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Antipsychotic medications are often prescribed to help manage dementia symptoms. Fiordaliso/Getty Images
  • In a new study, researchers are expanding the list of potential health dangers to people with dementia who are taking antipsychotic drugs.
  • The researchers say the highest risk is present soon after people start taking the medications.
  • They say caregivers should weigh the potential dangers before people with dementia start taking the drugs.

A new study reports that there are more health dangers associated with giving antipsychotic medications to people with dementia than previously believed.

The research, published in The BMJ (British Medical Journal), correlates antipsychotic drug use by people with dementia with elevated risks of heart attack, stroke, heart failure, blood clots, irregular heart rhythm, pneumonia,
fracture, and acute kidney injury when compared to people with dementia who are not using antipsychotics.

The study authors said the highest risk of side effects comes soon after people start the medications. They said this fact highlights the need for more caution during the early stages of treatment.

The researchers pointed out that antipsychotics are widely prescribed for psychological and
behavioral symptoms of dementia, including depression, anxiety, irritability, aggression, apathy,
delirium, and psychosis.

They said the typical regulatory warnings accompanying antipsychotics cover only increased risk for stroke and
death. They added that this research highlights the expanded risks of antipsychotics when used for dementia.

The researchers said they found the potential health issues by combing through primary care, hospital, and mortality data in England.

They identified 173,910 people, 63% of whom were women, who were diagnosed with dementia. The average age of individuals in the study was 82.

The subjects were diagnosed between January 1998 and May 2018 and weren’t prescribed an antipsychotic the year before their diagnosis.

The researchers matched up 35,339 people prescribed an antipsychotic on or after the day of their
dementia diagnosis with 15 randomly selected people with dementia who didn’t take antipsychotics.

Risperidone, quetiapine, haloperidol, and olanzapine were the most commonly prescribed antipsychotic drugs.

Researchers excluded people from the analysis who had a history of each specific outcome under
investigation before their diagnosis. They said they also accounted for possible factors such as personal patient characteristics, pre-existing medical conditions, lifestyle, and prescribed drugs.

The researchers reported that antipsychotic drug use was associated with increased risks for all outcomes, except ventricular arrhythmia, compared with people with dementia who weren’t taking the medications.

For example, during the first three months of treatment, researchers reported that the pneumonia rates among people taking antipsychotics were 4.48%, compared to 1.49% for non-users. After a year of antipsychotic use, that rate rose to 10.41% for users, compared to 5.63% for non-users.

The researchers said the risk of acute kidney injury was highest among people taking antipsychotic drugs (1.7-fold
increased risk). In addition, the risk of stroke and venous thromboembolism (1.6-fold increased risk) were higher when compared against non-users.

For almost all of the outcomes, they said the risks were highest during the first week of antipsychotic treatment, particularly for pneumonia.

Researchers said their study was observational and they couldn’t draw firm conclusions about cause and effect. They also said some misclassification of antipsychotic use may have occurred.

Although they said they adjusted for a range of factors, the researchers couldn’t rule out other unmeasured
variables affected their results.

They also said their study was a large analysis based on reliable health data investigating a wide range of
adverse events over several time periods.

Dr. J. Wes Ulm, a bioinformatic scientific resource analyst and biomedical data specialist
affiliated with the National Institutes of Health, the National Institutes of Health (NIH), and the Turning
Discovery Into Health, told Medical News Today that people with certain underlying conditions may be especially vulnerable to the drugs.

“Antipsychotic drugs have distinct mechanisms of actions that can have effects on the basic physiology of multiple organ systems, both directly and indirectly, through their impact on the nervous system,” said Ulm, who was not involved in the research. “This may be a major contributor to the observed findings.”

Ulm added that the treatment would have to be individualized to different people, but in general if a person is displaying pronounced psychotic signs and symptoms, the antipsychotic treatment may still be worth the risk “due to the marked decline in function.”

“However, it may be worth taking extra caution in such cases to select specific antipsychotics that may be of lower risk for such a side effect profile,” he said.

Dr. David Merrill is a geriatric psychiatrist and director of the Pacific Neuroscience Institute’s Pacific Brain Health Center at Providence Saint John’s Health Center in California.

Merrill, who was not involved in the study, told Medical News Today that the purpose of prescribing antipsychotics to people living with dementia is to relieve sometimes severe stress and suffering of both the person and their loved ones.

“It is recommended that non-pharmacological behavioral treatments be used first before resorting to psychotropic medications for behaviors due to dementia,” he said. “Medications should be reserved for recurrent severe behaviors that pose a harm to the patient or those around them such as hostile aggression.”

Merrill added that there’s evidence drugs such as risperidone reduce hostile aggressiveness that can be caused by dementia. That can help prevent the need to place someone in a residential care facility.

“That said, the potential down sides of antipsychotic use in dementia are real,” he noted. “This study finds those negative outcomes are more widespread than previously thought. All the more reason to identify and treat any unidentified medical issues that may be driving what appears to be behavioral agitation due to dementia.”

Merrill said those factors could include urinary tract infections, pneumonia, or electrolyte abnormalities.

“It may be that some of the cases treated with antipsychotics who then were identified as ill shortly thereafter, may have already had the beginnings of their medical illness,” he said. “Optimizing health, assisting with maintenance of good hygiene, and savvy caregiving techniques are all super important to caring for persons living with dementia.”

Dr. Jason Krellman, a neuropsychologist and assistant professor of neuropsychology at the Columbia University Irving Medical Center in New York, told Medical News Today that providers and caregivers must weigh possible side
effects with severe behavioral and psychological symptoms that can occur in the later stages of dementia, such as agitation, aggression, hallucinations, and delusions.

“This study suggests that there is a much wider range of health risks from taking these drugs than we previously thought,” said Krellman, who was not involved in the research. “However, sometimes patients’ later stage symptoms are so severe that prescribers and caregivers feel the benefits outweigh the risks. Unfortunately, many caregivers
do not have the stamina or financial resources to deal with the severe, persistent behavioral and psychological symptoms some later stage dementia patients experience.”

Krellman added that unless someone has the benefit of 24-hour care, episodes of agitation, pacing, wandering, and similar problems can be difficult to manage to keep the person safe and emotionally content.

“What’s worse, providing constant care for an individual with these kinds of symptoms can be very draining for even the most dedicated caregiver,” Krellman noted. “The risk/benefit debate is one that each provider and caregiver must have individually. Everyone’s situation is different and therefore pros and cons of any treatment can be different from person to person. Providers and caregivers need to consider the patient’s age, the severity of their symptoms, and the level of risk to the patient’s safety because of their symptoms.”