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The use of antipsychotics leads to a higher mortality rate among dementia patients than previously estimated. This was the result of a retrospective study with 91.000 dementia patients which was recently published in JAMA Psychiatry. The associated scientists hope that these insights will initiate a shift to non-medical therapies.

Antipsychotics are prescribed to dementia patients in cases of aggressive behaviour and psychosis. Next to the known adverse effects such as metabolic changes and extrapyramidal symptoms, previous studies suggested that cerebrovascular complications and increased mortality might also be associated with the use of antipsychotics. This correlation was confirmed by a large-scale study of the University of Michigan that discovered a mortality risk even higher than suspected.

The investigators collected data from dementia patients with and without drug usage that had otherwise similar characteristics. With this information, they compared 180-day mortality of antipsychotic, anticonvulsant and antidepressant users. Especially the antipsychotic haloperidol proved to increase the mortality rate with a number needed to harm (NNH) of 26. On average, 26 patients have to be treated with haloperidol to cause one extra death in the designated study period.  Previously, this number was estimated to be 100.

The same effect was seen with the antipsychotics olanzapine, quetiapine and resperidone with NNHs of 27 to 50. Furthermore, the mortality risk of all tested antipsychotics was increased when compared to antidepressants. In the study, different drug doses were taken into account which resulted in the discovery of a dose-response relationship between the intake of atypical antipsychotics and mortality of the users. 

According to psychiatrist Donovan Maust of the University of Michigan “the harms associated with using these drugs in dementia patients are clear, yet clinicians continue to use them.” He suspects that the distressing symptoms are the main cause for this policy. “These results should raise the threshold for prescribing further." In future, non-pharmacological strategies (DICE-strategy) like improving environmental factors and instructing care-takers, should be implemented more often. However, “non-pharmacologic approaches will only succeed if we as a society agree to pay front-line providers for the time needed to 'do the right thing'," says co-author and psychiatrist Helen Kales.

Source: JAMA Psychiatry and Eurekalert

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