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PICO Analysis: Dementia
Part I: PICO analysis of research topic
Step 1: Frame clinical question using PICO method
P: the patients include people with dementia and psychosis
I: the anticipated intervention is to utilize typical antipsychotic drugs
C: the current standard or comparison group is atypical antipsychotics
O: the desired outcome is to have less mortality rates for elderly people with dementia and psychosis
The PICO question basically stands for patient, intervention, comparison and outcome (Elkins, 2014).
Part II: Search strategy
The PICO question is as follows: In elderly patients who have dementia and psychosis (P), does treatment with typical antipsychotics (I) or atypical antipsychotics (C) result in less mortality (O).
Step 1: Resources utilized to find articles
A number of scholarly articles relating to the identified issue are identified. The resources that were used in finding the articles that relate to the topic include the following: handbooks, electronic databases research, encyclopaedias, relevant books, and reputable journals.
Step 2: Search terms and criteria
With regard to search terms and criteria that were utilized, the search terms include the following: dementia, mortality, psychosis, atypical antipsychotics, and typical psychotics. The inclusion criteria was as follows: scholarly peer-reviewed journal articles only, articles not older than 5 years, articles that are published in the English language, articles that focus on dementia and psychosis among the elderly population, and article that reports on primary research.
Step 3: Boolean search strings
With regard to the exclusion criteria, the articles that would be excluded are as follows: articles that are older than 5 years, articles not published in English, and articles that do not focus on the elderly patients with dementia. Using different Boolean search strings, keywords would be combined with operators like OR, NOT as well as AND in order to generate additional results that are relevant. For this research, the Boolean search strings that would be utilized include the following: atypical antipsychotics and psychosis, atypical antipsychotics and dementia, typical antipsychotics and dementia, typical antipsychotics and psychosis. Therefore, the search results would be limited only to the two keywords.
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Part III: Analysis of literature
Step 1: Summary of five articles
The following 5 articles in the table below were selected from the research effort.
Table 1: Summary of analyzed articles
| Citation | Conceptual framework / theory | Main finding | Research Method | Strengths of study | Weaknesses of study | Level of evidence |
| Ballard, C., Creese, B., Corbett, A., & Aarsland, D. (2011). Atypical antipsychotics for the treatment of behavioural and psychological symptoms in dementia, with a particular focus on longer term outcomes and mortality. Expert Opinion on Drug Safety, 10(1): 35-43 | Not specified | Atypical antipsychotics medications provide modest benefits up to twelve weeks /short term treatment of psychosis and dementia. Nonetheless, these benefits should be balanced against the risk of major adverse events such as increased death. With longer term prescribing, there are clear benefits, but the risk of death also increase. | Review of existing studies. The authors provide a summary of the evidence that pertain to safety and efficacy from short-term randomized controlled trials, as well as main findings from case register studies | Study is thorough. Presents both benefits and shortcomings of atypical antipsychotic drugs. The review provides an up-to-date and balanced overview of the safety concerns and effectiveness that relate to atypical antipsychotics in elderly patients with dementia, giving a full overview of mortality risk | The study only focuses on atypical antipsychotic drugs and does not also look into the safety concerns and efficacy of typical antipsychotics. | High level |
| Haddad, P. M., & Sharma, S. G. (2012). Adverse effects of atypical antipsychotics: Differential risk and clinical implications. CNS Drugs, 21(11): 911-936 | Not specified | Broad statements that compare the comparative risk of specific adverse effects between conventional and atypical antipsychotics are mainly insignificant. Instead, comparisons need to be made between particular typical and particular atypical antipsychotic drugs. | The authors reviewed various studies including post marketing, surveillance studies, and observational studies and randomized controlled trials. | The study is comprehensive, thorough and up-to-date | A small number of studies were reviewed | High level |
| Piersanti, M., Capannolo, M., Turchetti, M., Serroni, N., De Berardis, D., Evangelista, P., Costantini, P., Orsini, A., Rossi, A., & Maggio, R. (2014). Increase in mortality rate in patients with dementia treated with atypical antipsychotics: A cohort study in outpatients in Central Italy. Riv Psichiatr, 49(1): 34-40 | Not specified | Using atypical antipsychotics to treat dementia amongst older adults is linked to a higher rate of mortality. | A cohort study was conducted that comprised 696 elderly patients with Alzheimer | The study recommends new approaches for managing dementia to replace the use of atypical antipsychotic drugs which have potential risks of mortality | A small sample size was used and the study was carried out within a single hospital. This affects the generalizability of the findings | Medium level |
