Additional Comments

The Diagnosis and Treatment of Behavioral Disorders in Dementia by Prof. Dr. med. Torsten Kratz in issue 26/2017

I have some brief additional comments to the overall very welcome review article (1), the subject matter of which is relevant for most practicing clinicians.

Risperidone is licensed for treating psychotic symptoms—such as increased psychomotor activity, and aggressiveness—only in Alzheimer's dementia, and only in limited dosages and for restricted periods. In off-label use, penalties are to be expected as prescribing is not permitted for doctors practicing under contract with a statutory health insurer. Other atypical antipsychotics are not licensed for this particular indication.

In Parkinsonian manifestations, quetiapine often leads to a deterioration over time, occasionally with the most severe symptoms, especially in Lewy body dementia. Unfortunately, the only antipsychotic that is licensed for this indication is clozapine, but this is promising and usually low in adverse effects. In all experience, the increased effort required in terms of obtaining blood counts can be managed in collaboration with general practitioners.

I think the recommendation to prefer atypical neuroleptic drugs to treat behavioral disorders in dementia is problematic. These drugs are by no means as low in adverse effects as had been hoped initially. There are even indications of comparatively common and, in particular, severe adverse effects for quetiapine (2).

Citalopram and escitalopram should continue not to be given in combination with other drugs that prolong the QT interval. The use of the latter is likely to be considered as the rule rather than the exception in behavioral disorders in dementia (for example, risperidone).

The review article by Wenzel-Seifert et al. can be consulted for the differential indication of psychotropic drugs in the relevant patient population (3). Accordingly, sertraline should be the preferred serotonin reuptake inhibitor.

In my opinion, the fact that doctors employed within the statutory healthcare system are not permitted to prescribe certain drugs because this would constitute off-label use, as well as important contraindications, should be taken more seriously into account in evidence based (S3) guidelines.

DOI: 10.3238/arztebl.2017.0753a

Dr. med. Wolfgang J. Stein

Koblenz

Conflict of interest statement

The author declares that no conflict of interest exists.

References

1. Kratz T: The diagnosis and treatment of behavioral disorders in dementia. Dtsch Arztebl Int 2017; 114: 447–54

2. Jin H, Shih PA, Golshan S, et al.: Comparison of longer-term safety and effectiveness of four atypical antipsychotics in patients over age 40: a trial using equipoise-stratified randomization. J Clinical Psychiatry 2013; 74: 10–8

3. Wenzel-Seifert K, Wittmann M, Haen E: QTc prolongation by psychotropic drugs and the risk of torsade de pointes. Dtsch Arztebl Int 2011; 108: 687–93