Behavioral and Psychological Symptoms in Dementia (BPSD) and the Use of Antipsychotics

Abstract

Dementia affects about 47 million people worldwide, number expected to exponentially increase within 30 years. Alzheimer's disease (AD) is the most common dementia type, accounting on its own for almost 70% of all dementia cases. Behavioral and psychological symptoms (BPSD) frequently occur during the disease progression; to treat agitation, aggressiveness, delusions and hallucinations, the use of antipsychotic drugs should be limited, due to their safety issues. In this literature review regarding the use of antipsychotics for treating BPSD in dementia, the advantages and limitation of antipsychotic drugs have been evaluated. The available medications for the management of behavioral and psychological symptoms are the antipsychotics, classed into typical and atypical, depending on their action on dopamine and serotonin receptors. First generation, or typical, antipsychotics exhibit lack of tolerability and display a broad range of side effects such as sedation, anticholinergic effects and extrapyramidal symptoms. Atypical, or second generation, antipsychotics bind more selectively to dopamine receptors and simultaneously block serotonin receptors, resulting in higher tolerability. High attention should be paid to the management of therapy interruption or switch between antipsychotics, to limit the possible rebound effect. Several switching strategies may be adopted, and clinicians should "tailor" therapies, accounting for patients' symptoms, comorbidities, polytherapies and frailty.

Keywords: atypical antipsychotics; behavioral and psychological symptoms of dementia (BPSD); dementia; frailty; typical antipsychotics.

Figure 1

Potential drug-switching schemes. In each panel the old drug is blue, the new drug is red. The x axis represents the timeline and the y axis the percentage of the target dose. The abrupt switch consists of the immediate interruption of the old drug, starting the new drug at full dose. In the taper switch, the old drug is gradually reduced while the new drug is started at full dose. Cross-taper switch consists of gradual reduction of the old drug with gradual increase of the new drug, without overlapping the full doses. Plateau cross-taper switch consists of gradual increase of the new drug, a short overlapping of the two drugs at full dose and then gradual reduction of the old drug.

Figure 2

Flow chart for approaching patients with BPSD (in particular delusions/agitation/aggression/psychosis, hallucinations).