Efficacy of Atypical Antipsychotics to Treat Behavioral and Psychological Symptoms of Dementia in Nursing Home Residents: A Systematic Review of the Evidence from Randomized Controlled Trials

Background: Both behavioral and psychological symptoms of dementia and the use of atypical antipsychotics among nursing home residents with dementia are epidemic. However, the evidence from systematic reviews and randomized controlled trials for the benefits of using atypical antipsychotics in this population is conflicting and inconsistent. This study examines the evidence from randomized controlled trials for the use of atypical antipsychotics to treat nursing home residents with behavioral and psychological symptoms of dementia. Methods: PubMed, Cochrane review, the National Clinical Guideline Clearinghouse, previously published systematic reviews, and a search of references were used to find eligible randomized controlled trials on use of atypical antipsychotics to treat NH residents with behavioral and psychological symptoms of dementia. Inclusion and exclusion criteria were pre-defined. The papers were independently reviewed by two investigators. Risk of bias, applicability, and heterogeneity were assessed based on previously published methods. Results: Among 1469 citations, the 12 trials met the inclusion criteria. The variability of the diagnostic criteria and outcome measurements, as well as that of these verity of dementia and behavioral and psychological symptoms of dementia, prohibited meta-analysis of the selected 12 original studies. Among the total 4352 enrolled subjects across the 12 trials, age ranged from 77 to 84 years old. Seventy two percent of participants were female, and 64% of participants completed the trials. Mean duration of the 12 trials varied from six to 12 weeks. Four out of the 12 trials (33%) showed positive results. The BPSD reduction varied from 7% to 72%. Risk of bias included low concealment (58%) and high attrition rate (20-42%). The trict exclusion criteria and low recruitment fractions (69%) among the 12 trials reduced the applicability of the trials. Additionally, there was significant clinical heterogeneity and methodological diversity across the 12 trials. Conclusions: There is limited and inconsistent evidence to demonstrate the efficacy of atypical antipsychotics in the treatment of behavioral and psychological symptoms of dementia in nursing home residents. In addition, there are concerns about risk of bias, applicability, clinical heterogeneity, and methodological diversity among the 12 trials. We are less confident in the intervention effects of atypical antipsychotics on BPSD, and therefore do not recommend routinely prescribing atypical antipsychotics.