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string(672) "Antipsychotic medications like risperidone help manage severe agitation in dementia but can increase the risk of cardiovascular and cerebrovascular events (CVAE). Unlike schizophrenia, there are no clear monitoring guidelines for dementia patients using these drugs. This study will analyse clinical trial data to identify health markers linked to CVAE risk after risperidone use. Using advanced statistical models, we will also assess risks of sedation, falls, infections, and edema. Findings will inform dementia-specific monitoring guidelines for healthcare providers and caregivers, improving patient safety while ensuring appropriate treatment for those who need it."
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["property_scientific_abstract"]=>
string(1729) "Background:
Antipsychotic drugs like risperidone are the only licensed treatment for severe agitation and aggression in dementia. While avoiding starting unnecessary prescriptions is important to minimise harm it does not fully address safety management because there is still risk for those people where prescriptions are clinically indicated. Given some prescriptions are necessary, it follows that careful clinical monitoring during use is needed. However, while there is NICE guidance on physical health monitoring during antipsychotic prescription for people with schizophrenia there is none for antipsychotic use in dementia. We will address this gap by analysing individual-participant level clinical trial data to identify which clinical markers are associated with risk of antipsychotic-induced CVAE.
Objective:
We aim to develop dementia-specific physical health monitoring guidance for patients, clinicians, family members and social care workers. We will do this by determining the associations between changes in clinical monitoring measures after antipsychotic initiation and subsequent CVAE risk.
Study design:
Retrospective anlaysis of RCT data.
Participants:
RCT data from clinical trials of risperidone (vs placebo) in dementia.
Primary outcome:
CVAE after prescription in the risperidone group compared to the placebo group.
Secondary outcomes:
Sedation, falls, infections and edema after prescription in the risperidone group compared to the placebo group.
Statistical analysis:
Time-dependent Cox regression and joint longitudinal-survival models.
"
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string(2179) "Antipsychotic drugs like risperidone are the only licensed treatment for severe agitation and aggression in dementia. They are modestly effective but cause stroke/cerebrovascular adverse events (CVAE) and a number of other severe side effects. Annually, around 9% (~60,000) of people with dementia in the UK are prescribed an antipsychotic(1). Antipsychotics cause stroke in 8/1000 people with dementia (~500 people each year)(2). While avoiding starting unnecessary prescriptions is important to minimise harm it does not fully address safety management because there is still CVAE risk for those people where prescriptions are clinically indicated.
Given some prescriptions are necessary, it follows that careful clinical monitoring during use is needed. However, while there is NICE guidance on physical health monitoring during antipsychotic prescription for people with schizophrenia there is none for antipsychotic use in dementia(3,4). This lack of guidance is reflected in a 2023 NHS prescribing resource, which states “There are few guidelines around monitoring of antipsychotics for use in dementia…When long term low dose antipsychotics are used solely for the treatment of severe distress in people living with dementia a more personalised approach to monitoring should be considered.”(5) The guidance referred to in this resource is the NICE guidance for schizophrenia and there is no further detail on exactly what the “personalised approach” to monitoring should look like. To our knowledge there have been no empirical investigations of that physical health monitoring is most appropriate for people with dementia who have been prescribed antipsychotics. We will address this gap by analysing individual-participant level clinical trial data to identify which clinical markers (e.g., blood tests, ECG) are associated with risk of antipsychotic-induced CVAE and which thresholds on these markers should trigger discontinuation of use. Based on these results, we will develop physical health monitoring guidance based on personal medical information that has been empirically linked to treatment emergent CVAE risk in dementia.
"
["project_specific_aims"]=>
string(367) "1. Determine the associations between changes in clinical monitoring measures after risperidone initiation and subsequent CVAE risk.
2. Assess the potential for dynamic models of CVAE risk for dementia patients, based on time-updated monitoring measures.
3. We will contextualise findings by hosting a series of workshops with key stakeholders.
"
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["project_research_methods"]=>
string(144) "We will use all data from the RCTs listed (that is there is no exclusion criteria applied to the individual-level patient data in those trials)."
