New APA Guidelines: Limit Use of Antipsychotics for Agitation and Psychosis in Patients with Dementia
On May 1, the APA published new practice guidelines aimed at improving care for older adults with dementia—a vulnerable and growing population. Unlike previous practice guidelines that have broadly addressed disorders or categories of disorders, these guidelines focus on the use of antipsychotics for a specific set of conditions, agitation and psychosis in patients with dementia. The guidelines recommend judicious use of antipsychotic medications for these patients.
So why this particular focus? Several factors contribute to the need for this guidance: dementia is common among older adults (5–10 percent of adults over 65 years and 30-40 percent of adults over 85); most people with dementia will at some point develop agitation and psychotic symptoms; current treatment practices vary greatly; and there are substantial risks associated with antipsychotic use in this population, including mortality.
The guidelines recommend that, except for emergency situations, antipsychotics should only be used to treat agitation or psychosis in patients with dementia “when symptoms are severe, are dangerous, and/or cause significant distress to the patient.”
The Executive Summary of the guidelines, “Practice Guidelines on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients with Dementia,” appears in the May issue of The American Journal of Psychiatry (AJP). The full guidelines are available at PsychiatryOnline.
Importantly, while the guidelines are focused on antipsychotic use, medication decisions are not made in isolation. The guidelines emphasize the need for comprehensive, person-centered treatment planning focused on the overall quality of life and also emphasize that individuals, surrogate decision makers, family and others should be involved in all aspects of decision-making.
The guidelines were developed using an extensive review process and input from many experts and stakeholders. They were developed by the APA Practice Guideline Writing Group in a process following recommendations of the Institute of Medicine (IOM) and other national organizations. (See more on the guideline development process.) The Guideline Writing Group consisted of psychiatrists and experts from other disciplines (nursing, neurology, and geriatrics).
Overall, the guideline development included a review of 45 randomized controlled trials and 52 observational studies. The process involved systematic rating of the strength of research evidence and rating the strength of each recommendation. Non-drug treatments (such as behavioral treatments and support and training for caregivers) and other medications (such as antidepressants) were not reviewed.
To supplement the expertise of the members of the Writing Group, APA surveyed nearly 600 peer-nominated experts in dementia and antipsychotics. APA also worked with the Alzheimer’s Association to review the draft providing perspectives of patients, families and other care partners. The guideline was also made available to APA members, stakeholders and the public for comment in July 2015 and comments were received from 44 individuals and 11 organizations.
We feel these evidence-based recommendations, with the extensive review and broad input supporting them, provide a valuable resource for clinicians, individuals, caregivers and others. The guidelines will help promote the best decisions possible for patients with dementia and symptoms of agitation and psychosis and will contribute to improving care for many older adults.