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Originalartikel

Risiken von Antipsychotika im Alter, speziell bei Demenzen

1Prof. Dr. Hans Gutzmann zum 60. Geburtstag gewidmet.

Eine Übersicht

Published Online:April 23, 2009https://doi.org/10.1024/1011-6877.22.1.17

Abstract

Antipsychotika werden häufig zur Behandlung von herausforderndem Verhalten bei Demenz eingesetzt. Antipsychotika der zweiten Generation («atypische Neuroleptika») spielen dabei mittlerweile eine größere Rolle als die älteren Substanzen. Der nur mäßigen Wirksamkeit stehen schwerwiegende Risiken gegenüber: so ist unter allen Antipsychotika die Mortalität insgesamt erhöht, aber auch das Risiko für plötzlichen Herztod, Schlaganfallereignisse oder venöse Thrombosen. Die Unterschiede zwischen Antipsychotika der ersten und der zweiten Generation sind dabei gering: hochpotente Antipsychotika der ersten Generation führen häufiger zu extrapyramidalmotorischen Symptomen, unter Antipsychotika der zweiten Generation ist das allgemeine Mortalitätsrisiko wahrscheinlich etwas geringer, andererseits wahrscheinlich venöse Thrombosen und metabolische Nebenwirkungen häufiger. Für die übrigen Nebenwirkungen bestehen keine gesicherten Unterschiede. Angesichts der großen Heterogenität der Antipsychotika erscheint der Nutzen einer pauschalen Aufteilung in Antipsychotika der ersten und zweiten Generation fragwürdig. Für die Auswahl einer Substanz sind substanzspezifische Nebenwirkungen, Dosierung, Aufdosierungsgeschwindigkeit sowie Beachtung von Komorbidität, Kontraindikationen und Arzneimittelinteraktionen in Relation zum individuellen Patienten erheblich wichtiger als die Wahl nach bloßer pauschaler Zuordnung zu einer dieser beiden Gruppen. Am wichtigsten ist aber, dass Antipsychotika nur bei klarer Indikation zur Anwendung kommen!


Risks of Antipsychotics in Old Age, Particularly in Dementia: Review

Antipsychotics are widely used in the treatment auf challenging behaviour in dementia with second generation antipsychotics today being prescribed more often than the older agents. Given an only modest efficacy, several serious side effects must be considered: all-cause mortality is increased with all antipsychotics, and so are the risks of sudden cardiac death, cerebrovascular adverse events, and venous thrombembolism. There is only little difference between first and second generation antipsychotics: high potency first generation agents are more likely to cause extrapyramidal symptoms, with second generation antipsychotics there is probably little lower all-cause mortality, whereas venous thrombembolism and metabolic side effects appear to occur more often. There is no evidence with respect to differences in the other serious side effects. Given the heterogeneity of antipsychotic agents, it appears doubtful if there is any advantage in simply dividing them into first and second generation antipsychotics. In the decision of which agent to use it is much more prudent to consider substance-specific side effects, dose, pattern of dose titration, comorbidity, contraindications, and drug interactions matching the patient’s particular condition rather than to decide merely by assigning an agent to either one of these two classes or the other. But the main thing is to use antipsychotics only when they are clearly indicated.

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