From the Guidelines
For treating Alzheimer's-related psychosis or violent behavior, antipsychotic medications like risperidone (0.25-1mg daily), quetiapine (25-200mg daily), or olanzapine (2.5-10mg daily) should be used at the lowest effective dose for the shortest duration possible, as recommended by the American Psychiatric Association 1. These medications work by balancing neurotransmitters in the brain that affect behavior and mood. However, it's essential to note that antipsychotics carry a black box warning for increased mortality risk in elderly patients with dementia and should only be used when non-pharmacological approaches have failed. Before medication, the following non-pharmacological approaches should be tried:
- Environmental modifications
- Identifying triggers
- Maintaining routines
- Using redirection techniques Any medication should be initiated by a healthcare provider who can monitor for side effects like sedation, movement disorders, falls, and cardiovascular issues. Regular reassessment is essential to determine if the medication can be reduced or discontinued once behaviors improve, as suggested by expert consensus and research evidence 1. The use of antipsychotic medications should be based on a risk/benefit assessment, considering the potential benefits and harms of the medication, as well as the patient's goals and preferences 1. It's also important to consider alternative strategies, such as non-pharmacological interventions, before initiating drug treatments, as they can be effective in managing behavioral and psychological symptoms of dementia 1.
From the FDA Drug Label
Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Aripiprazole is not approved for the treatment of patients with dementia-related psychosis [see BOXED WARNING] Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. ZYPREXA is not approved for the treatment of patients with dementia-related psychosis. (5.1,8.5,17)
No suitable medication is explicitly stated in the provided drug labels for treating psychosis or aggressive behavior in Alzheimer's disease. Both aripiprazole 2 and olanzapine 3 have warnings against their use in elderly patients with dementia-related psychosis due to increased mortality risk.
- Aripiprazole and olanzapine are not approved for this indication.
- The labels advise against using these medications for dementia-related psychosis.
From the Research
Suitable Medications for Treating Psychosis or Aggressive Behavior in Alzheimer's Disease
- Risperidone and olanzapine are useful in reducing aggression and risperidone reduces psychosis, but both are associated with serious adverse cerebrovascular events and extra-pyramidal symptoms 4
- Risperidone offers a modest and statistically significant effectiveness in the clinical setting for treating behavioral and psychological symptoms of dementia (BPSD), including agitation, aggression, and psychosis 5
- Atypical antipsychotics, such as risperidone, probably reduce agitation slightly, but have a negligible effect on psychosis, and increase the risk of somnolence, extrapyramidal symptoms, and serious adverse events 6
- Risperidone significantly improved scores on the Behavioral Pathology in Alzheimer's Disease (BEHAVE-AD) Psychosis subscale and Clinical Global Impression (CGI) scale compared with placebo in patients with psychosis of Alzheimer's disease 7
- Risperidone appears effective in controlling agitation in patients with dementia and has a relatively benign adverse-effect profile, but more clinical trials are needed to elucidate its role for this indication 8
Key Findings
- Risperidone and olanzapine are effective in reducing aggression and psychosis in Alzheimer's disease patients, but are associated with increased risk of adverse events 4, 6, 7
- Atypical antipsychotics, such as risperidone, have a modest effect on agitation and a negligible effect on psychosis in dementia patients 6
- Risperidone has a relatively benign adverse-effect profile compared to traditional neuroleptics, but may increase the risk of extrapyramidal symptoms and somnolence 5, 8
Adverse Events
- Risperidone and olanzapine are associated with an increased risk of serious adverse cerebrovascular events, extrapyramidal symptoms, and other important adverse outcomes 4, 6, 7
- Atypical antipsychotics, such as risperidone, increase the risk of somnolence, extrapyramidal symptoms, and serious adverse events 6