A risk-benefit assessment of risperidone for the treatment of behavioural and psychological symptoms in dementia.

The importance of behavioural and psychological symptoms in dementia (BPSD) is increasingly being recognised. Symptoms such as verbal and physical aggression, agitation, sleep disturbances and wandering are common, cause great distress to caregivers and are likely to lead to institutionalisation of patients. At present, these symptoms are also more amenable to treatment compared with the progressive intellectual decline caused by dementing illnesses. The care of individuals with BPSD involves a broad range of psychosocial treatments for the patient and his or her family. If pharmacotherapy is deemed necessary to manage BPSD, a careful balance must be struck between the benefits of symptom control and the inherent risks associated with most psychotropic agents in the elderly. Elderly patients in general, and patients with dementia in particular, are more sensitive to medication adverse effects, including anticholinergic effects, orthostatic hypotension, sedation, parkinsonism, tardive dyskinesia and cognitive impairment than younger patients with dementia or individuals without dementia. To date, treatment of symptoms of aggression and psychosis has relied on the empirical use of antidepressants, anxiolytics, typical antipsychotics (neuroleptics) and other agents. Treatment-limiting adverse effects are frequently reported with all of these agents. However, it is the typical antipsychotics and the atypical antipsychotic clozapine that are associated with the greatest risk of adverse effects in the elderly. The present review highlights the issues that limit the use of older psychotropic agents in the elderly, and presents an assessment of the available evidence concerning the efficacy, safety and tolerability of the atypical antipsychotic risperidone, in the treatment of BPSD in elderly patients with dementia. The extensive clinical development programme for risperidone has shown the drug to be effective and well tolerated in many fragile patients. As a result of its efficacy and safety profile, risperidone can be used for the treatment of behavioural and psychological symptoms in patients with dementia. Risperidone therefore represents a significant addition to the armamentarium for BPSD. While efforts continue in the development of treatment for the cognitive decline associated with dementia, treatment is now available for the noncognitive symptoms. By treating the latter, risperidone has the potential to be of substantial benefit to patients with dementia, their carers and the costs of healthcare.