The Psychopharmacological Treatment of People With Severe Dementia

Findings of a cross-sectional study

More than half of the residents in Germany’s care homes living with dementia are already at the stage of severe dementia, and the trend is upwards (1). Neuropsychiatric symptoms dominate the clinical picture in the patients (2). Although the S3 guidelines on dementias (German Association for Psychiatry, Psychotherapy and Psychosomatics [DGPPN] and the Deutsche Gesellschaft für Neurologie [German Society for Neurology, DGN], long version 2016) recommends as the first-line treatment psychosocial therapy, antipsychotic drugs are often prescribed (3). We analyzed for the first time data on the prevalence of neuropsychiatric symptoms and the psychopharmacological care especially of persons with severe dementia in Germany, and assessed the guideline adherence of the prescriptions.

Methods

For the cross sectional analysis we used the baseline data of study participants of a randomized controlled longitudinal study to investigate a psychosocial intervention (MAKS-s). The sample consisted of 142 people with severe dementia (mini-mental state test <10) from 26 care homes in Germany (from five German states, urban and rural, different funders, open and protective wards). Care homes randomly selected from their internet pages were contacted in writing and subsequently by telephone. The study methods are described in detail in the study protocol (4). All long-term prescriptions of psychotropic drugs were extracted from patient files in 02/2020. The neuropsychiatric symptoms were assessed by using the neuropsychiatric inventory NPI-NH (5). Clinically relevant neuropsychiatric symptoms were defined—following the literature—as an NPI-NH item score ≥4 . In addition to the descriptive statistics we calculated binary regression models with the control variables age, sex, care level, comorbidities, cognitive and everyday practical skills for the most common groups of psychotropic drugs (antidementia drugs, antipsychotics, and antidepressants) in order to estimate the odds ratios (OR) for the prescriptions.

Results

The mean age of the participants (N=142) was 86 and about 75% were female, with a mean MMST score of 4. Table 1 shows all prescribed psychotropic drugs, Table 2 shows the prevalence rates of neuropsychiatric symptoms. 74% of persons received at least one psychotropic medication, the most common ones were antipsychotic drugs (56%). Contraindicated substances such as tricyclic drugs or olanzapine were not prescribed. 80% of patients displayed clinically relevant neuropsychiatric symptoms. When the control variables were included, older people (OR:0.908; 95% confidence interval [0.849; 0.972], p=0.005) as well as persons with more physical comorbidities (OR: 0.804; [0.645; 1.004], p=0.054) had a lower probability of being prescribed psychotropic medication. Persons with more physical comorbidities were prescribed significantly fewer dementia drugs (cholinesterase inhibitors) (OR:0.629; [0.415; 0.946], p=0.026). Women had a notably lower chance of being prescribed a dementia drug than men (OR: 0.160; [0.066; 0.565], p=0.003).

Table 1

Prevalence of long-term medication with psychotropic drugs by ATC code and name of active substance

Table 2

Prevalence of neuropsychiatric symptoms in NPI-NH

Discussion

The cross sectional analysis did not show any notable deviations from the guideline, with the exceptions of the number of prescriptions of antipsychotic drugs. Dementia drugs were prescribed sparingly but in a guideline-adherent manner. It was of note that men’s chance of being prescribed dementia drugs were by a factor of six higher than that for women. One reason for this difference might be the higher potential for aggression in men with dementia and the associated burden on their environment. Antidepressants, tranquillizers, and hypnotics/sedatives were very rarely prescribed as long-term medication, which is guideline conform. By contrast, more than half of people with severe dementia were prescribed antipsychotic medication for the long term, although the S3 guideline recommends prescribing antipsychotics sparingly. Of note, the present study found a high prescription rate of antipsychotic drugs and simultaneously a high prevalence of clinically relevant neuropsychiatric symptoms. In assessing the cross sectional results we assumed an unsatisfactory therapeutic approach (pharmacologically or non-pharmacologically) if the values of the neuropsychiatric symptoms were above the threshold for clinical relevance. This was the case for 80% of people with severe dementia under study. According to the S3 guideline (Recommendation 54), causes should be researched before treatment is decided on. Kales et al (2) identify in addition to pain the lack of activities and unmet needs, among others, as triggers of neuropsychiatric symptoms (2). Lacking resources in terms of time and staff in care homes in Germany might contribute to the fact that psychotropic drugs are used more commonly as a time-saving alternative compared with the psychosocial interventions that are recommended primarily for patients with neuropsychiatric symptoms (3).

As far as we know this is the first study that explicitly analyzed pharmacotherapy and the occurrence of neuropsychiatric symptoms in persons with severe dementia in care homes. The sample is relatively small—142 people—but because of the diversity of the 26 care homes gives a varied picture of the situation in residential care homes in Germany. Presumably the total prevalence of neuropsychiatric symptoms and psychotropic drugs was subject to an underestimate because people with severe depression and other serious mental disorders had been excluded and data were collected only on long-term medication. The key problem of cross sectional analysis is indication bias. The degree of neuropsychiatric symptoms before pharmacotherapy was not known, and the cross sectional design does not allow causal conclusions regarding cause and effect.

Conclusions

People with severe dementia also showed a high prevalence of neuropsychiatric symptoms with a concurrent high prescription rate of psychotropic drugs and especially antipsychotics. In our view, the indication for antipsychotic drugs in people with severe dementia should be defined more critically and the continuation of this treatment should be reconsidered regularly.

Kristina Diehl wrote the present article as part of the requirements for achieving the academic title „Dr rer. biol. hum.“.

The study was funded by Germany’s National Association of Statutory Health Insurance Funds (GKV).

Conflict of interest statement

Prof. Maas is the vice chair of the Deutsche Gesellschaft für Klinische Pharmakologie und Therapie (DGKliPha, the German Society for Clinical Pharmacology and Therapy) reg. assoc.

Prof. Fromm received financial support (third-party funding) for research projects from Boehringer Ingelheim, Dr Pfleger Arzneimittel, and Heidelberg Pharma Research. He and three colleagues received prize money in the context of the award of the MSD health award 2021 (1st place) for the AMBORA Project. For consultancy services he received honoraria from Boehringer Ingelheim. From Janssen-Cilag he received speaker fees.

The remaining authors declare that no conflict of interest exists.

Manuscript received on 28 February 2022, revised version accepted on 15 June 2022.

Translated from the original German by Birte Twisselmann, PhD.

Cite this as:
Diehl K, Kratzer A, Donath C, Maas R, Fromm MF, Kornhuber J, Graessel E: The psychopharmacological treatment of people with severe dementia—findings of a cross-sectional study. Dtsch Arztebl Int 2022; 119: 664–5.
DOI: 10.3238/arztebl.m2022.0257

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