The NICE/SCIE guideline on dementia recommends that those who develop non-cognitive symptoms or behaviour that challenges should be offered a pharmacological intervention in the first instance only if they are severely distressed or there is an immediate risk of harm to the person or others. Antipsychotics have been associated with an increased risk of cerebrovascular adverse events and greater mortality in people with dementia (see the NICE key therapeutic topic at the link below for further information) and NICE advises that treatment with an antipsychotic drug may be offered only after various conditions have been met. Other drugs that have been used (many off-label) for non‑cognitive symptoms of dementia include antidepressants, anticonvulsants, benzodiazepines, adrenergic beta-blockers and hypnotics. However, evidence to support their use is lacking.
The authors of the current research comment that the increased risk of mortality associated with the use of antipsychotics in patients with dementia seen in this study is higher than that previously reported from RCTs. Although RCTs are less subject to confounding by indication, they were of a shorter duration (6-12 weeks) and the authors argue that the longer period of analysis in the present study may more accurately reflect use in the community and therefore may more fully capture associations with mortality.
The study has a number of limitations that need to be considered when interpreting the results; these include lack of data on dementia severity and symptoms, the possibility of unmeasured confounders, and the limitation to initial episodes of medication monotherapy (which may limit generalisability). The authors acknowledge the possibility that part of the increased mortality risk seen in medication users could be related to the symptom or behaviour that prompted the prescription. They do however go on to conclude that “the balance of benefit to risk of antipsychotic treatment in dementia continues to shift” and they suggest that their findings can further assist physicians in minimising the potential harm associated with antipsychotic treatment.