The quality of evidence is downgraded by study limitations (incomplete outcome data, selective reporting and/or short follow-up).
Atypical antipsychotics are suggested for agitation in Alzheimer's disease or vascular dementia, if nonpharmacological methods are insufficient.
The recommendation is weak because of uncertain trade-off between benefits and harms/burden of treatment.
A Cochrane review [Abstract] 1 included 20 studies with a total of 5909 subjects. Neuropsychiatric symptoms are a common accompaniment of dementia. These include agitation/aggression, delusions and hallucinations. In some cases, the delusions or hallucinations meet the criteria for dementia-associated psychosis. Eight of the trials (n=2320) tested an atypical antipsychotic for agitation and 12 for psychosis (n=3589). The trials were performed in institutionalised or hospitalised for agitation and institutionalized, hospitalised and community-dwelling patients, or a combination of those, for psychosis. The trials had a duration between 3 to 12 weeks.
See tableT1.
| Outcomes | Absolute mean change from baselineor absolute risk in each group | Comparison of mean changes or risksbetween groups (treatment effect) | ||
|---|---|---|---|---|
| Placebo group | Antipsychotics group(95%CI) | Relative effect,RR (95% CI) | Absolute effect,MD or RD (95% CI) | |
| Agitation in units on CMAI (higher is worse), baseline mean was 58.8; SMD 0.21 less (0.30 to 0.12) | 15.0 decrease | 18.0 decrease(19.3 to 16.7) | NA | 3.0 greater decrease(4.3 to 1.7) |
| Psychosisin units of NPI-NH P (higher is worse), baseline mean was 11.2; SMD 0.11 less (0.18 to 0.03) | 4.7 decrease | 5.3 decrease(5.7 to 4.9) | NA | 0.6 greater decrease(1.0 to 0.2) |
| Extrapyramidal symptoms | 8 per 100 | 11 per 100(9 to 14) | 1.39(1.14 to 1.68) | 3 more per 100(1 to 6 more) |
| Somnolence | 7 per 100 | 14 per 100(11 to 17) | 1.93(1.57 to 2.39) | 7 more per 100(4 to 10 more) |
| Death | 19 per 1000 | 26 per 1000(17 to 39) | 1.36(0.90 to 2.05) | 7 more per 1000(2 less to 20 more) |
Overall, the evidence shows that most of the decrease in agitation and psychosis seen can be attributed to a favourable natural course of these symptoms, as observed in the placebo groups. Due to the unfavourable balance between beneficial effects and risks of adverse events of the atypical antipsychotics, it is advised to look at alternative therapeutic options. Treatment of the underlying possible psychosocial and somatic causes of agitation or psychosis should always be considered.
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