Maximizing Patient Benefits through Pharmacological Evidence-Based Approach to Symptom Management

Peter P. De Deyn, Laboratory of Neurochemistry and Behavior, Laboratory of Neurochemistry and Behavior, University of Antwerp / Born-Bunge Foundation, Antwerp, Belgium

Dementia is a multi-faceted condition, characterized by a progressive decline in cognitive function, and behavioral and psychological symptoms that may affect as many as 90% of sufferers. In particular, agitation and aggression tend to influence the decision to institutionalize the patient, disrupting families and increasing the cost of treatment. Optimal management of dementia involves a considered balance of non-pharmacological interventions and appropriate drug therapy. Trials show that even simple interventions, such as listening to a patient’s problems, will reduce a patient’s anxiety and hence the overall caregiver burden. Elsewhere, it has been demonstrated that participation in cognitively stimulating activities slows decline in cognitive function ? and reduces the risk of incident dementia.

Pharmacological interventions are designed to achieve maximum impact on dementia symptoms with minimum impact on patients in terms of side effects. Neuroleptic agents are usually more effective than other therapies such as b blockers or anxiolytics, but are limited by potentially serious side effects such as extrapyramidal effects and tardive dyskinesia. In recent years, newer atypical antipsychotic agents have been developed that appear to have a better tolerability profile. These drugs include risperidone, quetiapine, olanzapine and aripiprazole.

The efficacy and tolerability of the atypical antipsychotic, risperidone has been studied and established in three randomized, placebo-controlled trials (RCTs) in a large number of patients with behavioral and psychological problems associated with dementia. The data on the other atypical antipsychotic drugs quetiapine, olanzapine and aripiprazole is based on a smaller number of clinical trials, involving fewer patients.

Results from RCTs show that risperidone improves symptoms of aggression, agitation, and psychosis in dementia. In addition, quetiapine and olanzapine have demonstrated beneficial effects on patient agitation and aggression. Data on risperidone and olanzapine indicate benefit when assessed from the caregiver’s point of view. All the atypical antipsychotic drugs demonstrate a low level of extrapyramidal symptoms overcoming one of the more important limitations of conventional antipsychotic therapy.

In summary, in managing agitation, aggression, and psychosis in patients with dementia, the atypical medications have a proven beneficial effect on the symptoms, whilst having fewer side effects than the typical antipsychotics. With three consistent placebo-controlled randomized trials, risperidone is the best-studied atypical antipsychotic in the treatment of agitation, aggression, and psychosis in dementia.