Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: systematic review

Sir,

Lee et al have written an excellent review of published trials
comparing atypical antipsychotics with placebo and with typical
antipsychotics and found limited evidence that they work in patients with
behavioural and psychological symptoms of dementia (BPSD)(1). They state
that further evidence is required before atypical antipsychotics can be
endorsed in the management of behavioural and psychological symptoms of
dementia.

However, evidence about typical antipsychotics (including
haloperidol) is even more limited (2). In fact, legislation to restrict
antipsychotic prescription was introduced in the United States before
atypical antipsychotics were marketed, as side effects of the former were
considered frequent and severe. Typical antipsychotics have not been
explicitly licenced in most countries for the treatment of BPSD. Evidence
about other drugs is even weaker. Non-pharmacological treatments are
widely considered a first step in the treatment of BPSD, but evidence
about their use is also very limited (3).

Concerns have been raised about the risk of stroke with new
antipsychotics, but the mechanism of this association is unknown and data
about older antipsychotics are been reviewed to find if this is a group
effect or only some antipsychotics increase the risk.

As BPSD increase suffering of patients and their carers, increase the
risk of nursing home admission and increase cost of care, I believe
treatment is needed in severe cases. As good evidence is lacking for every
therapeutic intervention available, atypical antipsychotics are still
standing as a first line treatment of BPSD.

1. Lee PE, Gill SS, Freedman M, Bronskill SE, Hillmer MP, Rochon PA.
Atypical antipsychotic drugs in the treatment of behavioural and
psychological symptoms of dementia: systematic review. BMJ. 2004 Jun 11.

2. Lonergan E, Luxenberg J, Colford J. Haloperidol for agitation in
dementia. In: The Cochrane Library, Issue 3, 2003. Oxford: Update
Software.

3. Cummings JL. Drug therapy: Alzheimer’s disease. N Engl J Med 2004;
351:56-67.

Competing interests:
The author has received reimbursments by Almirall Prodesfarma, Astra Zeneca, Janssen-Cilag, Novartis and Pfizer (manufacturers of typical and atypical antipsychotic drugs in Spain), for organizing educational programs and speaking; and fees from Janssen-Cilag for consulting.