["project_main_outcome_measure"]=>
string(124) "Survival outcomes: primary: stroke/CVAE; secondary: sedation, fall, infection edema. All recorded as coded in the SAE data."
["project_main_predictor_indep"]=>
string(84) "Exposure: randomisation to either the atypical antipsychotic risperidone or placebo."
["project_other_variables_interest"]=>
string(386) "Longitudinal clinical markers: post-randomisation physical health markers: BMI, creatinine, eGFR, full blood count, lipids, HbA1c, blood pressure, ECG, liver function.
Baseline covariates: age, sex, cognitive and functional measures of dementia severity, concomitant medications (e.g., anti-inflammatories, antidepressants, other psychotropic medication)
"
["project_stat_analysis_plan"]=>
string(1620) "We will use time-dependent Cox regression to estimate the association between repeatedly measured longitudinal clinical markers and stroke risk. This will quantify the overall association (as a hazard ratio) between each marker and risk of stroke. We will then explore the use of more sophisticated joint longitudinal-survival models (which explicitly couple the survival model and a repeated measures model) to further understand the relationship
between each marker and stroke risk. Joint models attempt to capture the true, unobserved, longitudinal trajectory (in the data each marker is recorded intermittently and is subject to measurement error from random noise and
biological variation)(6). This means joint models can reduce bias and improve efficiency compared with simpler approaches(7). Another advantage of joint models is that they enable exploration of the associations between marker trajectories (rather than absolute values) and stroke (this is because a functional form is specified for the repeatedly measured elements). Estimates from all models will be benchmarked against a simple model incorporating only the baseline value of each longitudinal measure to quantify any additional benefit from incorporating the repeated measures. Where we see evidence of associations between longitudinal clinical markers and stroke, we will then extend the joint models to support dynamic prediction of stroke risk19. In exploratory analysis we will examine whether time-updated predictions of stroke risk can be made for an individual as new longitudinal information becomes available.
"
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["project_timeline"]=>
string(435) "Key milestones:
- Data acquisition from YODA: March-May 2025
- Process of hiring of post-doc to complete the work: May-Sept 2025
- Drafting and publication of analysis protocol (month 9): Sept-Dec 2025
- Preparation of data: Oct 2025-Jan 2026
- Analysis: Jan 2026 - March 2026
- New guidance co-produced with patients, caregivers and healthcare professionals: March 2026-June 2026
"
["project_dissemination_plan"]=>
string(1257) "1. Dementia-specific guidance for physical health monitoring during risperidone use developed with the needs of diverse patient groups in mind. This will include infographics
3. Report outlining the recommended steps needed for implementation of the new guidance
4. Dissemination workshop similar to that which have planned for our current study (scientific meeting): https://www.eventbrite.co.uk/e/safer-antipsychotic-prescribing-in-dementia-latest-information-tickets
1048915363087?aff=oddtdtcreator
5. Scientific outputs: We will disseminate outputs via relevant journals and to the wider public and healthcare community. All dissemination will be linked to our PPEI plan and developed with PPEI input. The study protocol will be preregistered (e.g., OSF; see here for Dr Creese’s site: https://osf.io/9zdur/). We will follow open science and FAIR (Findability, Accessibility, Interoperability and Reusability) principles for research reproducibility by releasing all
algorithms and code developed along with sufficient documentation under an open-source licence in a suitable repository. No dissemination (apart from scientific meetings) will take place before peer review journal acceptance.
"
["project_bibliography"]=>
string(1415) "
- Luo, H. et al. Rates of Antipsychotic Drug Prescribing Among People Living With Dementia During the COVID-19 Pandemic. JAMA Psychiatry (2023) doi:10.1001/jamapsychiatry.2022.4448.
- Ma, H. et al. The Efficacy and Safety of Atypical Antipsychotics for the Treatment of Dementia: A Meta Analysis of Randomized Placebo-Controlled Trials. Journal of Alzheimer’s Disease 42, 915–937 (2014).
