or, more frequently, with their carers too). Carers say they can't cope, we look at interventions that can help, but the changed thoughts and psychotic symptoms persist. There're a lot of retired miners in my corner. Many are used to getting up in the early hours of the morning and when dementing know with absolute conviction that they need to be getting up for work in the wee hours. To have a man getting up and wandering the streets at 4.00am each and every night is not the easiest thing to manage. Medication isn't a solution on its own but it can mean that he can understand and appreciate reassaurance and reality orientation that carers proffer. It can help. It can mean that my patient is less distraught and their carer can cope.

I agree, totally, that antipsychotics should only ever be used as part of a package of care and the drug should not be seen as a cure or solution to problems on its own. I agree that they can be over prescribed. I agree that acetylcholinesterase inhibitors have a greater role in the treatment of BPSD in Alzheimer's disease than antipsychotics do. I agree that other classes of drugs, such as benzodiazepines, can be more useful for some patients some of the time. I agree that antipsychotics have a risk (but an additional 2% chance a year of a stroke means there's a 98% chance that it won't cause one, which for many carers having intolerable situations are odds they'll go with each and every day).

It worries me that the MHRA said that olanzapine and risperidone shouldn't be used in dementia, but to give them their dues it has been clinical advice and not an edict written in tablets of stone. Clinical freedom's curtailed but still there's room for me to prescribe them if I really believe it's in my patient's best interests.

In the USA the risks of morbidity and death that antipsychotics cause scares clinicians so much (they then get sued a lot) that they're not commonly used in BPSD. Other techniques like physical restraint are used instead. Wandering? We can cure that, let's just handcuff both wrists of the patient to either side of the bed. Happened this month. Acceptable practice, to de-escalate risks with no serious chance of strokes that nasty drugs cause. As well as not giving drugs for BPSD, they're shy about drugs in frank barn door psychosis when paranoid delusions and the consequent disturbed behaviour are present.

This week, on Monday 16th June, in America the FDA said, "Antipsychotics are not indicated for the treatment of dementia-related psychosis."

If you have dementia, and have psychosis, you don't get an antipsychotic. They work, but since there's some risk, they're banned across the continent of North America.

Handcuffs or medication. I really, really hope folk in the UK take a more balanced view.