What is it about?
This article is a narrative review that examines the efficacy, safety, and risk–benefit profile of pharmacological treatments used to manage behavioral and psychological symptoms of dementia (BPSD), including agitation, aggression, depression, anxiety, psychosis, and sleep disturbances Specifically, the review: Synthesizes evidence from 93 studies published between 2018 and 2024 Focuses on antipsychotics (typical and atypical) and antidepressants, with contextual discussion of other agents (e.g., cholinesterase inhibitors, NMDA antagonists, benzodiazepines, mood stabilizers) Evaluates clinical effectiveness, adverse effects, and mortality and cardiovascular risks, particularly in older adults Emphasizes how dementia subtype, comorbidities, age, frailty, and polypharmacy influence treatment outcomes The review aims to support clinicians in making individualized, evidence-informed pharmacological decisions when non-pharmacological strategies are insufficient to control severe or distressing BPSD
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Why is it important?
This article is important for several interrelated clinical and public health reasons. a. BPSD are common, disabling, and high-risk Behavioral and psychological symptoms affect the majority of people with dementia at some stage and are a major driver of: • Reduced quality of life • Caregiver burden • Institutionalization • Increased healthcare costs Effective management of BPSD is therefore central to dementia care, not ancillary b. Pharmacological treatments carry substantial harm While antipsychotics and antidepressants are frequently prescribed, the review highlights consistent evidence of: • Increased mortality and cerebrovascular events with antipsychotics • Falls, sedation, QT prolongation, and cardiac events with antidepressants • Cognitive worsening and paradoxical agitation with several drug classes By explicitly weighing modest efficacy against significant risks, the article reinforces why medication use in BPSD must be guarded, time-limited, and closely monitored c. It supports individualized, patient-centered prescribing The review emphasizes that treatment response and risk vary according to: • Dementia subtype (e.g., Alzheimer’s disease, Lewy body dementia, vascular dementia) • Severity of cognitive impairment • Frailty and comorbid illness • Drug–drug interactions This is critical in countering reflexive or protocol-driven prescribing in vulnerable older adults. d. It reinforces the primacy of non-pharmacological care Although focused on medications, the article clearly situates pharmacological treatment as adjunctive, not first-line, and aligns with contemporary guidance advocating behavioral, environmental, and caregiver-based interventions whenever possible.
Perspectives
From my perspective, this review is particularly valuable because it confronts a persistent tension in dementia care: the clinical pressure to rapidly control distressing behaviors versus the ethical obligation to minimize harm in frail older adults. The authors do not present pharmacological agents as benign solutions; instead, they clearly articulate the narrow therapeutic window within which antipsychotics and antidepressants may be justified. I find the emphasis on risk stratification and individualized decision-making especially important. In real-world practice, BPSD often occur in patients with multimorbidity, polypharmacy, and limited physiological reserve—contexts in which even “moderately effective” treatments may carry disproportionate harm. By explicitly addressing mortality risk, cardiovascular complications, and cognitive adverse effects, the review supports more transparent clinician–caregiver discussions and informed consent. Equally important is the implicit reminder that pharmacological management should not eclipse non-pharmacological strategies. The review reinforces the need for integrated, multidisciplinary approaches—where medications are used cautiously, reassessed frequently, and withdrawn when risks outweigh benefits. In this sense, the article contributes not only to prescribing knowledge, but also to ethical, person-centered dementia care, particularly in aging and resource-limited healthcare settings
Dr. Zainab Alameeri
Emirates Health Services
Read the Original
This page is a summary of: Efficacy, safety, and risk assessment of antipsychotics and antidepressants for behavioral and psychological symptoms of dementia (BPSD): a narrative review, International Journal of Medicine in Developing Countries, January 2025, Discover Publishing Group,
DOI: 10.24911/ijmdc.51-1735300661.
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