- Rogowska, M. et al. Implications of Adverse Outcomes Associated with Antipsychotics in Older Patients with Dementia: A 2011–2022 Update. Drugs Aging 40, 21–32 (2023).
- Anderson, H. et al. Antipsychotic monitoring in dementia: quality of completion of antipsychotic monitoring forms in an older adult mental health service. BJPsych Bull 46, 271–277 (2022).
- Yorkshire and the Humber Clinical Network and London Clinical Network NHS England. Appropriate Prescribing of Antipsychotic Medication in Dementia. https://www.england.nhs.uk/london/wpcontent/uploads/sites/8/2022/10/Antipsychotic-Prescribing-Toolkit-for-Dementia.pdf (2023).
- Henderson, R., Diggle, P. & Dobson, A. Joint modelling of longitudinal measurements and event time data. Biostatistics 1, 465–480 (2000).
- Ibrahim, J. G., Chu, H. & Chen, L. M. Basic Concepts and Methods for Joint Models of Longitudinal and Survival Data. Journal of Clinical Oncology 28, 2796–2801 (2010)
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General Information
How did you learn about the YODA Project?:
Colleague
Conflict of Interest
Request Clinical Trials
Associated Trial(s):
- An open-label, long-term study of risperidone for the treatment of behavioral disturbances in patients with dementia
- Efficacy and safety of a flexible dose of risperidone versus placebo in the treatment of psychosis of Alzheimer's disease. A double-blind, placebo-controlled, parallel-group study.
- NCT00034762 - Efficacy And Safety Of A Flexible Dose Of Risperidone Versus Placebo In The Treatment Of Psychosis Of Alzheimer's Disease
- NCT00249145 - Risperidone in the Treatment of Behavioral Disturbances in Demented Patients: an International, Multicenter, Placebo-controlled, Double-blind, Parallel-group Trial Using Haloperidol as Internal Reference
- NCT00249158 - Risperidone in the Treatment of Behavioural and Psychological Signs and Symptoms in Dementia (BPSSD): a Multicentre, Double-blind, Placebo-controlled Parallel-group Trial
- NCT00253123 - A Randomized, Double-Blind, Placebo-Controlled Study of Risperidone for Treatment of Behavioral Disturbances in Subjects With Dementia
- Risperidone in the treatment of behavioural disturbances in patients with Alzheimer's dementia: a double-blind placebo-controlled trial
What type of data are you looking for?:
Individual Participant-Level Data, which includes Full CSR and all supporting documentation
Request Clinical Trials
Data Request Status
Status:
Ongoing
Research Proposal
Project Title:
Analysis or Predictors of Treatment-Emergent CVAE and other Side Effects during Risperidone Use in Dementia
Scientific Abstract:
Background:
Antipsychotic drugs like risperidone are the only licensed treatment for severe agitation and aggression in dementia. While avoiding starting unnecessary prescriptions is important to minimise harm it does not fully address safety management because there is still risk for those people where prescriptions are clinically indicated. Given some prescriptions are necessary, it follows that careful clinical monitoring during use is needed. However, while there is NICE guidance on physical health monitoring during antipsychotic prescription for people with schizophrenia there is none for antipsychotic use in dementia. We will address this gap by analysing individual-participant level clinical trial data to identify which clinical markers are associated with risk of antipsychotic-induced CVAE.
Objective:
We aim to develop dementia-specific physical health monitoring guidance for patients, clinicians, family members and social care workers. We will do this by determining the associations between changes in clinical monitoring measures after antipsychotic initiation and subsequent CVAE risk.
Study design:
Retrospective anlaysis of RCT data.
Participants:
RCT data from clinical trials of risperidone (vs placebo) in dementia.
Primary outcome:
CVAE after prescription in the risperidone group compared to the placebo group.
Secondary outcomes:
Sedation, falls, infections and edema after prescription in the risperidone group compared to the placebo group.
Statistical analysis:
Time-dependent Cox regression and joint longitudinal-survival models.
