As the role of pharmacists continues to head in a more clinical direction, opportunities to enhance medication safety among patients also are increasing. Pharmacists in ambulatory settings and geriatric-centered care are in a unique position to advocate for those who may not be able to do so themselves.

Frequently in patients with dementia, behavioral changes, including irritability, agitation, and aggression, as well as psychological changes, such as depression, hallucinations, and delusions, are seen.1 Medication for treatment include antipsychotics, which have a black box warning for increased risk of death in elderly patients with dementia, due to pneumonia and cardiac adverse effects.5,6 Other possible adverse effects include metabolic effects, extrapyramidal and anticholinergic symptoms, hypotension, strokes, akathisia, infections, falls, and cognitive worsening.1,5 

Antipsychotics are often ineffective for improving agitation and psychosis in elderly patients with dementia, and studies have shown inconsistent results.1 Some geriatricians have argued that a decrease in symptoms may be due to sedative effects alone.6 In spite of these concerns, the Government Accountability Office estimates 1 in 7 elderly patients with dementia, not in nursing homes, are prescribed an antipsychotic.2 Centers for Medicare and Medicaid services reports that nearly 16% of elderly in nursing homes were receiving antipsychotics as of 2017.3 Due to dangers of antipsychotics, the American Psychiatric Association (APA) recommends that in nonemergency situations, antipsychotics should “only be used for the treatment of agitation or psychosis in patients with dementia when symptoms are severe, are dangerous, and/or cause significant distress to the patient.”1

Nnonpharmacological options are recommended as first-line treatment for those with dementia and agitation or psychosis, and this approach provides an opportunity for pharmacists to utilize their services and knowledge. Before starting an antipsychotic, environmental triggers and types of interactions causing distress for a patient should be assessed.5 Pharmacists who do home visits or speak with caregivers and family members, may provide education on limiting aggravating factors and implementing potential calming strategies. Possibilities include improving sleep, decreasing clutter and noise, providing reassurance and redirection, increased daily structure and routines, massage therapy, pet therapy, bright light therapy, playing music, and activities, such as exercise and basic puzzles.1,5,8

After nonpharmacological strategies have been implemented and patient response is assessed, if the patient is still having severe, dangerous, or highly distressing symptoms of agitation or psychosis, other medications should be attempted before antipsychotics. Antidementia medications may improve symptoms, as well as cholinesterase inhibitors or SSRI’s.4 Other possible alternatives to antipsychotics include antiepileptics, anxiolytics, analgesics, lithium, β-adrenoceptor antagonists, cannabinoid receptor agonists, and hormonal therapies.7 The choice of which medication to try should be based on individual medical conditions and current therapy regimens.1 Risks and benefits of options should be discussed with family, caregivers and the individual when appropriate.

The APA recognizes that possible underlying conditions, such as depression, pain, and infection, should be evaluated and treated before beginning an antipsychotic, as these may be associated with psychosis symptoms.5 Polypharmacy and some medications, such as anticholinergics, can cause delirium and confusion, which may be mistaken for dementia symptoms.4,5 As the use of electronic medical records expand, pharmacists’ access to patient records will allow for a review of previous treatments, medical conditions, medication use, and possible drug-drug interactions, in order to ensure that an antipsychotic is a proper choice for the patient.1

Pharmacists who speak with caregivers, family members, and the patient also are able to educate them on the importance of starting antipsychotics at low doses and when to begin discontinuation, as well as assess response to treatment, and monitoring for adverse effects. 

Although antipsychotics may be needed in emergent situations when risk of harm to the patient or those around them is high, long term therapy may be extremely detrimental.1 Health care providers, including pharmacists, should guide pharmacologic and nonpharmacologic therapy choices based on unique individual patient profiles, keeping in mind the great risks associated with antipsychotic use in elderly with dementia.
 
This article was co-authored by Stevie Nesbitt, 2019 PharmD Candidate, and Andrew Yabusaki, PharmD.

 
References
  1. Reus V, Fochtmann L, Eyler E, et al. The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia. The American Journal of Psychiatry. Published May 2016. Accessed November 2018.
  2. Watts V. Mortality Risk High for Dementia Patients Taking Antipsychotics. The American Psychiatric Association. Published April 2015. Accessed November 2018.Sullivan T. CMS Releases Data on Antipsychotic Drugs Used in Nursing Homes. Policy & Medicine. Published May 2018. Accessed November 2018.
  3. Mishriky R, Reyad A. Pharmacological alternatives to antipsychotics to manage BPSD. Progress in Neurology and Psychiatry. 2018;22: 30-35.
  4. Steinberg M, Lyketsos CG. Atypical antipsychotic use in patients with dementia: managing safety concerns. Am J Psychiatry. 2012;169(9):900-6.
  5. Kales H, Mulsant B, Sajatovic M. Prescribing antipsychotics in geriatric patients: Focus on dementia. Current Psychiatry. 2017; 16(12):24-30.  
  6. Passmore M, Gardner D, Polak Y, et al. Alternatives to Atypical Antipsychotics for the Management of Dementia-Related Agitation. Drugs & Aging.2008;25(5):381-398.
  7. Millán-Calenti JC, Lorenzo-López L, Alonso-Búa B, de Labra C, et al. Optimal nonpharmacological management of agitation in Alzheimer's disease: challenges and solutions. Clin Interv Aging. 2016;11:175-84.