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Clinician Article

Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia.



  • Van Leeuwen E
  • Petrovic M
  • van Driel ML
  • De Sutter AI
  • Vander Stichele R
  • Declercq T, et al.
Cochrane Database Syst Rev. 2018 Mar 30;3:CD007726. doi: 10.1002/14651858.CD007726.pub3. (Review)
PMID: 29605970
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Disciplines
  • Family Medicine (FM)/General Practice (GP)
    Relevance - 6/7
    Newsworthiness - 5/7
  • General Internal Medicine-Primary Care(US)
    Relevance - 6/7
    Newsworthiness - 5/7
  • Psychiatry
    Relevance - 6/7
    Newsworthiness - 4/7
  • Geriatrics
    Relevance - 6/7
    Newsworthiness - 3/7
  • FM/GP/Mental Health
    Relevance - 5/7
    Newsworthiness - 3/7
  • Hospital Doctor/Hospitalists
    Relevance - 5/7
    Newsworthiness - 3/7
  • Internal Medicine
    Relevance - 5/7
    Newsworthiness - 3/7

Abstract

BACKGROUND: Antipsychotic agents are often used to treat neuropsychiatric symptoms (NPS) in people with dementia although there is uncertainty about the effectiveness of their long-term use for this indication and concern that they may cause harm, including higher mortality. When behavioural strategies have failed and treatment with antipsychotic drugs is instituted, regular attempts to withdraw them have been recommended in guidelines. Physicians, nurses and families of older people with dementia may be reluctant to stop antipsychotics, fearing deterioration of NPS.This is an update of a Cochrane Review published in 2013.

OBJECTIVES: To evaluate whether withdrawal of antipsychotic agents is successful in older people with dementia and NPS in primary care or nursing home settings, to list the different strategies for withdrawal of antipsychotic agents in older participants with dementia and NPS, and to measure the effects of withdrawal of antipsychotic agents on participants' behaviour and assess safety.

SEARCH METHODS: We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (ALOIS), theCochrane Library, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, clinical trials registries and grey literature sources up to 11 January 2018.

SELECTION CRITERIA: We included all randomised, controlled trials comparing an antipsychotic withdrawal strategy to continuation of antipsychotics in people with dementia who had been treated with an antipsychotic drug for at least three months.

DATA COLLECTION AND ANALYSIS: We used standard methodological procedures according to the Cochrane Handbook for Systematic Reviews of Interventions. We rated the quality of evidence for each outcome using the GRADE approach.

MAIN RESULTS: We included 10 studies involving 632 participants. One new trial (19 participants) was added for this update.One trial was conducted in a community setting, eight in nursing homes and one in both settings. Different types of antipsychotics at varying doses were discontinued in the studies. Both abrupt and gradual withdrawal schedules were used. Reported data were predominantly from studies at low or unclear risk of bias.We included nine trials with 575 randomised participants that used a proxy outcome for overall success of antipsychotic withdrawal. Pooling data was not possible due to heterogeneity of outcome measures used. Based on assessment of seven studies, discontinuation may make little or no difference to whether or not participants complete the study (low-quality evidence).Two trials included only participants with psychosis, agitation or aggression who had responded to antipsychotic treatment. In these two trials, stopping antipsychotics was associated with a higher risk of leaving the study early due to symptomatic relapse or a shorter time to symptomatic relapse.We found low-quality evidence that discontinuation may make little or no difference to overall NPS, measured using various scales (7 trials, 519 participants). There was some evidence from subgroup analyses in two trials that discontinuation may reduce agitation for participants with less severe NPS at baseline, but may be associated with a worsening of NPS in participants with more severe NPS at baseline.None of the studies assessed withdrawal symptoms. Adverse effects of antipsychotics (such as falls) were not systematically assessed. Low-quality evidence showed that discontinuation may have little or no effect on adverse events (5 trials, 381 participants), quality of life (2 trials, 119 participants), or cognitive function (5 trials, 365 participants).There were insufficient data to determine whether discontinuation of antipsychotics has any effect on mortality (very low-quality evidence).

AUTHORS' CONCLUSIONS: There is low-quality evidence that antipsychotics may be successfully discontinued in older people with dementia and NPS who have been taking antipsychotics for at least three months, and that discontinuation may have little or no important effect on behavioural and psychological symptoms. This is consistent with the observation that most behavioural complications of dementia are intermittent and often do not persist for longer than three months. Discontinuation may have little or no effect on overall cognitive function. Discontinuation may make no difference to adverse events and quality of life. Based on the trials in this review, we are uncertain whether discontinuation of antipsychotics leads to a decrease in mortality.People with psychosis, aggression or agitation who responded well to long-term antipsychotic drug use, or those with more severe NPS at baseline, may benefit behaviourally from continuation of antipsychotics. Discontinuation may reduce agitation for people with mild NPS at baseline. However, these conclusions are based on few studies or small subgroups and further evidence of benefits and harms associated with withdrawal of antipsychotic is required in people with dementia and mild and severe NPS.The overall conclusions of the review have not changed since 2013 and the number of available trials remains low.


Clinical Comments

Family Medicine (FM)/General Practice (GP)

Conventional wisdom and current evidence argue against using antipsychotic medications for control of neuropsychiatric symptoms in patients with dementia. So, it is reassuring that this review found no adverse effects when these were discontinued, with the possible exception of the subgroup discussed in the review. Systems-based efforts to reduce use of antipsychotics in those with dementia should be supported.

General Internal Medicine-Primary Care(US)

People that benefitted from antipsychotics may benefit from continuation; people with minimal behavioral disturbance probably are unchanged by discontinuation. It is likely that medical practitioners know this already, but this does carry the weight of a Cochrane review.

General Internal Medicine-Primary Care(US)

I appreciate this Cochrane Review. I hope this leads to change in behavior.

Geriatrics

This is a common situation and it would be helpful to know whether it better to withdraw or not to withdraw antipsychotic medications. Unfortunately, this review did not settle the issue.

Psychiatry

This is a reasonable review of a thorny topic: Can we stop antipsychotic meds in people with dementia and agitation? The answer will not surprise clinicians: Yes, if the agitation was mild; maybe not if the agitation was severe. This is not surprising news, but I suppose that it could be helpful insofar as it "validates" much of what most of us already do. As usual, a very well prepared review.

Psychiatry

Further evidence that psychotropics for NPS related to dementia have minimal, especially long-term, efficacy and that use of psychotropics including anti-psychotics should be limited to the minimal duration after other alternatives have been explored and exhausted.

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