Brief Project Background and Statement of Project Significance:
Antipsychotic drugs like risperidone are the only licensed treatment for severe agitation and aggression in dementia. They are modestly effective but cause stroke/cerebrovascular adverse events (CVAE) and a number of other severe side effects. Annually, around 9% (~60,000) of people with dementia in the UK are prescribed an antipsychotic(1). Antipsychotics cause stroke in 8/1000 people with dementia (~500 people each year)(2). While avoiding starting unnecessary prescriptions is important to minimise harm it does not fully address safety management because there is still CVAE risk for those people where prescriptions are clinically indicated.
Given some prescriptions are necessary, it follows that careful clinical monitoring during use is needed. However, while there is NICE guidance on physical health monitoring during antipsychotic prescription for people with schizophrenia there is none for antipsychotic use in dementia(3,4). This lack of guidance is reflected in a 2023 NHS prescribing resource, which states "There are few guidelines around monitoring of antipsychotics for use in dementia...When long term low dose antipsychotics are used solely for the treatment of severe distress in people living with dementia a more personalised approach to monitoring should be considered."(5) The guidance referred to in this resource is the NICE guidance for schizophrenia and there is no further detail on exactly what the "personalised approach" to monitoring should look like. To our knowledge there have been no empirical investigations of that physical health monitoring is most appropriate for people with dementia who have been prescribed antipsychotics. We will address this gap by analysing individual-participant level clinical trial data to identify which clinical markers (e.g., blood tests, ECG) are associated with risk of antipsychotic-induced CVAE and which thresholds on these markers should trigger discontinuation of use. Based on these results, we will develop physical health monitoring guidance based on personal medical information that has been empirically linked to treatment emergent CVAE risk in dementia.
Specific Aims of the Project:
1. Determine the associations between changes in clinical monitoring measures after risperidone initiation and subsequent CVAE risk.
2. Assess the potential for dynamic models of CVAE risk for dementia patients, based on time-updated monitoring measures.
3. We will contextualise findings by hosting a series of workshops with key stakeholders.
Study Design:
Individual trial analysis
What is the purpose of the analysis being proposed? Please select all that apply.:
New research question to examine treatment safety
Confirm or validate previously conducted research on treatment safety
Software Used:
R
Data Source and Inclusion/Exclusion Criteria to be used to define the patient sample for your study:
We will use all data from the RCTs listed (that is there is no exclusion criteria applied to the individual-level patient data in those trials).
Primary and Secondary Outcome Measure(s) and how they will be categorized/defined for your study:
Survival outcomes: primary: stroke/CVAE; secondary: sedation, fall, infection edema. All recorded as coded in the SAE data.
Main Predictor/Independent Variable and how it will be categorized/defined for your study:
Exposure: randomisation to either the atypical antipsychotic risperidone or placebo.
Other Variables of Interest that will be used in your analysis and how they will be categorized/defined for your study:
Longitudinal clinical markers: post-randomisation physical health markers: BMI, creatinine, eGFR, full blood count, lipids, HbA1c, blood pressure, ECG, liver function.
Baseline covariates: age, sex, cognitive and functional measures of dementia severity, concomitant medications (e.g., anti-inflammatories, antidepressants, other psychotropic medication)
Statistical Analysis Plan:
We will use time-dependent Cox regression to estimate the association between repeatedly measured longitudinal clinical markers and stroke risk. This will quantify the overall association (as a hazard ratio) between each marker and risk of stroke. We will then explore the use of more sophisticated joint longitudinal-survival models (which explicitly couple the survival model and a repeated measures model) to further understand the relationship
between each marker and stroke risk. Joint models attempt to capture the true, unobserved, longitudinal trajectory (in the data each marker is recorded intermittently and is subject to measurement error from random noise and
biological variation)(6). This means joint models can reduce bias and improve efficiency compared with simpler approaches(7). Another advantage of joint models is that they enable exploration of the associations between marker trajectories (rather than absolute values) and stroke (this is because a functional form is specified for the repeatedly measured elements). Estimates from all models will be benchmarked against a simple model incorporating only the baseline value of each longitudinal measure to quantify any additional benefit from incorporating the repeated measures. Where we see evidence of associations between longitudinal clinical markers and stroke, we will then extend the joint models to support dynamic prediction of stroke risk19. In exploratory analysis we will examine whether time-updated predictions of stroke risk can be made for an individual as new longitudinal information becomes available.
