Antipsychotic agents (also called neuroleptics) are approved for the treatment of specific psychiatric disorders such as schizophrenia and severe bipolar disorder. But they also are used to treat psychosis and subdue agitation in patients with dementia-an indication for which such drugs are not approved in the United States-despite evidence that they may hasten cognitive decline and increase risk of parkinsonism and cerebrovascular events. A recent British study designed to reduce the use of neuroleptics in nursing homes found that intensive training and support of staff in managing agitation can accomplish just that.

FIGURE. A patient at the Keswick Multicare Center in Baltimore, Maryland, examines the fiber-optic light curtain in the facility's Snoezelen room. Developed in the Netherlands in the 1970s, Snoezelen rooms combine sensory stimuli such as lighting, textures, smells, and sounds to soothe and stimulate patients with dementia and other severe mental disorders.

Researchers randomized 12 nursing homes, the staffs of which either received training and ongoing support in managing behavior or did not. The primary outcomes were the institutions' overall use of neuroleptic drugs and the mean daily use in each resident. Secondary outcomes included the levels of agitation and aggression among residents, the use of other psychotropic medications, quality-of-life scores (based on observational data), and adverse events (such as falls).

At one year, the percentage of residents receiving neuroleptics at the study institutions (23%) was a little more than half that at the control facilities (42%), and the mean daily use of the drugs was comparably lower in the study facilities. There were no significant differences in the use of other psychotropic medications, in the numbers of falls in the two groups, in the levels of agitation and aggression, or in quality-of-life scores.

Eight months into the study period, the Committee on Safety of Medicines urged all physicians in the country to stop using olanzapine and risperidone in patients with dementia. As expected, there was a drop in the use of those drugs in both groups, but levels in the control facilities crept back up at the end of one year. The study suggests that alternatives to the use of antipsychotic drugs for behavior management in this population should be vigorously pursued.

Fossey J, et al. BMJ 2006;332:756-61.