What are the safest medications for managing hallucinations in patients with Neurocognitive (NCD) disorders?

From the Guidelines

Atypical antipsychotics like risperidone (0.25-2 mg daily) are generally the safest medications for managing hallucinations in neurocognitive disorder patients. These medications should be started at the lowest possible dose and titrated slowly based on response and side effects, following the "start low, go slow" principle, as recommended in the guidelines for managing Alzheimer's disease 1. Treatment duration should be regularly reassessed, with attempts to taper or discontinue after symptoms stabilize, typically reviewing every 3-6 months.

Key Considerations

• Risperidone is preferred due to its relatively low risk of extrapyramidal symptoms and tardive dyskinesia compared to typical antipsychotic agents 1.
• Other atypical antipsychotics like olanzapine (2.5-10 mg daily) and quetiapine (12.5-200 mg twice daily) may also be considered, but risperidone is generally recommended as the first-line treatment due to its favorable side effect profile 1.
• Non-pharmacological approaches should be tried first, including maintaining a consistent environment, addressing sensory deficits, and ensuring adequate sleep.
• Regular monitoring for side effects is essential, including orthostatic blood pressure, movement disorders, sedation, and metabolic parameters.

Alternative Options

• If one medication is ineffective or poorly tolerated, switching to an alternative atypical antipsychotic may be beneficial before considering conventional antipsychotics, which generally have more side effects in this population 1.
• Mood-stabilizing drugs like divalproex sodium (125 mg twice daily) may be considered as alternative treatments for managing hallucinations and agitation in neurocognitive disorder patients, but their use should be carefully monitored due to potential side effects 1.

From the FDA Drug Label

In placebo-controlled trials with risperidone, aripiprazole, and olanzapine in elderly subjects with dementia, there was a higher incidence of cerebrovascular adverse reactions (cerebrovascular accidents and transient ischemic attacks) including fatalities compared to placebo-treated subjects Quetiapine is not approved for the treatment of patients with dementia-related psychosis Olanzapine is not approved for the treatment of patients with dementia-related psychosis

The safest medications for managing hallucinations in patients with Neurocognitive (NCD) disorders are not explicitly stated in the provided drug labels. Key considerations for medication selection include:

• Cerebrovascular risk: Elderly patients with dementia-related psychosis are at increased risk of cerebrovascular adverse events, including stroke and transient ischemic attacks.
• Medication approval: Quetiapine and olanzapine are not approved for the treatment of patients with dementia-related psychosis.
• Metabolic changes: Atypical antipsychotics, including quetiapine and olanzapine, have been associated with metabolic changes, such as hyperglycemia, dyslipidemia, and weight gain. Given the lack of direct information, no conclusion can be drawn about the safest medications for managing hallucinations in patients with NCD disorders 2 3.

From the Research

Safest Medications for Managing Hallucinations in Patients with Neurocognitive Disorders

• The study 4 compared the efficacy and tolerability of quetiapine and risperidone in elderly patients with dementia and symptoms of disturbed perception, thought content, mood or behavior, and found that both medications were equally effective and generally well tolerated.
• The study 4 also found that low doses of quetiapine and risperidone did not cause cognitive impairment in elderly patients with dementia.
• Another study 5 found that antipsychotics, including quetiapine and risperidone, had a significant improvement in behavioral and psychological symptoms of dementia (BPSD), but noted that they should be avoided where possible due to the high risk of serious adverse events.

Non-Pharmacological Interventions for Managing Hallucinations

• A study 6 found that non-pharmacological interventions, including validation therapy, reminiscence therapy, and music therapy, were effective in reducing hallucinations in patients with dementia.
• The study 6 also found that these interventions reduced caregivers' distress and burden.
• Another study 7 found that non-pharmacological interventions, including psychosocial interventions, may be beneficial for individuals with mild cognitive impairment and their caregivers.
• A systematic review 8 found that non-pharmacological interventions, including dysphagia management and cognitive stimulation, may be beneficial for patients with Lewy body dementia, but noted that the evidence was limited and of poor quality.
• A systematic overview 5 found that functional analysis-based interventions and music therapy were effective in managing BPSD, and recommended that these interventions be used as first-line management due to their lack of associated adverse events.