Narrative Summary:
Antipsychotic medications like risperidone help manage severe agitation in dementia but can increase the risk of cardiovascular and cerebrovascular events (CVAE). Unlike schizophrenia, there are no clear monitoring guidelines for dementia patients using these drugs. This study will analyse clinical trial data to identify health markers linked to CVAE risk after risperidone use. Using advanced statistical models, we will also assess risks of sedation, falls, infections, and edema. Findings will inform dementia-specific monitoring guidelines for healthcare providers and caregivers, improving patient safety while ensuring appropriate treatment for those who need it.
Project Timeline:
Key milestones:
- Data acquisition from YODA: March-May 2025
- Process of hiring of post-doc to complete the work: May-Sept 2025
- Drafting and publication of analysis protocol (month 9): Sept-Dec 2025
- Preparation of data: Oct 2025-Jan 2026
- Analysis: Jan 2026 - March 2026
- New guidance co-produced with patients, caregivers and healthcare professionals: March 2026-June 2026
Dissemination Plan:
1. Dementia-specific guidance for physical health monitoring during risperidone use developed with the needs of diverse patient groups in mind. This will include infographics
3. Report outlining the recommended steps needed for implementation of the new guidance
4. Dissemination workshop similar to that which have planned for our current study (scientific meeting): https://www.eventbrite.co.uk/e/safer-antipsychotic-prescribing-in-dementia-latest-information-tickets
1048915363087?aff=oddtdtcreator
5. Scientific outputs: We will disseminate outputs via relevant journals and to the wider public and healthcare community. All dissemination will be linked to our PPEI plan and developed with PPEI input. The study protocol will be preregistered (e.g., OSF; see here for Dr Creese's site: https://osf.io/9zdur/). We will follow open science and FAIR (Findability, Accessibility, Interoperability and Reusability) principles for research reproducibility by releasing all
algorithms and code developed along with sufficient documentation under an open-source licence in a suitable repository. No dissemination (apart from scientific meetings) will take place before peer review journal acceptance.
Bibliography:
- Luo, H. et al. Rates of Antipsychotic Drug Prescribing Among People Living With Dementia During the COVID-19 Pandemic. JAMA Psychiatry (2023) doi:10.1001/jamapsychiatry.2022.4448.
- Ma, H. et al. The Efficacy and Safety of Atypical Antipsychotics for the Treatment of Dementia: A Meta Analysis of Randomized Placebo-Controlled Trials. Journal of Alzheimer's Disease 42, 915--937 (2014).
- Rogowska, M. et al. Implications of Adverse Outcomes Associated with Antipsychotics in Older Patients with Dementia: A 2011--2022 Update. Drugs Aging 40, 21--32 (2023).
- Anderson, H. et al. Antipsychotic monitoring in dementia: quality of completion of antipsychotic monitoring forms in an older adult mental health service. BJPsych Bull 46, 271--277 (2022).
- Yorkshire and the Humber Clinical Network and London Clinical Network NHS England. Appropriate Prescribing of Antipsychotic Medication in Dementia. https://www.england.nhs.uk/london/wpcontent/uploads/sites/8/2022/10/Antipsychotic-Prescribing-Toolkit-for-Dementia.pdf (2023).
- Henderson, R., Diggle, P. & Dobson, A. Joint modelling of longitudinal measurements and event time data. Biostatistics 1, 465--480 (2000).
- Ibrahim, J. G., Chu, H. & Chen, L. M. Basic Concepts and Methods for Joint Models of Longitudinal and Survival Data. Journal of Clinical Oncology 28, 2796--2801 (2010)