Despite the FDA black box warning (BBW) that advises avoiding antipsychotic agents for the treatment of dementia-related psychosis, their use in these patients continues to decrease the neuropsychiatric symptoms that can often lead to unnecessary earlier institutionalization. The risks outlined in the BBW are clearly noted; however, growing recognition of an increased incidence of head injury among patients taking these medications is spurring a new conversation about the potential risks of this treatment strategy. 

Coauthor Vesa Tapiainen, MD, of the University of Eastern Finland in Kuopio, and colleagues set out to explore the association of antipsychotic use and risk of head injuries among community dwellers with Alzheimer’s disease (AD). Despite the BBW to avoid use in people with dementia who are experiencing psychosis, antipsychotics are commonly prescribed for persons with AD to treat neuropsychiatric symptoms. This BBW advises that such use is associated with an increased risk of death due to medical complications such as stroke and infection.  

According to a recent meta-analysis, antipsychotic use was associated with a 54% higher likelihood of falls among older people. The authors noted that the number of persons with dementia is expected to increase, reaching 74.7 million in 2030 and up to 131.5 million in 2050. The research team highlights the importance of their work, which raises awareness and assesses the risks associated with antipsychotic use in this population. 

“To our knowledge, this is the first study examining the association of antipsychotic use with the risk of head injuries and TBIs. Our findings are supported by previous meta-analysis showing 54% higher risk of falls among older persons using antipsychotics because TBIs [traumatic brain injuries] are mostly fall-related injuries among older persons. Our main result is also in line with previous studies reporting higher risk of hip fracture, another fall-related injury, among older people using antipsychotics,” the authors wrote.

The team concluded that not only may antipsychotic use increase the risk of head injuries, including traumatic brain injuries, in individuals with AD, but also that certain antipsychotic agents, such as quetiapine, may be riskier than others, such as risperidone. Therefore, their use should be restricted to the most severe neuropsychiatric symptoms, as recommended by the AGS Beers Criteria. Additionally, higher relative risk of TBIs in quetiapine users compared with risperidone users should be confirmed in further studies.

Although the team acknowledges the limitation of their study, they believe it supports restricting the use of APS in patients with AD to only those with the most severe neuropsychiatric and behavioral symptoms.

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