Risperidone Therapy for BPSD in Aged Care

Managing the complex behavioural and psychological symptoms of dementia (BPSD) in aged care presents a significant challenge. The symptoms, which can include agitation, aggression, delusions, and anxiety, not only affect the quality of life of individuals with dementia but also pose considerable strain on caregivers and healthcare systems. Risperidone, an atypical antipsychotic, has emerged as a pivotal component in the therapeutic arsenal against BPSD, particularly when non-pharmacological interventions prove insufficient.

Here, we explore the strategic use of risperidone in treating BPSD within aged care settings, highlighting its therapeutic benefits, potential side effects, and the critical considerations for its use. The discussion extends to the judicious integration of risperidone into comprehensive care plans, underscoring the importance of balancing efficacy with safety to optimise outcomes for elderly residents with dementia. By examining the guidelines, benefits, and careful administration of risperidone, healthcare professionals will have the insights necessary for making informed decisions in managing BPSD effectively.

Understanding Treatment of BPSD in Aged Care

BPSD encompasses a range of symptoms including agitation, aggression, delusions, and hallucinations, which are common in patients with dementia. Managing these symptoms effectively is crucial for improving quality of life and reducing distress for both patients and caregivers.

Use and Benefits of Risperidone in BPSD

Risperidone is an atypical antipsychotic with specific indications for treating a range of psychiatric conditions, including schizophrenia, bipolar disorder, and severe behavioural disturbances associated with autism spectrum disorder. In the context of aged care, it is particularly noted for its application in managing BPSD.

Among its uses, risperidone is uniquely positioned as the only antipsychotic listed on the Pharmaceutical Benefits Scheme (PBS) specifically for BPSD in Alzheimer’s disease for up to 12 weeks. This approval is contingent on the presence of psychotic symptoms and aggression after other non-pharmacological treatments have failed, highlighting its role as a secondary line of treatment. The careful control and limitation of its use underscore the cautious approach needed due to the potential severe side effects associated with antipsychotics.

Risperidone may offer significant benefits in reducing distressing symptoms such as agitation and aggression in patients with moderate to severe Alzheimer’s disease. These symptoms often pose a challenge in dementia care, impacting the quality of life for patients and the burden on caregivers. While risperidone can be effective, its benefits are generally best observed in the short-term management of BPSD. It is most beneficial for those specific patients who demonstrate a clear and significant response to the medication within the initial weeks of treatment.

Guidelines generally recommend that antipsychotics like risperidone should not serve as the first-line treatment for BPSD due to the risk profile and the varied efficacy among the dementia population—approximately only one in five individuals may show a positive response. The use of risperidone is guided by a stringent protocol where continuation beyond the initial 12-week period should be based solely on a significant reduction in symptoms of psychosis or aggression, and always with an aim towards dose tapering and exploring cessation.

Before the initiation of risperidone, non-pharmacological interventions should always be attempted. Treatments such as cognitive stimulation, music therapy, and reminiscence therapy not only avoid the risks associated with medications but also can enhance cognition, improve behavioural symptoms, and promote independence in dementia patients. These interventions align with a holistic care approach that prioritises the well-being and overall quality of life of the elderly.

For those patients who are placed on risperidone, careful monitoring is required to assess efficacy and watch for any adverse effects. Adjustments or discontinuation should be considered if there is no improvement or if negative symptoms worsen. The therapeutic goal always remains to manage symptoms with the lowest effective dose and to reduce or cease the medication when feasible, supported by sustained non-pharmacological measures.

Risperidone Side Effects

While risperidone can be effective in managing certain severe symptoms of BPSD, it is associated with significant risks, particularly in the elderly population, which requires careful consideration and monitoring.

One of the most serious concerns with the use of risperidone in the elderly, especially those with dementia, is the increased risk of cerebrovascular adverse events, such as stroke and transient ischemic attacks (TIAs). Studies indicate that the risk of such events may be increased up to threefold compared to a placebo. This risk is most pronounced early in the treatment and increases with higher doses. Additionally, the use of antipsychotics in elderly patients with dementia is associated with a higher risk of death, which has led to strong recommendations against their use unless absolutely necessary.

Risperidone, like other antipsychotics, can cause a range of extrapyramidal symptoms, which are drug-induced movement disorders that include:

Dystonias: These are painful and prolonged muscular spasms or abnormal postures, typically occurring within the first few days of treatment.
Akathisia: This is a condition of restlessness and an inability to stay still, often presenting within the first few days to weeks of initiating therapy.
Parkinsonism: Symptoms such as tremor, rigidity, and bradykinesia may develop after prolonged treatment with risperidone, resembling Parkinson’s disease.
Tardive Dyskinesia: This is a serious and often irreversible condition characterised by involuntary, repetitive body movements. It typically occurs after long-term use of antipsychotics but can arise sooner in susceptible individuals.

Other adverse effects associated with risperidone include:

Sedation and Drowsiness
Postural Hypotension
Metabolic Changes
Hyperprolactinemia

Due to these potential side effects, it is crucial to monitor patients closely throughout the duration of risperidone treatment. Adjustments in dosage or discontinuation of the drug should be considered if adverse effects outweigh the benefits. Deprescribing should be a structured process, involving gradual dose reduction to minimise withdrawal symptoms and avoid sudden re-emergence of BPSD symptoms.

Given the severity and range of potential side effects, the decision to use risperidone must be made with careful consideration, involving a thorough assessment of risks versus benefits, and always with a preference for the lowest effective dose. Non-pharmacological interventions should be prioritised whenever possible to manage BPSD safely and effectively.

Risperidone Dosage & Administration

Understanding the correct dosage and administration is crucial for achieving the desired therapeutic effects of risperidone while minimising potential risks.

