As physicians attempt to decrease antipsychotic use in seniors with dementia, they need to be aware that trazadone, frequently used as an alternative, is associated with a similar risk of falls and major fractures as atypical antipsychotics, according to new research in CMAJ (Canadian Medical Association Journal).

“As clinicians move to decrease antipsychotic use, we should not consider trazadone as a uniformly safer alternative to atypical antipsychotics, because trazadone use was associated with a comparable risk of falls and major osteoporotic fractures to atypical antipsychotics — drugs associated with these adverse outcomes in our patient population,” writes Dr. Jennifer Watt, St. Michael’s Hospital, Toronto, Ontario, with coauthors.

The rate of dementia in Canada is  seven per cent, but it approaches almost 25 per cent in people older than age 85. In long-term care facilities, 62 per cent of residents have dementia, and many exhibit aggressive behaviour. Although evidence is limited on efficacy, antipsychotics and trazadone, an antidepressant also used for sleep issues, are commonly prescribed for patients with dementia.

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Using linked data from ICES, researchers looked at data on 6588 seniors newly dispensed trazadone and 2875 newly dispensed an atypical antipsychotic. They found that patients dispensed trazadone had a rate of falls and major fractures, including hip fractures, similar to that of the group receiving atypical antipsychotics. However, trazadone was associated with a lower risk of death in these patients.

“We hope this information can be used to inform conversations that patients and caregivers are having with clinicians about the benefits and risks of different treatment options,” says Dr. Watt.

“Watt and colleagues also underscore the importance of prioritizing nonpharmacological approaches for the management of behavioural and psychological symptoms of dementia,” writes Dr. Elia Abi-Jaoude, The Hospital for Sick Children (SickKids) and University Health Network, Toronto, Ontario, with coauthors in a related commentary. “Nonpharmacological approaches comprise a variety of behavioural, environmental and caregiver-supportive interventions, and existing evidence suggests that these show greater effect than many psychotropic drug therapies.”

“Comparative risk of harm associated with trazodone or atypical antipsychotic use in older adults with dementia: a retrospective cohort study” is published November 26, 2018.