Atypical Antipsychotic Use in Patients With Dementia: Managing Safety Concerns
Atypical Antipsychotic Use in Patients With Dementia: Managing Safety Concerns
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DOI：
10.1176/appi.ajp.2012.12030342
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发表时间：
2012-09-01
影响因子：
17.7
通讯作者：
Lyketsos, Constantine G.
中科院分区：
文献类型：
--
作者：
Steinberg, Martin;Lyketsos, Constantine G.
神经精神症状，如激越和妄想，常见于老年痴呆症患者，并经常导致显着的痛苦。非典型抗精神病药物的疗效数据最强，但必须非常谨慎地使用这些药物。痴呆患者的不良反应包括死亡和脑血管事件风险增加，以及代谢影响、锥体外系症状、福尔斯、认知恶化、心律失常和肺炎。传统的抗精神病药物可能会带来更大的安全风险。没有明确的疗效证据支持使用替代精神药物类别（例如，抗抑郁药、抗惊厥药），尽管它们可能是更安全的选择。当非药物干预不成功，神经精神症状或相关行为导致严重痛苦或构成重大安全风险时，需要进行抗精神病药物试验。在开始使用非典型抗精神病药物之前，应进行全面评估，以排除神经精神症状的医学原因，并确定是否存在任何环境或护理人员因素。应与患者和代理决策者讨论风险、益处和替代方案，并有机会提出问题。剂量应该是必要的最低剂量，并应定期监测代谢参数。面对面的访问对于监测反应，耐受性和继续治疗的必要性非常重要。对于神经精神症状明显改善或缓解3-6个月的患者，应考虑中止试验。通过仔细选择适当的患者进行治疗，对患者和护理人员进行教育，并密切监测，可以最大限度地减少安全风险。
Neuropsychiatric symptoms such as agitation and delusions occur commonly in elderly patients with dementia and often cause significant distress. Data on treatment efficacy are strongest for atypical antipsychotics, but these agents must be used with great caution. Adverse effects in patients with dementia include an increased risk of mortality and cerebrovascular events, as well as metabolic effects, extrapyramidal symptoms, falls, cognitive worsening, cardiac arrhythmia, and pneumonia. Conventional antipsychotics may pose an even greater safety risk. No clear efficacy evidence exists to support the use of alternative psychotropic classes (e.g., antidepressants, anticonvulsants), although they may be safer options. An antipsychotic trial is warranted when nonpharmacological intervention is unsuccessful and neuropsychiatric symptoms or associated behaviors cause severe distress or pose a significant safety risk. Before an atypical antipsychotic is started, a comprehensive assessment should be performed to rule out medical causes of the neuropsychiatric symptoms and to ascertain whether any contributing environmental or caregiver factors are present. Risks, benefits, and alternatives should be discussed with the patient and surrogate decision maker, with an opportunity given to ask questions. Dosages should be the lowest necessary, and metabolic parameters should be regularly monitored. Face-to-face visits are important to monitor response, tolerance, and the need for continued treatment. For patients in whom neuropsychiatric symptoms have been much improved or have been in remission for 3-6 months, a discontinuation trial should be considered. Through careful selection of appropriate patients for treatment, education of patients and caregivers, and close monitoring, safety risks can be minimized.