Starting & Adjusting Dosage

For managing BPSD, risperidone should be initiated cautiously. The recommended starting dose is typically 0.25 mg administered twice daily. This conservative approach helps to assess the individual’s response to the medication and to minimise the risk of adverse effects..

Depending on the patient’s response and tolerance to the initial dosage, adjustments might be necessary. If required, the dose can be increased by increments of 0.5 mg every second day. It’s important to closely monitor the patient during this titration period to gauge the effectiveness of the medication and observe any emergent side effects.

Once the patient’s condition stabilises, transitioning to once-daily dosing may be appropriate. The usual dosage range for the maintenance of therapeutic effects in BPSD is between 0.5 to 1.5 mg daily. This dosage may vary based on the severity of symptoms and the individual patient’s response to the medication.

Treatment with risperidone for BPSD is approved for a duration of 12 weeks by the Pharmaceutical Benefits Scheme (PBS), reflecting the typical window for evaluating the effectiveness of the medication in managing psychotic symptoms and aggression. If there is a significant reduction in these symptoms, the medication might be continued beyond this period under careful supervision, primarily for tapering purposes.

Continuation of treatment beyond the initial 12 weeks should be based on a thorough evaluation of the patient’s response to the medication. This decision should also consider the potential risks of long-term antipsychotic use, such as increased risk of cerebrovascular events and mortality in elderly patients. If treatment is to be extended, it should include trials of dosage reduction or cessation to minimise exposure to risperidone while maintaining symptom control through non-pharmacological measures wherever possible.

Deprescribing Rationale and Procedure

If the patient experiences worsening symptoms or significant side effects, or if there is no appreciable benefit from the treatment, discontinuation should be considered. The process of deprescribing should be gradual, reducing the daily dose by 25-50% every 1 to 2 weeks, to prevent withdrawal symptoms. Close monitoring during this period is essential to manage any re-emergence of symptoms effectively.

As-needed (PRN) doses of risperidone are generally not recommended for managing ongoing severe behaviours due to their ineffectiveness in this context. PRN dosing may be considered for episodic or rapidly changing clinical presentations but should have a specific indication and a maximum dose defined to avoid excessive use.

FAQs

What is Risperidone used for in aged care settings?

Risperidone is utilised in aged care primarily for the management of BPSD, which includes symptoms such as psychosis and aggression in patients with moderate-to-severe dementia of the Alzheimer type. It is considered when non-pharmacological measures fail to alleviate these challenging behaviours.

When is Risperidone prescribed for BPSD?

Risperidone is prescribed for BPSD when there is documented evidence of psychotic symptoms and aggression that have not responded to non-drug interventions. It is approved for use under these conditions by the Pharmaceutical Benefits Scheme (PBS) for a duration of 12 weeks, after which its effectiveness should be re-evaluated.

What are the guidelines for Risperidone dosage in treating BPSD?

The recommended starting dosage of Risperidone for BPSD is 0.25 mg twice daily. This dose may be increased by 0.5 mg every second day if necessary, depending on the patient’s response and tolerability, with a usual maintenance dose ranging from 0.5 to 1.5 mg daily.

How effective is Risperidone in treating BPSD?

Risperidone can be effective in managing severe agitation and aggression associated with Alzheimer’s disease. However, its effectiveness is generally limited to the short-term management of these symptoms, and it is estimated that only about one in five people with Alzheimer’s disease respond favourably to this treatment.

Are there specific risks associated with the use of Risperidone in the elderly?

Yes, the use of Risperidone in elderly patients, particularly those with dementia, is associated with increased risks, including cerebrovascular events like stroke and transient ischemic attacks, and even a heightened risk of mortality. These risks are most significant at higher doses and early in the course of treatment.

Key Takeaways

Risperidone should not be the first-line treatment for Behavioral and Psychological Symptoms of Dementia (BPSD) due to potential risks and moderate efficacy. It is recommended only after non-pharmacological measures have failed and is appropriate for managing severe psychotic symptoms and aggression.
Risperidone is prescribed under strict conditions with a clear protocol for initiation and continuation only if there is significant improvement in symptoms. Continuous monitoring for efficacy and side effects is crucial.
The benefits of risperidone in managing BPSD are generally observed within the first few weeks of treatment. However, its effectiveness beyond three months is minimal, and long-term use is associated with significant risks.
Risperidone increases the risk of cerebrovascular adverse events like stroke and transient ischemic attacks by threefold compared to placebo, particularly in elderly patients with dementia. This risk is highest early in the treatment and with higher doses.
The medication can cause serious side effects, including extrapyramidal symptoms like dystonias, akathisia, Parkinsonism, and tardive dyskinesia, which can affect patients’ quality of life and compliance with treatment.
If risperidone is found to be ineffective or if adverse effects outweigh the benefits, a careful deprescribing protocol should be followed. This involves a gradual dose reduction to mitigate withdrawal symptoms and prevent a rebound increase in BPSD symptoms.
Before considering risperidone, non-pharmacological interventions such as cognitive stimulation, music therapy, and reminiscence therapy should be prioritised as they are safer and can effectively improve cognition and behavioural symptoms.
The HALT study shows that deprescribing antipsychotics in long-term care settings does not lead to an increase in BPSD or other adverse outcomes, highlighting the potential overuse of such medications in residential aged care facilities.

Summary

Risperidone can be a valuable part of managing severe BPSD in aged care when used judiciously. It requires careful consideration, regular monitoring, and should always be part of a broader care strategy that prioritises non-pharmacological interventions. Deprescribing should be planned and executed with care to avoid withdrawal symptoms and manage BPSD effectively.

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