From the Guidelines
Quetiapine is generally considered the best antipsychotic for behavioral and psychological symptoms of dementia (BPSD) in Parkinson Disease Dementia, due to its lower risk of worsening motor symptoms compared to other antipsychotics, as noted in a study from 1. Treatment typically starts with a low dose of 12.5-25mg at bedtime, which can be gradually increased as needed to 50-200mg daily, divided into 2-3 doses. Some key points to consider when treating BPSD in PDD include:
- Non-pharmacological approaches should be tried first, including addressing underlying causes of agitation such as pain, constipation, or environmental factors, as recommended by 1 and 1.
- When medication is necessary, treatment should be regularly reassessed every 4-6 weeks with attempts to taper or discontinue once symptoms are controlled, as suggested by 1.
- The effectiveness of these medications stems from their unique receptor binding profiles that provide antipsychotic effects with minimal blockade of dopamine D2 receptors in the nigrostriatal pathway.
- Clozapine is an effective alternative but requires regular blood monitoring, as noted in 1. It's also important to consider the potential risks and benefits of antipsychotic medication in elderly patients with dementia, including the increased risk of adverse effects such as falls, stroke, and death, as highlighted in 1. Overall, the goal of treatment should be to improve the patient's quality of life while minimizing the risk of adverse effects, as emphasized in 1.
From the Research
Antipsychotic Options for BPSD in PDD
- The most effective intervention for BPSD is training of formal caregivers, and other non-pharmacological interventions are also beneficial 2.
- Antipsychotics should be prescribed only when behaviors pose a significant safety risk or if the person with dementia is very distressed 2.
- Atypical antipsychotics are widely used as the first line pharmacological approach to treat BPSD 3.
- Quetiapine is an atypical antipsychotic that has been found to be useful and well-tolerated as a first drug to treat drug-induced psychosis in PD 4.
- Pimavanserin, a selective serotonin inverse agonist, is a promising option for the treatment of hallucinations in PDD, with a more favorable side effect profile compared to other antipsychotics 5.
Considerations for Antipsychotic Use
- The use of antipsychotics should be based on the individual's risk-benefit ratio, and the use of atypical antipsychotics seems to be a better choice 6.
- Antipsychotics can have significant side effects, including extrapyramidal symptoms, somnolence, hypotension, constipation, and cognitive impairment 5.
- Clozapine carries a risk of agranulocytosis, necessitating close monitoring of blood counts 5.
- Pimavanserin has been linked to corrected QT (QTc) interval prolongation, while quetiapine has been reported to be associated with an increased risk of mortality 5.