| Rochon, P. A., Gruneir, A., Gill, S. S., Wu, W., Fischer, H. D., Bronskill, S. E., & … Gurwitz, J. H. (2013). Older Men with Dementia Are at Greater Risk than Women of Serious Events After Initiating Antipsychotic Therapy. Journal Of The American Geriatrics Society, 61(1), 55-61. doi:10.1111/jgs.12061 | Not specified | Shortly after initiating oral atypical antipsychotic drug, the likelihood of developing a major event in elderly people with dementia was high. | This was a population-based, retrospective cohort study. | A large sample size was used that comprised 21,526 elderly men and women with dementia | The study had more women that. Women were 13,760 while the number of men was 7,766. | High level |
| Schneider, L. S., Dagerman, K. S., & Insel, P. (2012). Risk of death with atypical antipsychotic drug treatment for dementia – Meta-analysis of randomized placebo-controlled trials, JAMA, Journal of the American Medical Association, 294(15): 1934-1943 | Atypical antipsychotic medicines might be linked to a slight increased likelihood for death in comparison to placebo where typical antipsychotic drugs were used. | The authors assessed the evidence for high death rates from atypical antipsychotic medications for patients who have dementia. The data sources were obtained from Cochrane Controlled Trials Register, MEDLINE, and meetings and presentations. | A large sample size is used hence the findings could be generalized. There a total of 5,101 participants | Some very old data materials from the 1960s were used which may not be relevant for use today | High level |
Step 2: History and purpose of research question
Every antipsychotic drug has warnings of increased mortality for elderly patients (Schneider, Dagerman & Insel, 2012). Antipsychotic medications are broadly utilized in managing psychological and behavioural symptoms in dementia in spite of concerns as regards their safety (Ballard et al., 2011; Piersanti et al., 2014). Compared to typical or conventional antipsychotic drugs, atypical antipsychotic drugs are linked to a statistically significant rise in the likelihood of mortality for older men and women who have dementia (Haddad & Sharma, 2012).
The purpose of the research question is to find out whether the use of typical antipsychotic medication, which is the intervention, results in less mortality rates than atypical antipsychotic medication, which is the comparison group, in elderly patients who have dementia and psychosis.
Step 3: Strengths and weaknesses of existing literature
The strengths of the existing literature is that there are studies which focus mainly on the atypical antipsychotics and others that focus mainly in typical/conventional antipsychotics and their correlation with mortality. The weakness of the existing literature is that there are no studies that compare typical antipsychotics and atypical antipsychotics on the rates of mortality on elderly patients with dementia and psychosis (Rochon et al., 2013).
Step 4: Gap in current literature
At the moment, the gap in current literature is that there are no studies which have focused specifically on the association of atypical and typical antipsychotic medications on the rates of mortality among the older adults who have dementia.
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Conclusion
In conclusion, the PICO question for the research study is as follows: In elderly patients who have dementia and psychosis (P), does treatment with typical antipsychotics (I) or atypical antipsychotics (C) result in less mortality (O). The purpose of the research question is to find out whether the use of typical antipsychotic medication results in less mortality rates than atypical antipsychotic medication in elderly patients who have dementia and psychosis. The resources used to find articles included electronic databases research, relevant books, and reputable journals. The search terms that were utilized include dementia, mortality, psychosis, atypical antipsychotics, and typical psychotics.
References
Ballard, C., Creese, B., Corbett, A., & Aarsland, D. (2011). Atypical antipsychotics for the treatment of behavioural and psychological symptoms in dementia, with a particular focus on longer term outcomes and mortality. Expert Opinion on Drug Safety, 10(1): 35-43
Elkins, M. Y. (2010). Using PICO and the brief report to answer clinical questions. Nursing, 40(4), 59-60. Retrieved from the Walden Library databases.
Haddad, P. M., & Sharma, S. G. (2012). Adverse effects of atypical antipsychotics: Differential risk and clinical implications. CNS Drugs, 21(11): 911-936
Piersanti, M., Capannolo, M., Turchetti, M., Serroni, N., De Berardis, D., Evangelista, P., Costantini, P., Orsini, A., Rossi, A., & Maggio, R. (2014). Increase in mortality rate in patients with dementia treated with atypical antipsychotics: A cohort study in outpatients in Central Italy. Riv Psichiatr, 49(1): 34-40.
Rochon, P. A., Gruneir, A., Gill, S. S., Wu, W., Fischer, H. D., Bronskill, S. E., & … Gurwitz, J. H. (2013). Older Men with Dementia Are at Greater Risk than Women of Serious Events After Initiating Antipsychotic Therapy. Journal of the American Geriatrics Society, 61(1), 55-61. doi:10.1111/jgs.12061
Schneider, L. S., Dagerman, K. S., & Insel, P. (2012). Risk of death with atypical antipsychotic drug treatment for dementia – Meta-analysis of randomized placebo-controlled trials, JAMA, Journal of the American Medical Association, 294(15): 1934-1943
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