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• W1753040646 abstract "Behavioural and psychological symptoms of dementia (BPSD) are the most frequent cause of not being able to be cared for at home. BPSD cannot be treated using ordinal medicines, except for antipsychotics. It is often inevitable to use antipsychotics for BPSD to satisfy both patients and caregivers. Meanwhile, the side-effects of antipsychotics have been widely pointed out,1, 2 such as extrapyramidal symptoms of ataxia and falls,3-5 aspiration followed by aspiration pneumonia,6-8 constipation followed by paralytic ileus, heart failure, lack of spirits and so on.9, 10 Because these adverse effects of antipsychotics are sometimes life-threatening, a balance between benefit and adverse effects of antipsychotics should be critically focused on to care for BPSD.11 Recently, we experienced two cases of normal older subjects who had been prescribed antipsychotics resulting in reduced cognitive function and requiring care as for dementia (Table 1). Case 1 (86-year-old woman) had been prescribed seven tablets of three different antipsychotics per day, including tiapride hydrochloride, sodium valproate and etizalam for memory disturbance, problematic behavioural changes and fighting with family while living at home. After stopping the antipsychotics, the patient's Mini-Mental State Examination (MMSE, maximum points of 30) went from 19 to 29, and she has had a clear response since then. Case 2 (79-year-old woman) was similar to case 1. Her family was worried about too much memory disturbance and asked her to stay in a geriatric hospital. After stopping four tablets of two different antipsychotics per day, including risperidone and tiapride hydrochloride, her MMSE recovered from 13 to 22 and she had a relatively clear response. She was discharged from the geriatric hospital and resumed her duties at home as a housewife with the aid of her husband. Dementia is defined as a state in which the patient cannot carry out usual daily activities because of memory disturbance. MMSE is one of the indices to differentiate dementia. However, overdiagnosis of dementia because of subtle memory impairments might be disastrous in older people, as in cases 1 and 2. Forty to fifty years ago, older people were more comfortable in the community, because more intimate communication in the community than the present ones would make it possible for older patients to stay at home, even with slight memory impairment. In recent years, older people with slight memory loss cannot engage in daily life because of limited communication within the community, resulting in poor support from their neighborhood and complicated manuals such as pushing bottoms to use house equipments. Families are too much afraid of dementia. The patients might be treated as if they were experiencing delirium.12 Caregivers often complain of dementia symptoms and confusion of behaviour of self-care older subjects.13 Antipsychotics might be prescribed independently of specialist doctors and be in the interests of caregivers, but are not in the interests of patients. Antipsychotics can accelerate memory impairment and problematic behavioural changes, especially in older patients, which might result in the additional prescribing of antipsychotics. Case 2 showed a slightly lower MMSE, but she could assume daily life with the aid of her husband. Every organ function degrades with age, including brain function.14 Loss of memory with age is natural, but not a disease. With the advancement of age, activity also reduces.15, 16 Subtle memory impairment should not disturb daily life, so it is not dementia at all. Case 3 (68-year-old woman) originally complained of a sleeping disorder as a result of the stress of work (Table 1). She was prescribed antipsychotics in addition to sleeping pills because of severe anxiety and a depressive state. After 1 year, she was diagnosed with dementia and was an inpatient in a nursing home. She suffered a right hip fracture and was surgically operated on. Her husband asked our hospital to obtain a second opinion about dementia. She completely stopped taking nine tablets of five different antipsychotics per day, including risperidone and quetiapine fumarate. After stopping antipsychotics, she complained of an unstable mind for 2 months and returned to normal cognition 2 months later (MMSE returned to 29 from 19). Now, she is taking triazolam and lives normally as a housewife. Case 4 (66-year-old woman) is similar to case 3. She originally suffered neurosis because of anxiety about her husband's terminal illness. She had complained of sleep disturbance and depression. After magnetic resonance imaging and positron emission tomography, she was suspected to have Pick's disease because of slight atrophy of the frontal brain and unknowingly taking items while shopping. Twelve tablets of five different antipsychotics per day, including sodium tiapride hydrochloride, valproate, phenytoin, etizolam and trazodonehydrochloride, were prescribed and she stayed in a geriatric hospital for 4 years. After stopping these antipsychotics, her MMSE recovered from 15 to 27 and her behaviour became normal. She went back home and resumed her duties as a housewife. Depression has been speculated to be one of the probable factors of dementia.17 People are unable to make clear judgements when affected by depression and anxiety, which could be diagnosed as dementia. Once diagnosed with dementia because of some unusual symptoms, which could be mistaken as BPSD, a certain amount of antipsychotics might be prescribed, which can disturb normal responses and cause further memory impairment. It is disastrous to treat tentative depression symptoms in normal people as dementia. It is not recommended that antipsychotics be prescribed temporarily for many psychological diseases, as psychotic diseases can relapse. However, in dementia patients, antipsychotics should not be prescribed continuously. We have to be reminded that antipsychotics can reduce cognitive function, even in normal older people. Case 5 and 6 are typical dementia patients with BPSD (Table 1). Antipsychotics of 17 tablets in case 5 and 25 tablets in case 6 per day, including risperidone, quetiapine fumarate, olanzapine, tiapride hydrochloride and more, had been prescribed and their MMSE were 0 points. In case 6, malignant syndrome was observed. After stopping all antipsychotics, the MMSE returned to 10 in case 5 and 12 in case 6. Usually, cognitive function would not be affected by antipsychotics in dementia patients. However, we have to be aware that in some cases cognitive function is severely influenced. Cognitive function becomes impaired with age. In dementia patients, BPSD is common and antipsychotics have been widely prescribed. In impaired cognitive function, it could be speculated that antipsychotics would further reduce cognitive function. BPSD is a kind of burst of various emotions.18 Minor, but frequent, unfair treatment of a patient might accumulate and finally appear as BPSD, in the manner of priming and eliciting between antigen and antibody in an immune response. Bursts of emotion, such as anger, crying, violence and so on, are observed even in normal subjects, especially in patients with cerebrovascular diseases. Such frequent natural symptoms of BPSD can be treated without medicine.19 Non-medical treatment of BPSD has been developed and satisfies both patients and caregivers.20, 21 No medicine makes patients smile, but favorite stimulation to the limbic system alleviates anger or violence and can make patients happy.22, 23 Non-medical stimulation to the limbic system can be much more significant than antipsychotics, although stimulation to the limbic system is very difficult. However, how to bring happiness to patients instead of easy treatment by antipsychotics should be studied more intensely. In the present study, it was suggested that cognitive function could be reduced by antipsychotics in both normal older subjects and dementia patients. The amount of antipsychotics being prescribed is important, but we should be aware that antipsychotics might reduce cognitive function in some patients. Mental impairment is one of the most difficult symptoms to care for.24, 25 Present cases are limited in number, but there have been many patients treated using antipsychotics, and a reduction of cognitive function should be noticed as one of the severe side-effects of antipsychotics." @default.
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• W1753040646 date "2011-06-01" @default.
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• W1753040646 title "Antipsychotics and cognitive function" @default.
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