lowestnnt

DITORIALTOOLSFORPRACTICEAntipsychoticsforagitationindementiaJoeyTonPharmDJamilRamjiACPRG.
MichaelAllanMDCCFPClinicalquestionWhatarethebeneftsandharmsofantipsychoticsforagitationindementiaBottomlineAntipsychoticsprovidelittleimprovementoverpla-ceboonagitationscales.
However,a50%improve-mentinbehaviouroccursinabout46%ofthosetakingantipsychoticsversusabout33%takingpla-cebo.
Harmsareserious(eg,1increaseddeathin80over3months)andcommon.
Antipsychoticsshouldbereservedforsevereaggression,andwithdrawalshouldbeattemptedassoonaspossible.
EvidenceEvidenceincludes6systematicreviews(5to16RCTsof856to5110patientsthatlasted10to12weeks).
1-6Resultsarestatisticallysignifcantunlessindicatedotherwise.
Placebohadlargeeffects(eg,11-pointincreaseona144-pointscale—aclinicallymeaningfuldifference).
7Studiesofatypicalantipsychoticsrevealedthefollowing:-Meanimprovementonmultiplescaleswastrivial(eg,3ona144-pointscale[notlikelyclinicallymeaningful]).
1-3-Individualantipsychoticshadgenerallysimilarresults.
2,5-Somepatientsattained50%improvementonscales(eg,46%withrisperidonevs33%withplacebo,num-berneededtotreat[NNT]=8).
4-Harmsincludedstoppingowingtoadverseevents(numberneededtoharm[NNH]=13to39).
2Seriousharmsincludeddeath(NNH=77to84)1,4andcerebro-vascularevents(NNH=48to104).
1,2,4-Mini-MentalStateExaminationscorewas0.
73pointsworse(statistically,notclinically,signifcant).
4-Otherharmsweresomnolence(NNH=7to11),gaitabnormalities(NNH=11to20),extrapyramidalsymptoms(NNH=16to44),andperipheraledema(NNH=20to25).
1,2,4First-generationantipsychotics(eg,haloperidol)appeartohavesimilarratesofharmsbutinconsis-tentbenefts.
6ContextCholinesteraseinhibitors,selectiveserotoninreuptakeinhibitors,trazodone,andvalproateprovidenomean-ingfulimprovementinagitation.
8-11-Benzodiazepinesmightapproachantipsychoticsineffcacyforagitationbutalsohaveharms.
12Stoppingantipsychoticsmightreducedeath(NNT=4at2years)withlittleeffectonneuropsychiatricsymptoms.
13ImplementationMedical,psychological,andenvironmentaltriggersshouldbeassessedandtargetedinpatientswithagita-tion.
14Painisacommoncauseofagitationindementia,occurringin57%ofpatients,andpainresolutioncanimproveagitation.
15A3Rsapproach(repeat,reassure,redirect)isrecommended.
14Insevereaggressionthatthreatensthesafetyofthepatientorothers,useatypicalantipsychoticstotargetsymptomswithoutsedatingthepatient.
16Thelowesteffectivedoseshouldbeusedfortheshortesttime.
Adeprescribingalgorithmisavailable.
16DrTonandMrRamjiareKnowledgeTranslationExpertswiththePEERGroupintheDepartmentofFamilyMedicineandinthePhysicianLearningProgramattheUniversityofAlbertainEdmonton.
DrAllanisProfessorwiththePEERGroupintheDepartmentofFamilyMedicineattheUniversityofAlberta.
CompetinginterestsNonedeclaredTheopinionsexpressedinToolsforPracticearticlesarethoseoftheauthorsanddonotnecessarilymirrortheperspectiveandpolicyoftheAlbertaCollegeofFamilyPhysicians.
References1.
MaH,HuangY,CongZ,WangY,JiangW,GaoS,etal.
Theeffcacyandsafetyofatypicalantipsy-choticsforthetreatmentofdementia:ameta-analysisofrandomizedplacebo-controlledtrials.
JAlzheimersDis2014;42(3):915-37.
2.
BallardCG,WaiteJ,BirksJ.
AtypicalantipsychoticsforaggressionandpsychosisinAlzheimer'sdisease.
CochraneDatabaseSystRev2006;(1):CD003476.
3.
YuryCA,FisherJE.
Meta-analysisoftheeffectivenessofatypicalantipsychoticsforthetreatmentofbehaviouralproblemsinpersonswithdementia.
PsychotherPsychosom2007;76(4):213-8.
4.
SchneiderLS,DagermanK,InselPS.
Effcacyandadverseeffectsofatypicalantipsychoticsfordemen-tia:meta-analysisofrandomized,placebo-controlledtrials.
AmJGeriatrPsychiatry2006;14(3):191-210.
5.
CheungG,StapelbergJ.
Quetiapineforthetreatmentofbehaviouralandpsychologicalsymp-tomsofdementia(BPSD):ameta-analysisofrandomisedplacebo-controlledtrials.
NZMedJ2011;124(1336):39-50.
6.
LonerganE,LuxenbergJ,ColfordJM,BirksJ.
Haloperidolforagitationindementia.
CochraneDatabaseSystRev2002;(2):CD002852.
7.
RosenbergPB,DryeLT,PorsteinssonAP,PollockBG,DevanandDP,FrangakisC,etal.
ChangeinagitationinAlzheimer'sdiseaseintheplaceboarmofanine-weekcontrolledtrial.
IntPsycho-geriatr2015;27(12):2059-67.
8.
CampbellN,AyubA,MalazBoustaniM,FoxC,FarlowMR,MaidmentI,etal.
Impactofcholines-teraseinhibitorsonbehavioralandpsychologicalsymptomsofAlzheimer'sdisease:ameta-analysis.
ClinIntervAging2008;3(4):719-28.
9.
SeitzDP,AdunuriN,GillSS,GruneirA,HerrmannN,RochonP.
Antidepressantsforagitationandpsychosisindementia.
CochraneDatabaseSystRev2011;(2):CD008191.
10.
Martinn-TorresG,FioravantiM,GrimleyEvansJ.
Trazodoneforagitationindementia.
CochraneDatabaseSystRev2004;(3):CD004990.
11.
LonerganE,LuxenbergJ.
Valproatepreparationsforagitationindementia.
CochraneDatabaseSystRev2009;(3):CD003945.
12.
McCrackenR,AllanGM.
Agitationindementia–arebenzosabackupEdmonton,AB:ToolsforPractice;2015.
13.
AllanGM,BehnSmithD.
WhataretherisksofstoppingantipsychoticsintheelderlyEdmonton,AB:ToolsforPractice;2013.
14.
SadowskyCH,GalvinJE.
Guidelinesforthemanagementofcognitiveandbehavioralproblemsindementia.
JAmBoardFamMed2012;25(3):350-66.
15.
HuseboBS,BallardC,SandvikR,NilsenOB,AarslandD.
Effcacyoftreatingpaintoreducebehaviouraldisturbancesinresidentsofnursinghomeswithdementia:clusterrandomisedclinicaltrial.
BMJ2011;343:d4065.
16.
BjerreLM,FarrellB,HogelM,GrahamL,LemayG,McCarthyL,etal.
Deprescribingantipsychoticsforbehaviouralandpsychologicalsymptomsofdementiaandinsomnia.
Evidence-basedclini-calpracticeguideline.
CanFamPhysician2018;64:17-27(Eng),e1-12(Fr).
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