Anti-Psychotic Medicines and Dementia

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This page shares excerpts and links for caregivers who want to understand more about using anti-psychotics for dementia behavior. It provides links to pages from the Alzheimer’s Society, UK and Alzheimer’s Association, USA. Caregivers can read these to prepare for the discussion with their doctors.

Most persons with dementia experience behavioural and psychological symptoms (BPSD) (examples: aggression, agitation, loss of inhibitions, delusions, etc) and these can be distressing or harmful. Concerned families seek treatment and anti-psychotics may be prescribed. Families need to know the pros and cons to be able to discuss such treatment with doctors, because such medication may not be helpful and can even harm, and experts believe that anti-psychotics are prescribed more often than necessary for dementia cases.

Alzheimer’s Society, UK, as part of its data from NHS Digital, states[1] (quote reconfirmed October 2023):

For the vast majority of people with dementia, antipsychotic drugs are an outdated and inappropriate way to treat some of the behavioural symptoms  that can be associated with dementia. They can increase risk of death, likelihood of stroke and accelerate cognitive decline, as well as having a profound effect on quality of life, leaving people heavily sedated.[1]

There is a very detailed discussion on the use of antipsychotics and other drug approaches on a page of the Alzheimer’s Society, UK’s site [2] where they explain (all quotes from this page reconfirmed October 2023):

Antipsychotic drugs may be prescribed for people with dementia who develop changes such as aggression and psychosis. However this is usually only after other drugs have been tried such as anti-depressant, anti-dementia and anticonvulsant drugs.[2]

The page provides explanations on anti-depressants, anti-dementia and anticonvulsants, and goes on to say (this is in the context of UK),

Antipsychotic drugs are used to treat people who are experiencing severe agitation, aggression or distress from psychotic symptoms, such as hallucinations and delusions. They tend to be used only as a last resort, such as when the person, or those around them, are at immediate risk of harm.

For some people, antipsychotics can help to reduce the frequency or intensity of these changes. However, they also have serious risks and side effects, which the doctor must consider when deciding whether to prescribe them.

The first prescription of an antipsychotic should only be done by a specialist doctor. This is usually an old-age psychiatrist, geriatrician or GP with a special interest in dementia.[2]

The page provides a detailed explanation of where antipsychotics can help and where they cannot, and the caution needed.

The decision to use antipsychotics should be taken very seriously. Benefits may sometimes come at the expense of the person’s health and quality of life.

When considering prescribing an antipsychotic, the doctor will check if the person has high blood pressure, an irregular heartbeat, diabetes or a history of strokes. This is because these conditions carry additional risks for a person taking antipsychotic drugs.

There is evidence that some people with dementia who may not need antipsychotics are still being prescribed them. For example, they are being prescribed to treat distress or aggression before non-drug approaches have been tried thoroughly. Also, some people are kept on an antipsychotic for too long without a review at 12 weeks or a clear plan for when they should come off the drug.[2]

The Alzheimer’s Association, USA, on its page, Treatments for Behavior[3] suggests guidelines for considering/ using antipsychotics. An excerpt (reconfirmed in October 2023):

Based on scientific evidence, as well as governmental warnings and guidance from care oversight bodies, individuals with dementia should use antipsychotic medications only under one of the following conditions:
• Behavioral symptoms are due to mania or psychosis.
• The symptoms present a danger to the person or others.
• The person is experiencing inconsolable or persistent distress, a significant decline in function or substantial difficulty receiving needed care.
Antipsychotic medications should not be used to sedate or restrain persons with dementia. The minimum dosage should be used for the minimum amount of time possible. Adverse side effects require careful monitoring.

Note that some common anti-psychotics can cause severe damage if given to someone with Lewy Body Dementia [4]. (Excerpt below, reconfirmed October 2023):

IMPORTANT NOTE: It is estimated that a high percentage of DLB patients exhibit worsening parkinsonism, sedation, immobility, or even neuroleptic malignant syndrome (NMS) after exposure to antipsychotics. NMS is a rare, life-threatening medical emergency characterized by fever, generalized rigidity, and breakdown of muscle tissue that can cause renal failure and death. The heightened risk of NMS in DLB mandates that typical or traditional antipsychotics (such as haloperidol, fluphenazine. or thioridazine) should be avoided.

Unfortunately, persons with Lewy Body Dementia are often misdiagnosed as having Alzheimer’s Disease. As a result, they may be given medicines that harm them. Any use of anti-psychotic medication requires great care and review.

Documents referred to above

This page is referred to from: Handling Behavior Challenges.

[The information on this page is a collation from standard, authoritative sources, provided only for convenience. Caregivers can check out these and other sources to get better informed about this topic.]

Dementia Care Notes